Inspection·May 18, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete BIMS (Brief Interview Mental Status) score is a 10, which means her cognition is moderately impaired. Resident #7 had a significant amount of weight loss. A review of the resident's care plan revealed there is not a care plan documenting weight loss and weight loss interventions. During an interview on 05/18/23 at 9:32 AM with MDS Coordinator, she was asked how she knows if there has been a change in resident's care and to update the care plan she stated, I come in everyday I check on the PCC dashboard (it has the census listing of discharges, admissions, payor changes,) section of new orders of antibiotics, and psychotropics and I pull an order report for the past 24 hours. She was then asked if she could review Resident #1 and Resident #7's care plans and show the surveyor their care plan for weight loss and Resident #1's pressure ulcer care plan. She stated that Resident #1 has a care plan for impairment of skin integrity, but acknowledges it does not mention anything about pressure ulcers and that both have a basic care plan for nutrition. She acknowledged there was no care plan for weight loss. She stated she has only been here at the facility for two months and is still going through care plans. Event ID: Facility ID: 106097 If continuation sheet Page 2 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure appropriate care and services for 2 of 10 sampled residents. Coordination between Hospice and facility nurses related to the suprapubic catheter of Resident #13 was not maintained. Facility nurses failed to notify the physician of a hypertension (increased blood pressure) medication being held two days in a row for Resident #8. Residents Affected - Few The findings included: 1) During an observation and interview on 05/16/23 at 10:06 AM, Resident #13 was lying in bed, holding onto the tubing of his suprapubic catheter (urinary draining device) and stated, Can you look at this? The area on his abdomen lacked any type of dressing, and the skin around the tubing was reddened with dried scabbing around the insertion site. Review of the record revealed Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], after hospitalization. Review of the paper record documented an order dated 04/28/23 to cleanse the suprapubic catheter site with normal saline, apply Cleocin cream, and cover with a dry dressing twice daily. Review of the electronic medical record revealed this order was discontinued on 04/29/23. Review of the current care plans initiated on 01/17/23 documented Resident #13 needed physical assistance by staff for toileting. These care plans also included that Resident #13 had an indwelling suprapubic catheter, but lacked any type of documented care. During an interview on 05/16/23 at 11:15 AM, the facility's Nurse Practitioner was asked about the care to the suprapubic catheter. The Nurse Practitioner stated she recalled Hospice had recommended the Cleocin Cream or gel for use. When asked if she knew why the Cleocin was not provided and discontinued from the orders, the Nurse Practitioner was unsure, and stated she did not recall it being discontinued. During an interview on 05/16/23 at 11:19 AM, Staff D, Registered Nurse (RN), was asked when or if the Cleocin cream was being applied to the suprapubic site of Resident #13. The RN stated that care was done by the Hospice nurse. Staff D further stated the facility nurses check the dressing and do it as well. The RN stated the Certified Nursing Assistant (CNA) just told her there was no dressing that morning, and that she will check it. The RN found Cleocin gel in the treatment cart (Photographic Evidence Obtained). Review of the medication label documented the gel was to be applied twice daily. When asked how often the Hospice nurse comes to the facility, the RN was unsure. The record lacked any documented evidence of the provision of Cleocin gel. During an interview on 05/16/23 at 3:08 PM, when asked what care was being provided to the suprapubic catheter of Resident #13, Staff E, Licensed Practical Nurse (LPN) and the resident's usual evening nurse, explained she just looks at it to ensure a dressing is in place with no drainage or obvious problems. The LPN volunteered that a couple of weeks ago they had a cream ordered, but the ordered care just disappeared from the electronic medical record (EMR). The LPN explained that then a gel showed up, but it never got put into the EMR. The LPN stated she never followed up on the noted gel. 2) During a medication pass observation on 05/16/23 at 8:43 AM, Staff D, Registered Nurse (RN), held the blood pressure medication Cozaar, stating Resident #8's blood pressure was too low with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 3 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 