Health inspection·December 3, 2021

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few times the physician signed a yellow DNRO, and a written physician order was not obtained at the same time. The DON and the SSD confirmed Resident #178 did not have an order written to coincide with the signed DNRO. On [DATE] at 2:37 p.m. a telephone interview was conducted with Resident #178's Attending Physician, who stated a telephone order for the DNR status may come a couple days later and obtaining one depended on the facility. He stated he does not necessarily write an order for code status once he signed the DNRO form. The Attending Physician stated his expectation was if the code status of the resident changed the chart should reflect it. The facility provided multiple copies of the policy titled Residents' Rights Regarding Treatment and Advance Directives, copyrighted 2021 by The Compliance Store, LLC. The policy implemented [DATE] indicated that it was the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The policy identified that On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive and During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. The policy, Cardiopulmonary Resuscitation (CPR) implemented [DATE], identified that it was the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). The compliance guidelines indicate if a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. in accordance with the resident's advance directives, or b. In the absence of advance directives or a do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 2 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to provide the resident or representative and the Office of the State Long Term Care (LTC) Ombudsman with detailed written notice of discharge and hospital transfer for one (#28) of twenty-two sampled residents. Findings included: Review of Resident #28's record revealed admission to the facility on [DATE] with diagnosis that included severe dementia, psychosis and agitation. A review of the interdisciplinary Progress Notes dated 11/1/21 indicated the resident was transferred to the hospital on [DATE] related to agitation and aggressive behavior. Continued review of the record revealed a two page Nursing Home Transfer and Discharge Notice with an effective date of 11/1/21 The form indicated the reason for transfer was The safety of other individuals in this facility in endangered, and the section titled Notice given to: was blank. The notice did not indicate it had been provided to the resident/representative or the LTC Ombudsman. In an e-mail communication with the local office of the LTC Ombudsman dated 11/30/2021 at 10:10 AM, concerns were identified related to consistently receiving discharge notifications from the facility. They reported the notices are typically not completed properly. In an Interview on 12/01/21 at 2:17 PM with the Social Service Director (SSD), she confirmed there was no documentation of the resident/representative receiving all pages of the Nursing Home Transfer and Discharge Notice. At this time the SSD said she could not confirm the appropriate notice was sent to the resident/representative and to the LTC Ombudsman. During an interview on 12/01/21 at 2:24 PM with the Nurse Consultant, she confirmed the documentation was incomplete for the Nursing Home Transfer and Discharge Notice for Resident #28. Review of the undated facility policy titled Transfer and Discharge (including AMA), under the sub-heading of 7. Emergency Transfers/Discharges j. Provide transfer notice as soon as practicable to resident and representative. k. Social Service Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 3 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a bed hold notice to one (#28) of twenty-two sampled residents at the time of transfer to the hospital. Findings included: Review of Resident #28's record revealed admission to the facility on [DATE] with diagnosis that included severe dementia, psychosis and agitation. A review of the interdisciplinary Progress Notes dated 11/1/21 indicated the resident was transferred to the hospital on [DATE] related to agitation and aggressive behavior. Continued record review revealed a Bed-Hold and readmission Policy Acknowledgement form; the form was type-written but did not include documentation that indicated a signature or date the resident/representative had acknowledged receipt of the form. An interview was conducted on 12/01/21 at 2:17 PM with the Social Service Director (SSD). The SSD said she was not responsible for bed-hold forms, and stated, the nurses complete that task when they are transferring residents out to the hospital. In an interview on 12/01/21 at 2:24 PM with the Nurse Consultant she confirmed the documentation was incomplete. She reported the bed-hold policy was incomplete and the resident/representative signature was missing. Review of the undated facility policy titled Bed Hold Prior to Transfer revealed the following: 4. The facility will give written information concerning the bed-hold policies to the resident and/or resident representative as part of the admissions packet and a signed and dated copy of the bed-hold notice information will be kept in the resident's admission file. Review of the undated facility policy titled Bed Hold Notice Upon Transfer revealed the following: 5. