Inspection·September 27, 2023

F 0880 The surveyor requested the facility records for outbreak testing of residents and staff. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on [DATE] at approximately 3:00 PM with the Director of Nursing (DON). The DON reported that the facility only tested those individuals who exhibited symptoms. She further stated that COVID is not transmitted if you don't have symptoms. She further expressed that they no longer have to conduct mass testing. The surveyor further inquired about the testing done regarding those individuals identified as exposed to COVID positive residents or staff. She again stated that the facility only tested those individuals who exhibited symptoms. Residents Affected - Some The surveyor reviewed with the DON on [DATE] the CDC recommendations. The Centers for Disease Control (CDC) Overview of Testing for SARS-CoV-2, the virus that causes COVID-19 documented: Testing asymptomatic people who have had recent known or suspected exposure to SARS-CoV-2 Viral Testing is recommended for individuals who have been exposed to someone with COVID-19. People who have had an exposure to someone known or suspected of having COVID-19 should be tested at least 5 days after the exposure. If symptoms develop before 5 days, they should get tested immediately. Testing people who have recently tested positive, and recovered from COVID-19 If someone has had exposure to someone with COVID-19 and is asymptomatic, but has had COVID-19 within the past 30 days*, testing to identify a new infection is generally not recommended. If someone has become newly symptomatic after having had COVID-19 within the past 30 days*, antigen tests should be used to identify a new infection. If they test negative, they should repeat the antigen test following FDA recommendations. The FDA recommends repeat testing following a negative result whether or not you have COVID-19 symptoms. If you receive a negative result, the test did not detect the SARS-CoV-2 virus at the time of that test. If you have COVID-19 symptoms, test again 48 hours after the first negative test, for a total of at least two tests. If you get a negative result on the second test and you are concerned that you could have COVID-19, you may choose to test again 48 hours after the second test, consider getting a laboratory molecular-based test, or call your health care provider. If you do not have COVID-19 symptoms and believe you have been exposed to COVID-19, test again 48 hours after the first negative test, then 48 hours after the second negative test, for a total of at least three tests. If you get a negative result on the second test, test again 48 hours after the second test. If you get a negative result on the third test and you are concerned that you could have COVID-19, you may choose to test again using an antigen test, consider getting a laboratory molecular-based test, or call your health care provider. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 2 of 6 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 09/27/2023 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 If someone had exposure to another person with COVID-19, but the exposed individual has had COVID-19 within the past 31-90 days*, consider using antigen tests (rather than an NAAT, such as a PCR test) to identify a new infection. They should get tested at least 5 full days after their exposure. If they test negative with an antigen test, they should repeat the antigen test following FDA recommendations. *The clock starts from the day the person is tested (not the day they received their positive test result) or their original onset of symptoms, whichever came first. An interview was conducted on [DATE] at 11:30 AM with the Public Health Preparedness Coordinator for the county's health department. The surveyor initially questioned her generally regarding outbreak testing. She explained about the recent rule changes regarding routine testing previously done in facilities had expired. However in outbreak testing, the facilities are to perform contact tracing and test individuals who were exposed to the COVID positive person. It is also recommended that repeat testing is done 5 days later. The surveyor then questioned her about the practice of testing only if symptomatic. Symptomatic individuals are to be tested immediately. Asymptomatic individuals are to be tested if they have been exposed to the COVID positive person. If the exposed person is negative, then it is recommended that the test is repeated on day 5. The surveyor also inquired about the asymptomatic people's ability of being COVID positive and transmitting the virus to others. She confirmed that there is still the possibility of COVID positive individuals not exhibiting symptoms but could still have the ability to transmit the virus to others. She expressed that the probability is less than a symptomatic positive person but there it is still possible. Thus she emphasize individuals utilizing the practice of universal precautions. The surveyor then specifically asked her regarding the facility. She confirmed receiving the line listing of individuals who tested positive and she was contacted by the Director of Nursing. The facility also had another outbreak in May and one resident expired. Further review of the facility follow-up revealed that Resident # 3 shared a room with Resident # 9, who was admitted to the facility on [DATE] with a diagnosis of Acute Respiratory Failure. There was no testing documented in the clinical record for the resident. However, interview with the Director of Nursing on [DATE] in the afternoon, revealed that the facility tested the resident on [DATE] the results of that test was negative. The facility then moved the resident to another room. However, the facility did not conduct any repeat COVID testing of this resident. Additionally, Resident # 8, who tested positive on [DATE] shared a room with Resident # 10. There was no testing documented in the clinical record for the resident. However, interview with the Director of Nursing on [DATE] in the afternoon, revealed that the facility tested the resident on [DATE], the results of that test was negative. The facility again moved the resident to another room. Again the facility did not perform any repeat COVID testing on Resident # 10. Furthermore, review of the staff testing, revealed that the facility tested on e staff because she exhibited symptoms. The surveyor requested the facility's investigation and contact tracing from the [DATE] outbreak. The facility investigation yielded that the spouse of Resident # 1 