reading of 97/58 and heart rate of 57. Level of Harm - Minimal harm or potential for actual harm Review of the record on 05/17/23 revealed the Cozaar was again held that same morning by the same nurse for a blood pressure reading of 102/48 and heart rate of 58. The order lacked any hold parameters. Further review of the record lacked any communication with the physician related to the low blood pressure and heart rate, or the holding of the medication on both days. Residents Affected - Few During an interview on 05/18/23 at 1:31 PM, the facility's Nurse Practitioner confirmed Resident #8 was on the medication Cozaar for hypertension (high blood pressure). When asked if she had been told it had been held the past two days, the Nurse Practitioner stated not that she recalled, but agreed the nurses should have let her know. The Nurse Practitioner stated she would look into his medications to see if changes needed to be made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 4 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the provision of wound care was rendered, as per ordered, and failed to ensure coordination of care between the wound care physician and facility nurses for 1 of 1 sampled residents (Resident #1). Residents Affected - Few The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE], and developed pressure wounds to the coccyx and left heel on or about 04/18/23. During a wound care observation on 05/16/23 at 12:04 PM, the wound care physician debrided the wounds, stating the wounds to the coccyx had deteriorated. The physician stated, Be sure the air mattress is functioning because the last time it deteriorated there was a problem with the specialty air mattress. Wound care notes for Resident #1 all documented the order and use of the specialty air mattress. On 05/16/23 at 12:43 PM, Staff F, Licensed Practical Nurse (LPN) and nurse who usually rounded with the wound care physician, upon gathering her supplies stated that the wound care had changed with this physician visit, compared to what was currently in the electronic medical record (EMR). The LPN provided wound care to the left heel that included the use of Santyl (a debriding ointment) to the wound bed, triple antibiotic ointment around the wound, gauze for cushioning and a Kerlix wrap. The LPN provided wound care to the coccyx that included the use of Santyl to the wound bed, a packing of gauze soaked in a Dakins (an antiseptic for cleaning infected wounds) solution, and Allyvn (a foam dressing) for coverage. The LPN then looked at her tray of supplies and stated she had to add the alginate silver (absorbent antimicrobial) dressing over the Dakins to the heel dressing, unwrapped the Kerlix, applied the forgotten wound dressing, rewrapped the foot and stated, I'm not sure why he is doing this. The LPN explained the wound care physician sends the weekly wound care notes with orders the day after his visit, and she would then put the orders into the EMR. Review of the most current wound care orders from before this observation revealed a date of 04/20/23. These orders included the use of Santyl and triple antibiotic ointment, then Dakins soaked gauze, then Alginate Silver for the left heel. The coccyx was being treated with Collagen powder and Calcium Alginate. Review of the new order dated 05/17/23 for the coccyx documented the use of Santyl and triple antibiotic ointment to the wound, Dakins soaked gauze, and a border dressing for coverage. Review of the wound care note written by the physician on 05/16/23 documented the treatment plan for the heel was Santyl and triple antibiotic ointment directly to the wound, followed by Dakins soaked gauze, but did not include any alginate silver as was applied by the LPN. The treatment plan for the coccyx was Santyl and gentamicin (a different antibiotic) to the wound bed, followed by the Dakins dressing. The new order for care to the coccyx dated 05/17/23 entered by the LPN lacked the gentamicin, but continued with the triple antibiotic ointment. During an interview on 05/18/23 at 10:53 AM, Staff F, LPN, stated the wound care physician verbalized no changes to the heel wound, but only changes to the coccyx wound. The LPN stated she did review the 05/16/23 wound care physician note with new orders that she received yesterday, but did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 5 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 note the change to the gentamicin or the deletion of the alginate silver, nor did she clarify with the wound care physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 6 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on record review and staff interviews, the facility failed to: Residents Affected - Many 1) Accurately document the number of Certified Nursing Assistants (CNAs) directly responsible for