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 4 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to assess the skin appropriately and timely for two (#3 and #5) of two residents reviewed for pressure ulcer care. Residents Affected - Some Findings included: The admission Record of Resident #3 identified the resident was admitted on [DATE] with diagnoses not limited to dementia and acute renal failure. Resident #3 was observed on 1/19/22 at 10:46 a.m., lying in bed atop an air mattress set for normal pressure. An area of the residents left leg, below the knee, was noted wrapped with rolled gauze, and an island dressing attached to the posterior of the resident's right leg. Resident #3's skin appeared to be thin and fragile, the skin on the resident's bilateral lower extremities appeared to have large areas of reddish-purple coloring. An observation with Staff Member C, Staff Member F (CNA - Certified Nursing Assistant), and Staff E Regional Minimum Data Set nurse (RMDS) on 1/19/22 at 10:46 a.m., revealed an area to the mid coccyx which Staff C claimed as almost closed. An observation of Resident #3's left heel, at 11:09 a.m. on 1/19/22 revealed a flat blister which Staff C applied skin prep. A review of Resident #3's physician order sheet, printed on 1/10/22 at 4:18 p.m., indicated that staff was to conduct a skin sweep every week. A physician order, dated 1/3/22, indicated staff were to Apply skin prep to left heel once a day for the indication of a blister and an additional order, dated 1/3/22, instructed staff to float left heel while in bed related to a blister. A physician order, dated 1/10/22, instructed staff to Apply skin prep to left heel once a day due to a Deep Tissue Injury (DTI). During an interview, the RMDS stated, on 1/19/22 at 2:30 p.m., the Certified Nursing Assistant (CNA) shower sheets were the weekly skin assessments and if any skin impairment was observed the CNA would notify the nurse to assess the area. After reviewing the chart of Resident #3 she stated the first documentation she found regarding Resident #3's heel wound was 1/3/22, when an order was obtained for treatment. During an interview on 1/19/22 at 3:09 p.m., the Unit Manager (Staff D) identified weekly skin assessments for residents were to be done on one of the two shower days assigned to the residents. The Shower Schedule indicated the resident was to have a shower on Wednesday and Saturdays. A review with Staff D of Resident #3's Skin Evaluations, on 1/19/21, indicated a skin evaluation was conducted by Licensed Practical Nurses (LPN), on 12/22/21, 12/29/21, and 1/5/22. The skin evaluations did not identify the blister located on the resident's left heel had been noted on any evaluations. The skin evaluation form did not indicate a weekly skin evaluation was conducted on 1/12/22. The January 2022 Treatment Record identified staff had completed a skin sweep for Resident #3 on 1/5 and 1/12/22. The January 2022 Treatment Record for Resident #3 included undated instructions for staff to Float left (L) heel and skin prep blister on L heel every (q) shift and as needed (prn). The treatment record indicated staff had applied skin prep and floated the L heel since the 7 a.m.- 7 p.m. shift on 1/1/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 5 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0641 Level of Harm - Minimal harm or potential for actual harm On 1/19/22 at 2:58 p.m., Staff Members C and D reported they had checked in Medical Records and were unable to locate any skin evaluations identifying Resident #3's left heel Deep Tissue Injury (DTI). The progress notes, provided by the facility did not include a description of the blister located on the Resident #3's left heel. A note, dated 1/8/22 at 4:15 p.m., indicated a Skin sweep performed. Residents Affected - Some The care plan for Resident #3 indicated the resident had an alteration in skin integrity. The interventions did not include a skin assessment would be completed weekly and as needed. The care plan for the resident's pressure injury did not include a weekly skin assessment would be completed. The admission Record for Resident #5 indicated that the resident was admitted on [DATE], with diagnoses not limited to dementia/Alzheimer's and hypertension (HTN). The clinical record indicated that the resident was transferred on 12/26/21 to an acute care facility for evaluation and treatment following an unwitnessed fall and returned to the facility on [DATE]. An observation was conducted, on 1/19/21 at 11:14 a.m., with Staff Member C, the RMDS, and Staff Member G, Regional Nurse for Assisted Living Facility (ALF) of Resident #5's pressure ulcer wound care. The observation revealed an open area to the resident's coccyx and a scabbed area to the left heel. The physician's order sheet, printed on 12/20/21 and signed by the provider on 1/4/22 indicated staff were to perform a skin