visited and exhibited symptoms and tested positive on [DATE]. Resident # 1 was symptomatic with positive test on [DATE]. Resident # 1 and Resident # 2 shared a room (room [ROOM NUMBER]) and attended therapy five (5) times a week in the room and in the wellness center and was on Certified Nursing Assistant Assignment 3. Resident # 2 also tested positive on [DATE]. Resident # 3 (room [ROOM NUMBER]) also attended therapy 5 times a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 3 of 6 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 09/27/2023 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 week in the room and in the wellness center. The resident was on CNA assignment 1. Resident # 4 and Resident # 5 shared a room (room [ROOM NUMBER]) and participated in therapy 5 times a week in the room and in the wellness center. The residents were also on CNA assignment 1. Both residents were symptomatic and tested positive on [DATE]. Two more residents Residents # 6 and # 7, who shared a room (room [ROOM NUMBER]) and participated in therapy 5 times a week in the room, were symptomatic and tested positive on [DATE]. The residents were on CNA assignment 1. Resident # 8 (room [ROOM NUMBER]) was symptomatic, tested positive on [DATE]. The resident was on CNA assignment 1. The facility identified 18 staff through contact tracing who were exposed to COVID positive residents (8 Licensed Staff, 7 Certified Nursing Assistant; 3 contract therapy staff) . One staff (Activities) was tested. This staff exhibited symptoms and tested positive on [DATE]. Several staff test themselves on their own because the facility did not offer testing. Additionally, the facility did not perform repeat testing of residents who initially tested negative or offered the staff who self-tested a repeat test as recommended. An interview was conducted with the Director of Nursing on [DATE] at 2:00 PM. She confirmed that the facility did not test the 18 staff identified through contact tracing. The DON also reported the following information regarding the Therapy staff: The full time Physical Therapist tested herself on [DATE] and reported a negative test. The staff did not report experiencing symptoms. This test was not reported, nor did the staff retest. The part-time Occupational Therapist did not test. The DON reported that the therapist had a recent positive COVID test from another facility's identified outbreak. She was uncertain about the time frame of the previous positive COVID test. Another therapist was pregnant and tested herself on [DATE]. She did not exhibit symptoms and the test results were not reported. The staff did not retest as recommended. The facility failed to follow their policy and procedure and the CDC recommendations regarding testing during an outbreak, exposing the residents and staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 4 of 6 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 09/27/2023 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical and administrative record review and staff interview, the facility failed to ensure the clinical record provided documentation or evidence that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This failure is evidenced by the review of 5 residents for immunizations history revealed that the facility failed to provide evidence of offering the pneumococcal vaccine to 3 of 5 residents reviewed (Resident #4, #11, #12) and failed to provide evidence of vaccinating 1 of the 2 remaining residents reviewed, when the resident consented to receive the pneumococcal vaccine (Resident #10). Residents Affected - Few The finding included: The facility's policy Infection Control - Influenza and Pneumococcal Immunization for Residents, date 06/08/22, documented regarding Pneumococcal Immunization: 1. Before offering the pneumococcal immunization, each resident and or resident representative receives education regarding the benefits and potential side effects of the immunization. 2. Each resident is offered pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized; 3. The resident and/or resident representative has the opportunity to refuse immunization; and 4. The resident's medical record includes documentation that indicates, at a minimum, the following: i. That the resident or resident representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and ii. That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medication contraindication or refusal. 5. Pneumococcal immunization will be offered in accordance with most updated CDC immunization algorithm. 1) Review of the clinical record on 09/26/23 for Resident #4 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record did not reveal evidence that the resident or her representative was provided education and/or was offered the pneumococcal vaccine. 2) Review of the clinical record on 09/26/23 for Resident #12 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record did not reveal evidence that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 5 of 6 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 09/27/2023 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 resident or her representative was provided education and/or was offered the pneumococcal vaccine. Level of Harm - Minimal harm or potential for actual harm 3) Review of the clinical record on 09/26/23 for Resident #11 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record did not reveal evidence that the resident or her representative was provided education and/or was offered the pneumococcal vaccine. Residents Affected - Few An interview was conducted on 09/26/23 in the afternoon with the Director of Nursing, who confirmed that the clinical record did not provide evidence that the residents had been offered the pneumococcal vaccine. 4) Review of the clinical record on 09/26/23 for Resident #10 revealed that the resident was admitted to the facility on [DATE]. Further review of the clinical record revealed a Pneumococcal Polysaccharide Vaccine (PPSV23) informed consent signed by the resident on 02/07/22. Additional review of the clinical record failed to provide evidence that the resident was administered the vaccine. An interview was conducted on 09/27/23 in the afternoon with the Director of Nursing. She confirmed the current clinical record did not provide evidence that the resident was administered the vaccine. She will investigate further and inform the surveyor if located. At the time of this writing, no further evidence was provided to indicate that the resident was administered the vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 6 of 6