resident care and the actual hours worked by the CNA's on the 6:00 AM - 2:00 PM shift on 2 of 14 days reviewed in May 2023; and 2) Post the total number of nurses and CNA's working each shift on the Nurse Staffing Information document. The findings included: 1) The staffing schedules, including call-ins and staff postings for the past month, were reviewed with the Director of Nursing (DON) on 05/18/23 at 11:15 AM. There was a discrepancy noted between the number of CNAs on the May Schedules and the total CNA hours posted on the Nurse Staffing Information. The DON provided Daily Staffing Sheets showing the actual staff on duty during 05/01/23 and 05/15/23. There was a discrepancy in the number of CNAs on 05/04/23, 05/10/23, 05/18/23, and 05/12/23. Time sheets were requested from the Human Resource (HR) Manager to review for the actual names and hours worked by the CNAs on these dates. On 05/18/23 at approximately 12:15 PM, the HR Manager brought in copies of the Daily Labor Report for these 4 dates. On 05/04/23, it was documented that only 2 CNAs worked from 6 AM - 2 PM (Staff B and Staff C). The number of CNA hours for this shift on this date would have been 15 hours (2 CNAs X 7.5 hours = 15hours); However, the Nurse Staffing Information posted for 05/04/23 documented the number of CNA hours worked as 22.5 hours, accounting for 3 CNAs instead of the actual 2 CNAs that worked at this time (3 CNAs X 7.5 hours = 22.5 hours). On 05/10/23, it was documented that only 2 CNAs worked from 6 AM - 2 PM (Staff B and Staff C). The number of CNA hours for this shift on this date would have been 15 hours (2 CNAs X 7.5 hours. = 15 hours); However, the Nurse Staffing Information posted for 05/10/23 documented the number of CNA hours worked as 22.5 hours, accounting for 3 CNAs instead of the actual 2 CNAs that worked at this time (3 CNAs X 7.5 hours = 22.5 hours). 2) The Daily Nurse Staffing Information posted each day during the annual survey (05/15/23 - 05/18/23), located on the opposite wall from the nurse's station, contained the total number of Nursing and CNA hours for each shift; however, the actual number of Nurses and CNAs were not included on this posting. It was discussed with the DON on 05/18/23 11:15 AM and with the Administrator on 05/18/23 at 3:15 PM that the number of staff must be included on the Nurse Staffing Information along with the total staffing hours for each shift, per regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 7 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to safely store wound care medications and supplies for 2 of 2 sampled residents receiving wound care (Residents #13 and #1), and failed to ensure expired supplements and laboratory supplies were removed from 1 of 1 medication storage rooms. A random observation on [DATE] revealed the treatment cart was left unattended and unlocked. The findings included: Review of the policy Medication Storage dated [DATE] documented, Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments . 5. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed per manufacturer guidelines and standards of practice. 1) During an observation and interview on [DATE] at 11:19 AM, Staff D, Registered Nurse (RN) obtained a tube of Cleocin (an antibiotic) gel from the treatment cart to provide wound care to Resident #13. The RN went to the room of Resident #13, but the door was closed and personal care was being provided. The RN set the tube of antibiotic gel on top of the cart and left it there while attending to other residents. An observation on [DATE] at 11:52 AM revealed the antibiotic gel remained on top of cart (Photographic Evidence Obtained). During an observation on [DATE] at 12:23 PM, the Director of Nursing (DON) saw the antibiotic gel on top of cart and removed it. The DON was told it had been there for just over an hour, and acknowledged the concern. Review of the requested list of residents who could self propel throughout the unit revealed 6 of the current 17 residents, including sampled residents #7, #11, and #16. These residents, along with any staff or visitors would have the ability to take the unsecured antibiotic gel. On [DATE] at 12:25 PM, Staff D, RN, provided wound care to the suprapubic catheter of Resident #13 using the Cleocin gel. After the provision of the care, the RN put the gel back into the box, and placed it in the top drawer of the resident's dresser. This dresser was located just inside the resident's room, when going straight into the room from the hallway. During an observation and interview on [DATE] at 3:32 PM, with Staff E, Licensed Practical Nurse (LPN), the Cleocin gel was noted still in the top drawer of the resident's dresser (Photographic Evidence Obtained). The LPN agreed that medications were not to be stored in resident rooms. 