sweep every week. The admission Evaluation and Interim Care Plan completed on 12/28/21 identified an open area to the coccyx area and scabs and bruising to bilateral upper and lower extremities. A review of the resident's clinical record indicated one skin evaluation was not dated. The Unit Manager (Staff D) (UM) confirmed, on 1/19/21 at 3:09 p.m., Resident #5 had not had a weekly skin assessment completed since returning from the acute care facility on 12/28/21. A review of the Treatment Record was conducted with the UM, and she confirmed nursing staff had documented a skin sweep had been completed on 1/6/22 and 1/13/22. The progress notes for Resident #5 indicated on 1/6/22 staff had documented that the resident had suffered a skin tear to the right hand and a wound care order had been obtained. The notes on 1/6/22 did not indicate a skin sweep had been completed. The progress note, dated 1/13/22, indicated the resident was discussed in a meeting due to a fall and identified the resident had multiple wounds. The progress note did not indicate a skin sweep was completed. A CNA Bath and Shower Documentation Sheet dated 1/10/21 indicated a skin impairment on the resident's coccyx and right shin. The Shower sheet did not include the pressure injury to the resident's left heel and was signed by a licensed nurse. A review of Resident #5's care plan indicated the resident had an alteration in skin integrity related to the skin tear to the right inner shin. The interventions implemented on 1/19/22 instructed staff to complete a skin assessment weekly and as needed. The care plan that identified that the resident had a coccyx pressure injury, and that nursing staff should complete a skin assessment weekly. The policy, Skin Assessment, copyrighted 2021, identified that It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. The Policy Explanation and Compliance Guidelines indicated that A full body or head to toe, skin assess, etc. will be conducted by a licensed or registered nurse upon admission/re-admission, daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 6 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0641 Level of Harm - Minimal harm or potential for actual harm for three days, and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. The procedure included instructions to staff to - Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath medical devices. Residents Affected - Some - Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. The policy identified that the documentation of a skin assessment should include: - date and time of the assessment, your name and position title. - document observations. - document type of wound. - describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). - document if resident refused assessment and why. - document other information as indicated or appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 7 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to provide appropriate nail care for one (#8) of twenty-two sampled residents. Residents Affected - Few Findings included: Review of Resident #8's record revealed admission to the facility on 9/10/21. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, and the resident required extensive physical assistance of one person for personal hygiene. A review of the resident's care plan dated 9/20/21 revealed he required limited to extensive assistance with personal activities of daily living (ADLs). During an observation and interview with Resident #8 on 11/30/21 at 11:31 AM he reported he had no use of his right hand. An observation of the resident's hands revealed he had elongated nails on both of his hands, which were noted to be approximately half an inch above the top of his fingers. The resident stated, the staff are supposed to cut them, and said he does not like his nails long and would like them cut. A subsequent observation of Resident #8 on 12/01/21 at 10:40 AM revealed the resident's nails on his bilateral hands were still elongated. In an interview with the resident at that time, he stated, the nails still need cutting. During an interview on 12/01/21 at 10:51 AM with Staff D, Certified Nursing Assistant (CNA) she said on the resident's shower days part of their task is to clean and trim the resident's nails. The CNA reports she does not usually work on this resident's assigned shower days. In an interview on 12/01/21 at 11:01 AM with Staff A, Licensed Practical Nurse (LPN), she said the CNAs are not allowed to clip the residents' fingernails, but they should be filed if they are jagged or if the residents ask for them to be trimmed. An interview conducted on 12/01/21 at 11:08 AM with the Director of Nursing (DON) revealed the CNAs should be looking at resident's nails on their shower days. The DON said either the nurse or the CNA should be clipping the resident's nails unless the resident is diabetic. She reported it was her expectation that resident nails were trimmed and clean. Review of the facility policy titled Activities of Daily Living (ADL's) dated 9/10/21 revealed that Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; Review of the facility policy titled Nail Care dated 9/10/21 revealed the following: 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 8 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 observations, record reviews, and interviews, the facility failed to ensure a pressure ulcer was assessed, identified, and documented at the time of discovery, and wound care was provided in a sanitary manner for one (#26) of four sampled residents. Residents Affected - Few Findings included: A review of the admission record for Resident #26 revealed admission to the facility on [DATE], and diagnoses not limited to Congestive Heart Failure (CHF), chronic Atrial Fibrillation (A-fib), and hypoxia. The Skin Evaluation dated 10/29/21 indicated redness to the left buttock and on 11/12/21 there was redness to the sacral/coccyx area. A review of the November 2021 Treatment Administration Record (TAR) indicated that a Physician's Order dated 11/24/21, which instructed staff to cleanse wound on buttocks with Normal Saline (N/S), apply Leptospeream honey, cover with Calcium Alginate, and cover with border gauze. The TAR indicated wound care was not completed on 11/30/21. Continued review of Resident #26's clinical record did not identify documentation of a wound assessment on 11/24/21, or that the resident's representative had been notified of the wound. In an interview on 12/1/21 at 1:23 p.m., the Education Consultant/Infection Control Preventionist (ICP) stated documentation related to the wound was maintained in the office. At 1:25 p.m., Staff Member A, Licensed Practical Nurse (LPN) joined the interview. She said the Wound Care physician came to the facility every Monday and the floor nurses do their own wound care. After reviewing the resident's record, the ICP and Staff A, LPN stated they were unable to locate any information regarding identification or assessment of the wound. On 12/2/21, the facility provided a Wound Evaluation Flow Sheet for Resident #26, dated 11/24/21. It indicated during Week #1 an open area was evaluated that measured 2 x 1 x 0 and the wound was pink and dry. The flow sheet indicated the wound was In-House acquired and the current treatment instructed staff to cleanse wound on buttocks with normal saline (NS), apply honey, calcium alginate, and gauze every day. A review of a Wound Physician evaluation and summary, dated 11/29/21, indicated Resident #26 was seen and evaluated. The summary identified a Stage 3 Pressure Wound of the Left buttock with a duration of greater than (>) one day. The wound measured 3 x 2 x 0.2 centimeter (cm) with moderate serous exudate, 20% slough, 30% granulation tissue, and 50% of other viable tissues. The evaluation indicated that this wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. An observation of Resident's #26's wound care was conducted at 2:15 p.m. on 12/1/21. Staff Member A, LPN was observed removing a pair of scissors from the cargo pocket of her pants and used them to cut a piece of gauze tape. The scissors were placed on top of the other wound care supplies on a barrier atop of the over-the-bed table in the resident's room. The staff member cleansed the wound, patted it dry with gauze, ungloved, and used the scissors to cut through the unopened packaging of Calcium Alginate to extract an approximate 1-inch x 1-inch square of the material. Staff A applied Medi-honey to the top of the square of Calcium Alginate, placed it on the wound, and covered the wound with a 6x6 bordered dressing. The staff member did not clean the scissors after removing them from her pants pocket, or before using them to cut through the outside packaging into a sterile piece of Calcium Alginate. Staff A then used the scissors to cut the gauze off the resident's right wrist. After (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 9 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 Level of Harm - Minimal harm or potential for actual harm ungloving and washing her hands, the staff member removed a second pair of scissors from the cargo pocket of her pants. She cleaned the skin tear on the resident's right wrist with normal saline, patted it dry, ungloved and then donned another pair of gloves. She used the second pair of scissors to cut a 1x1 piece of Xeroform through the outside packaging. The staff member placed the Xeroform on the skin tear and wrapped it with rolled gauze. Residents Affected - Few In an interview on 12/1/21 at 2:45 p.m., Staff A stated she had cleaned the scissors when I came in and confirmed she had the scissors in her pocket during the shift until she had used them for Resident #26's wound care. She stated, I probably should not have cut through the packaging of the Calcium Alginate and Xeroform. During an interview with the Director of Nursing (DON) on 12/1/21 at 3:15 p.m., she said she was aware of the missing documentation related to Resident #26's wound. The DON reviewed the record for Resident #26 and confirmed there was no documentation on 11/24/21 identifying that a wound had been discovered and assessed. The DON stated scissors should be cleaned after removing them from a pocket as the pocket