2) On [DATE] at 3:03 PM, an observation of the treatment cart with Staff F, Licensed Practical Nurse (LPN) who rounds with the wound care physician, revealed expired wound treatment supplies (Photographic Evidence Obtained) to included Silvercel non-adherent dressings that expired on [DATE] and used during a wound care observation with Resident #1, and Hydrocellulare Foam dressings that expired 12/2022. Two unidentifiable dressings were cut opened and left in the treatment cart. The name of the dressing had been cut off. A Calcium Alginate Dressing was opened and partially used, and stored open in the treatment cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 8 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 3) During an observation of the medication storage room on [DATE] at 3:31 PM with the Director of Nursing (DON), the following expired items were identified: Level of Harm - Minimal harm or potential for actual harm A bottle of BioTech Vitamin D3 with 100 capsules expired 11/2022. Residents Affected - Few Two expired culture sets that contained Curative Collection Kits expired 01/2022. 4) During a random observation on [DATE] at 1:22 PM, the treatment cart that contained multiple wound care ointments and supplies, was noted in the hallway next to the closed door of room [ROOM NUMBER], unattended and unlocked (Photographic Evidence Obtained). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 9 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary comfortable environment and help prevent the development and transmission of communicable diseases and infections, as evidenced by the failure to ensure proper infection surveillance related to numerous Urinary Tract Infections (UTI's) in [DATE], for 3 of 4 sampled residents, affecting Residents #12, #13, and #23; failure to ensure appropriate Transmission Based Precautions for 1 of 1 sampled resident, Resident #4 who had Methicillin Resistant Staphylococcus Aureus (MRSA) of a wound; failure to ensure contact tracing with supplemental testing for the last COVID-19 positive staff identified (Staff G, cook); failure to ensure consistent monitoring of positive COVID-19 for 2 of 2 sampled residents, for Residents #12 and #14; failure to clean and disinfect the glucometer after use for 1 of 1 sampled resident, with Resident #14 by Staff D, Registered Nurse (RN) and Staff E, Licensed Practical Nurse (LPN); and failure to provide wound care and handle wound care supplies appropriately during the care for 2 of 2 sampled residents, of Residents #1 and #13. Residents Affected - Some The findings included: Review of the policy, titled, Infection Prevention and Control Program, implemented [DATE] documented, in part, Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and services as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 3. Surveillance: a) A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b) The Infection Preventionist services as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and report surveillance findings to the facility's Quality Assessment and Assurance Committee. 10. Supplies Protocol: . d) Non-sterile supplies are stored and maintained as clean prior to use. Review of the policy, titled, Glucometer disinfection, implemented [DATE] documented, in part, Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use . 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. 4. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review of the policy, titled, Infection Control - Standard and Transmission-Based Precautions dated [DATE] documented, in part, Procedure: . Contact Precautions 1. Contact Precautions are implemented most often for residents who have an infection due to an epidemiologically important organism such as multi-drug resistant organism. Enhanced Barrier Precautions . a. Enhanced Barrier Precautions may be implemented for residents with the following: . Wound infections due to an MDRO (Multi Drug Resistant Organism) such as MRSA as long as the dressing remains intact, . c. Gowns and gloves must be worn when providing direct resident care . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 10 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the policy, titled, Clean Dressing Change dated [DATE] documented, in part, Policy Explanation and Compliance Guidelines: . 2. Multi-use wound care supplies will be dated and initialed when opened. They will be maintained clean after initial use. 5. c. Place only the supplies to be used per wound on the clean field at one time. e. Use no-touch techniques to remove ointments and creams from their containers (i.e., use tongue blade or applicator). Liquid solutions should be poured directly onto gauze sponges. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 1. Review of the [DATE] Infection Control Log revealed seven UTIs (Urinary tract Infections) that included sampled Resident #13, with onset dates of [DATE] and [DATE]; Resident #23, with onset dates of [DATE] and [DATE]; and Resident #12 with an onset date of [DATE]. None of these had documented evidence of tracking and trending the infections, or evidence as to whether the infections were developed within the facility or community acquired. The second UTI infection on [DATE] for Resident #13 documented it was community acquired, which was inaccurate as this was the resident's return to the facility after having been sent to the hospital with a UTI from the facility. Three of these infections, the two for Resident #13 who had an indwelling urinary catheter and one for Resident #12, included the organism E-Coli, which indicated improper personal care. The facility failed to provide additional education related to personal care with the identification of multiple UTIs. Further review of the record indicated Resident #13 was admitted to the hospital on [DATE] with a diagnosis of septic shock and UTI. During an interview on [DATE] at 4:15 PM, the Infection Control Preventionist (ICP) confirmed all of the UTIs were facility acquired and there was no subsequent additional education related to personal care. 2. Review of the [DATE] Infection Control Log revealed Resident #4 had MRSA (Methicillin Resistant Staphylococcus Aureus) of the wound with an onset date of [DATE]. Review of the record lacked evidence of the use of any type of transmission-based precautions. During an interview on [DATE] at 11:14 AM, Staff C, Certified Nursing Assistant (CNA), stated there was a communication problem at the facility related to the infection status of the residents. Staff C stated she found out after Resident #4 had passed [expired], that he had MRSA. Staff C stated they were not made aware of the infection and there were no precautions put in place. When specifically asked if there was any additional PPE (personal protective equipment) used during the resident's care, the CNA stated there was none. The CNA stated she is concerned about getting some kind of infection at the facility and possibly taking it home to her family. During an interview on [DATE] at 3:48 PM, when asked if any type of transmission-based precautions were used for residents with MRSA, the ICP stated if the MRSA was being treated, they would use contact precautions. When asked specifically about Resident #4, the ICP confirmed he did have MRSA of the wound and confirmed he was on an antibiotic. When asked if any type of precautions were used during the care of Resident #4, the ICP stated they did not because they use contact precautions on everyone. When asked if she meant they use standard or universal precautions on everyone, the ICP agreed. The ICP was shown the Infection Control policy that described the use of either contact or enhanced barrier precautions for a resident with MRSA and agreed with the findings. 3. Review of the COVID-19 positive line lists revealed Staff G, a cook, tested positive for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 11 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some virus on [DATE] after having had symptoms of headache, runny nose, cough, and sore throat since [DATE]. Review of the Employee Schedule Report revealed Staff G worked in the skilled nursing facility's kitchen on [DATE], [DATE], and [DATE], the five days prior to her positive COVID-19 result. On [DATE] and [DATE], Staff G worked in the Independent Living kitchen on the same property, but a different location. During an interview on [DATE] at 4:08 PM, when asked if the ICP did any contact tracing or conducted any additional testing, with a minimum of the staff who work in the kitchens, the ICP stated she had not as none of the other staff had any signs or symptoms of the virus. The ICP was reminded of mandated outbreak testing, and again stated she did not do any further testing but educated the staff to immediately report any signs or symptoms of the virus. 4. Review of the COVID-19 positive line list for residents revealed Resident #12 tested positive for the virus on [DATE]. Review of the record revealed the physician orders for vital signs to include oxygen saturation (O2 sats) every shift related to the resident's COVID-19 positive status. The facility utilized three eight hours shifts per day. Review of the COVID-19 Daily Evaluations lacked evaluations on [DATE], [DATE], and [DATE], 3 of the usual 10-day virus observation period. These evaluations did include the temperature reading and oxygen levels but were not completed each shift. Review of the oxygen saturation levels for Resident #12 from [DATE] through [DATE], revealed levels were only completed for 2 of 30 shifts ([DATE] on evening shift and [DATE] on evening shift). During the continued interview on [DATE] at 4:08 PM, the ICP was made aware of the lack of consistent assessments for the COVID-19 positive residents and had no response. 