was not a clean area. She stated if the scissors were not cleaned then they had been contaminated. On 12/3/21 at 2:21 p.m., in an interview with the Nursing Home Administrator (NHA), she said she did not believe the facility had a policy for pressure ulcers. Review of the policy for Pressure Injury Risk Assessment, implemented 9/10/21, indicated that It is our policy to perform a pressure injury risk assessment as part of our systematic approach to pressure injury prevention. A risk assessment does not always identify who will develop a pressure injury but will determine which residents are more likely to develop a pressure injury. The explanation of the policy indicated that a Pressure injury risk assessments will be conducted by a licensed or registered nurse on admission/re-admission, weekly times four weeks, then quarterly. Assessments may also be conducted after a change of condition or after any newly identified pressure injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 10 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, observation, and policy review the facility failed to ensure appropriate dialysis care and services were documented in the medical record for one resident (#27) of two dialysis residents in the facility. Residents Affected - Few Findings included: Record review for Resident #27 revealed admission to the facility on [DATE] with diagnoses not limited to ESRD (end stage renal disease) and type 2 diabetes mellitus. A review of the Minimum Data Set (MDS) assessment dated [DATE], Section O, Special Treatments, Procedures, and Programs, reflected Resident #27 received dialysis. A review of Physician's Orders revealed an order dated 11/13/21 Cefepime 2 gm [grams]/100 NS (normal saline). Activate, dissolve, and infuse over 30 minutes at a rate of 200 ml [milliliters]/hour once daily three times weekly (Monday, Wednesday, Friday) after hemodialysis session. Further review of the Physician's Orders revealed no order to monitor the dialysis access site. On 12/01/21 at 9:41 AM an interview was conducted with Staff A, LPN (licensed practical nurse). Staff A, LPN said the dialysis center gives Resident #27 his IV (intravenous) antibiotic for his diabetic ulcer during dialysis. An observation of Resident #27 was conducted at that time. Staff A, LPN completed the facility's section of the dialysis communication form, gave Resident #27 his medications, and she checked his lunch bag in preparation for transport to dialysis. Resident #27 was observed in his wheelchair wearing a foam boot on his right foot; he was clean, dressed, and groomed, and a wound vacuum was present in the resident's right foot. A review of Dialysis Communication forms for Resident #27 reflected the following findings: -one dated 11/22/21, with the facility portion filled out. The section for the dialysis center was not completed, including any pre and post dialysis weights, shunt site condition, or any labs or medications completed during dialysis. The section on the bottom of the form for the facility to complete upon the resident's return to the facility, was also not completed and blank. -one form dated 12/1/21 reflected the facility had completed the pre-dialysis information at the top of the form. The dialysis center communication was not completed including the section indicating medications given during dialysis. The section on the bottom of the form for the facility to complete when the resident returned, was also not completed and blank. The form did not indicate any labs or medications given during dialysis. -no additional Dialysis Communication forms were present in the medical record. Review of the November Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation related to assessment or monitoring of the dialysis access site. A review of nurses' notes in the medical record also reflected the dialysis access site was not being assessed or monitored. At 11:25 PM on 12/02/21 an interview was conducted with the Director of Nursing (DON). The DON said she was aware of the missing dialysis communication forms and had started education. The DON confirmed there were only two forms in the resident's record. The DON also confirmed any medications given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 11 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0698 at the dialysis center should be communicated with the facility. Level of Harm - Minimal harm or potential for actual harm In a follow-up interview with the DON on 12/02/21 at 4:52 PM, she stated, there should be an order to monitor the dialysis access site. There should be an order for dialysis. They need to monitor the access site and it needs to be documented. Residents Affected - Few Policy review of the policy, Hemodialysis, dated 9/10/21, reflected the following: Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices, and Ongoing communication and collaboration with the facility regarding dialysis care and services. Compliance guidelines 2. The facility will coordinate and collaborate with the dialysis facility to assure that: C. Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner, and dialysis team; and D. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. 4. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration initiated, held, or discontinued by the nursing home and or dialysis facility b. Physician/treatment orders, laboratory values, and vital signs; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 12 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0698 Level of Harm - Minimal harm or potential for actual harm e. Dialysis treatment provided and resident's response, including declines in functional status, falls and the identification of symptoms that may interfere with treatments; F. Dialysis adverse reactions complications and/or recommendations for follow up observations and monitoring, and or concerns related to the vascular access site. Residents Affected - Few 7. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications. 11. The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency. By auscultating for a bruit and palpating for thrill. If absent the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 13 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, interviews, and policy review, the facility failed to ensure the medication error rate was below 5% for three residents (#4, #11, and #18). Seven errors were identified during thirty-three opportunities, resulting in an error rate of 21.21%. Residents Affected - Some Findings included: Resident #11 was admitted to the facility with a diagnosis of adult failure to the thrive, according to review of the face sheet in the admission record. An observation was conducted on 12/01/21 at 9:50 AM with Staff A, Licensed Practical Nurse (LPN) during medication administration for Resident #11. Staff A, LPN poured medications including Aspirin 81 mg [milligram], Citalopram 20 mg, Folic Acid 1 mg, Gabapentin 100 mg, Memantine 10 mg, and Tolteridine 2 mg into a medication cup; there were six pills in the medication cup. Next, Staff A, LPN performed hand hygiene, and administered the medications to Resident #11. Review of the physician's orders for Resident #11 reflected there were seven scheduled medications, as follows: -aspirin chew 81 mg chew and swallow one tablet by mouth daily, 9:00 AM -carvedilol tab 3.125 mg by mouth twice daily 9:00 AM -citalopram tab 20 mg by mouth once daily 9:00 AM -folic acid tab 1 mg by mouth once daily 9:00 AM -gabapentin cap 100 mg by mouth once daily 9:00 AM -memantine tab Hcl 10 mg by mouth twice daily 9:00 AM -tolteridine tab 2 mg by mouth once daily 9:00 AM Review of the Medication Administration Record (MAR) reflected Staff A, LPN signed (indicating administered) the carvedilol which not administered during the observation, and did not sign (indicating not administered) the aspirin. Review of the face sheet for Resident #4 reflected she was admitted to the facility with a diagnosis of dementia. On 12/02/21 at 9:19 AM an observation was conducted with Staff C, LPN. Staff C, LPN performed hand hygiene, and administered a 50 mg tablet of zinc to Resident #4. Upon review of the physician's orders in the medical record, the following order was discovered: -zinc cap 220 mg one capsule daily by mouth On 12/02/21 at 4:48 PM in an interview with Staff C, LPN she said the only zinc available in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 14 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0759 medication cart was a 50 mg tablet. Staff C, LPN also confirmed the order was for 220 mg. Level of Harm - Minimal harm or potential for actual harm Review of the face sheet in the admission record for Resident #18 reflected a diagnosis of chronic A fib (atrial fibrillation). Residents Affected - Some On 12/02/21 at 9:35 AM an observation was conducted during medication administration for Resident #18 with Staff B, LPN. Staff B, LPN performed hand hygiene and poured medications for Resident #18 that included Eliquis 5 mg, Furosemide 40 mg, Loratadine 10 mg, Magnesium oxide 400 mg, Mucinex 600 mg, Olanzapine 2.5 mg, Potassium Chloride 10 meq [milliequivalents], Sertraline 50 mg, Spironolactone 25 mg, Vitamin C 500 mg, Zinc 50 mg, and Docusate 100 mg; there were twelve pills total in the medication cup. Staff B, LPN said the Diltiazem was not in the mediation cart, and she had to check the resident's pulse before giving digoxin; she did not pour digoxin. Staff B, LPN checked Resident #18's right radial (wrist) pulse for one minute, and said his pulse was 54. Staff B, LPN administered the medications to the resident. At 9:59 AM Staff B, LPN confirmed the Diltiazem was not in the EDK (emergency drug kit) and said she would call the pharmacy and order it. Upon review of the physician's orders in the medical record, the following findings were discovered: -diltiazem ER (extended release) 180 mg by mouth once daily 8:00 AM -metoprolol tartrate tab 50 mg by mouth twice daily 8:00 AM -vitamin B12 5,000 mcg (micrograms) by mouth once daily 8:00 AM -zinc sulfate cap 220 mg by mouth once daily 8:00 AM -mucinex DM tab 30-600 mg ER by mouth twice daily 8:00 AM On 12/02/21 at 10:40 AM an interview was conducted with Staff B, LPN. Staff B, LPN said she the pharmacy will send the Diltiazem on the next run. On 12/02/21 at 2:14 PM an interview was conducted with Staff B, LPN. Staff B said she gave the Metoprolol, stating she had to check the resident's blood pressure to give it. Staff B, LPN said they did not have 5,000 mcg of B12 on hand, and she informed the DON, who said to give what is on hand. Staff B, LPN confirmed the only Mucinex in the medication cart was not the type and dose ordered; she confirmed she had given Mucinex 600 mg. Staff B, LPN also confirmed the only Zinc in the medication cart was 50 mg, which was not what the resident had ordered. In a follow up interview on 12/02/21 at 4:39 PM with Staff B, LPN she said the Diltiazem had not been delivered, and confirmed she had not informed the physician. Upon further review of the MAR for Resident #18 the following findings were revealed: -Metoprolol tartrate was initialed and circled, indicating it was not given. -Diltiazem was initialed and circled indicating it was not given. -Vitamin B12 5,000 mcg was signed indicating it was administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 15 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/02/21 at 4:02 PM a telephone interview was conducted with the Consultant Pharmacist. He said 'over the counter' medications are house stock, and the order should be changed to what they have in stock, or they should get what was ordered. He stated, if it's the wrong dose, it's a medication error. You have to give the right drug and dose. On 12/02/21 at 4:55 PM an interview was conducted with the DON. She stated if a medication is not available, we need to look in the EDK. If it is not in there, then we need to contact pharmacy. If they can't get it soon, depending on the medication, and if an alternative is available, they can ask the doctor if we can give an alternative, so the medication is provided in some form. They also need to notify the family. The heart rate could get out of control with the diltiazem. The blood pressure medications are also heart medications. The same process needs to be followed. A review of the policy, Medication Reconciliation, dated 9/10/21, revealed the following: Policy: This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5%. Policy explanation and compliance guidelines: 1. medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff. 5. Daily processes: B. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. C. Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. E. Verify medications received match the medication orders. 6. Weekly processes: A. Perform medication cross match of medications to verify medications on hand match physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 16 of 17 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 106138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewalk on Harden Health and Rehabilitation, LL 3110 Oakbridge Blvd E Lakeland, FL 33803 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain the kitchen in a safe and sanitary manner related to failing to ensure that the ice machine and the Proof Box was free of dirt and debris. Findings included: During an initial tour of the kitchen on 11/30/21 at 10:30 AM a large free standing Ice Machine was observed. Inspection of the interior of the ice machine revealed there were black and grey specs of debris on the white plastic dispensing rim, as well as a gray substance noted on the backside of the plastic dispensing rim (photographic evidence was obtained). Continued observation of the kitchen during the initial tour revealed the kitchen housed a free standing Proof Box, which was located next to the stove. Closer observation of the Proof Box revealed a half tray seated in the bottom of the unit, which was observed filled to the rim with soiled water. The Proof Box was also noted to have a white substance on the rim, which was easily dislodged. Continued observation of the Proof Box revealed the glass door was dirty and the rubber seal around the bottom of the door was coated with an orange and black substance, which was easily dislodged (photographic evidence was obtained). During the comprehensive inspection of the kitchen on 12/01/21 at 7:45 AM the Certified Dietary Manager (CDM) reported the Proof Box was now clean and it was on the cleaning schedule to be cleaned daily. Inspection of the Proof Box revealed that the Proof Box was now clean. Continued comprehensive inspection of the kitchen at that time revealed the dark gray area of the plastic dispensing rim on the ice machine was still present (photographic evidence was obtained). At that time the CDM confirmed the observation. On 12/01/21 at 9:25 AM an interview was conducted with the Consultant Registered Dietician, who provided the cleaning schedule for the equipment in the kitchen. He reported the facility does not have a policy related to cleaning of the equipment. Review of the cleaning schedule dated from November 18th, 2021, to December 1st, 2021, revealed the ice machine was to be cleaned on Fridays and was last cleaned on 11/26/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 17 of 17