5. During a medication pass observation on [DATE] at 11:41 AM, Staff D, RN (Registered Nurse), obtained the glucometer for Resident #14 out of the medication cart, and took it, while in its black canvas bag, into the resident's room. The RN stated, I just wiped it off. The RN placed the black canvas bag directly on the over the bed table being used by Resident #14, and then placed the glucometer on a tissue. The RN obtained the blood glucose reading from Resident #14, disposed of the used items, and placed the glucometer back into the black canvas bag without any type of cleaning or disinfecting. The RN placed the canvas bag back into the medication cart. Resident #14 was the only current resident on blood sugar checks at the time of the survey. During a second observation on [DATE] at 11:49 AM, Staff E, LPN (Licensed Practical Nurse), took the glucometer out of the black canvas bag from the medication cart, went into Resident #14's room, and set the glucometer directly on the resident's over-the-bed table, where Resident #14 was currently eating. The LPN obtained the blood sugar level and then placed the glucometer back on the resident's table. The LPN disposed of the used items, did a quick swipe of the end of the glucometer where the strip is placed, with an alcohol swab, and returned to the medication cart. The LPN wiped the glucometer with a disinfectant wipe and placed it immediately back into the black canvas bag. During an interview immediately after the observation, when asked the timeframe for disinfecting, the LPN stated, one minute kill time pointing to the container label and then stated, So I should have wrapped it for the one minute. Review of the Mikrokill disinfectant wipes instructions documented directions to maintain a wet time of one minute. 6. During a wound care observation on [DATE] at 12:04 PM, the wound care physician donned gloves, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 12 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 removed the dressing to Resident #1's left heel, then changed gloves without any hand hygiene. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:43 PM, the wound care for Resident #1 was completed by Staff F, the LPN who normally rounds with the wound care physician. Staff F gathered supplies to include the bottle of Dakins quarter strength solution, the tube of Santyl ointment in its box, and a full unopened pack of 4x4 gauze dressings along with a partially used pack of 4x4 gauze dressings. The LPN took all of the supplies into the resident's room. After the provision of wound care to Resident #1, the LPN placed the bottle of Dakins, the box of Santyl ointment, and now opened pack of 4x4s back into the treatment cart. Residents Affected - Some During an interview on [DATE] at 3:03 PM, Staff F was made aware of the observations, agreed she had taken supplies in and out of the resident's room and placed them back into the medication cart, and agreed with the infection control concerns. During an observation on [DATE] at 12:25 PM, Staff D, RN, obtained Cleocin gel in its box container, along with other wound care supplies, and entered the room of Resident #13. The RN cleaned the area around the resident's suprapubic catheter insertion site. The RN opened the box of Cleocin gel with her gloved hands, put some of the gel on her gloved finger, and applied the gel around the insertion site. The RN then put the tube of gel back into the box. The RN failed to change gloves before application of the gel and failed to use some type of application device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 13 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Potential for minimal harm Based on record review and interview, the facility failed to ensure documented evidence of the provision of the influenza vaccine for 4 of 5 sampled residents, was maintained in the medical record (Residents #8, #11, #12 and #14). Residents Affected - Some The findings included: Review of the records revealed Resident #8 consented to receive the influenza vaccine on 10/22/22, Resident #11 consented on 10/27/22, Resident #12 consented on 10/27/22, and Resident #14 consented on 10/25/22. Further review of these records lacked any evidence of the provision of the influenza vaccine to the four residents. The Director of Nursing (DON), who was also the Infection Control Preventionist (ICP), was asked to locate and provide evidence of the provision of the influenza vaccine to the four residents. The DON/ICP provided a single list of residents in the facility who all received the influenza vaccine on 11/18/22. The DON/ICP agreed the information was not maintained in the resident's clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 14 of 14