Inspection·August 8, 2023

F 0770 right arm. Both were negative for a deep venous thrombosis. No new orders at this time. Level of Harm - Minimal harm or potential for actual harm On 07/05, at 3:31 p.m. PT/INR critical results received. MD in facility with orders to hold coumadin. Nurse made aware. Residents Affected - Few On 07/10 at 12:08 a.m. Change in Condition Evaluation or Situation / Background / Assessment / Recommendation (SBAR) was performed for nausea and vomiting. Resident was on Coumadin. Result of the last PT/INR was 4.97 on 07/05/23. Recommendations are to send to emergency room (ER) for evaluation and treatment. On 07/10 at 12:11 a.m., the resident began to experience hematemesis (bloody vomiting) at 11 p.m. this evening. Vital signs were temperature 96.8, blood pressure 106/74, pulse 110. Transfer to hospital summary: Resident then experienced two more episodes with considerable amounts of bright red blood noted. MD notified and order received to send resident out for evaluation. Resident sent out at 12:00 a.m. via Emergency Medical Services (EMS) with her belongings. A message was left for the nephew. Record review of Resident #3's physician order summary report showed, PT/INR every Tuesday and Friday, order date 6/26/2023 PT/INR one time only, order date 06/22/2023 Coumadin 5 mg (milligrams) in the evening related to a-fib, order date 06/22/23 Review of the June 2023 Medication Administration Record (MAR) showed, Coumadin 5 mg 1 tablet by mouth in the evening, start date 6/22/2023, D/C (discharge) date 7/11/2023. The Coumadin 5 mg was marked as given to the resident each day 6/22/23 through 6/30/23. Review of the July 2023 MAR showed, Coumadin 5 mg 1 tablet by mouth in the evening, start date 6/22/2023, hold date 7/5/2023 to 7/6/2023, D/C (discharge) date 7/11/2023. The Coumadin 5 mg marked as given to the resident on July 1, 2, 3, 4, 7, 8, and 9. Coumadin 5 mg was marked as held on July 5 and 6. Review of the June 2023 Treatment Administration Record (TAR) showed, PT/INR every Tuesday and Friday for A-Fib, start Date 06/27/23, D/C date 7/11/2023. The labs were not marked as drawn on 06/27/23 and 06/30/23. Review of the July 2023 TAR showed PT/INR every Tuesday and Friday for A-fib, start Date 06/27/23, D/C date 7/11/2023. A blank space showed on the document for Tuesday 7/4/2023. The lab was marked as drawn on 07/07/23 (Friday). Review of Resident # 3's Laboratory Results showed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 2 of 4 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 08/08/2023 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 0770 06/23/23: PT/INR: 10.3(Reference Range is 9.6 to 12.2)/0.96(Reference Range 0.80 to 3.50) Level of Harm - Minimal harm or potential for actual harm 06/27/23: not performed 06/30/23: not performed Residents Affected - Few 07/05/23: PT/INR: 50.0 / 4.97 (same reference range) 07/07/23: not performed Record review of the care plans showed none related to anticoagulants. During an interview on 08/08/23 at 2:13 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated that the DON reviews all discharges to the hospital to review for possible keeping from transfer in the future. The DON was notified that the discharge of Resident #3 was a possible gastrointestinal (GI) bleeding and related possibly to Coumadin therapy. The DON started the investigation on 07/12/23. A venous doppler was ordered on 06/22/23 due to swelling of the lower extremities. She was placed on Coumadin 5 mg daily and a doppler was ordered. The doppler was negative with no Deep Venous Thrombosis. The attending physician was made aware of the negative doppler results. No new orders were given and to continue with the Coumadin. On 07/05/23 and INR was done, and it was critical. Attending physician was notified of the INR results. The attending physician orders were to put the Coumadin on hold and repeat the INR on Friday, 07/07/23. The DON stated that the nurse who worked on that shift, Staff A, Registered Nurse (RN), was interviewed regarding when the ordered PT/INR was to be done. The DON asked Staff A, RN what happened. Staff A stated she was confused and thought the 07/05/23 results were the 07/07/23 results. She clicked the TAR on 07/07/23 as being completed when it was not. The computer did a reset and the on-hold orders were removed for Coumadin 5 mg and it was put back on the MAR to be given. The DON put a Performance Improvement Project (PIP) in place to not place Coumadin on hold but to discontinue it instead. The Coumadin was on-hold for the two days because of the medication being put on-hold, but it then it was restarted. The resident went to the hospital on [DATE] for blood in emesis at 11:00 p.m. The resident's vitals were stable, and she was sent to the hospital for a GI bleed. The resident was on hospice. The DON stated she did not know why the resident was not placed back on Eliquis instead of Coumadin. The DON verified that the two labs (06/27/23 and 06/29/23) prior to the critical one were not performed, and the 07/07/23 lab. They had an Interdisciplinary Team (IDT) meeting to discuss the findings of the review of Resident #3's record. The attending physician was included. They also investigated the other two residents in the facility on Coumadin, Resident #10 and Resident #11. Resident #11 was changed from Coumadin to Eliquis. Resident #10 was kept on Coumadin due to her diagnoses. The DON reviewed Resident #11's chart. The DON stated they performed audit tools to monitor them. They changed the PT/INR to Monday and Thursday instead of Tuesday and Fridays. The results can be reviewed by the DON. The results can be reviewed before the weekend. She stated they retrained all the nurses, 100%, regarding Coumadin therapy and the PT/INR labs. The nurses were educated to not put Coumadin on hold, but to discontinue the medication. After the PT/INR results the nurses are to input a new Coumadin order. The education will be ongoing as part of the hiring process. Resident #11 was discharged on 07/28/23. They do not currently have any residents on Coumadin therapy. The DON was asked what she had put into place to make sure all labs ordered were scheduled on the TAR and lab portal. The DON stated that she had not reviewed all the residents' charts to ensure all the labs ordered had been scheduled in the TAR and lab portal. She had not thought of it. The DON stated that at the morning meetings they review all orders including for labs and review the actual lab results. We have not reviewed that the lab orders were placed in the TAR or lab portal during the morning meeting. At morning meeting, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 3 of 4 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 08/08/2023 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few we can see the order for the lab that was ordered but cannot see that it was scheduled to be done. Asked if there was a possibility that if the PT/INR was performed on 06/27 and / or 06/29 it may have shown an increase in the INR? She did not answer. During the DON and ADON interview the Nursing Home Administrator (NHA) and the Medical Director, who was Resident #3's attending physician, entered on 08/08/23 at 4:18 p.m. The physician stated he was involved in the PIP regarding the Coumadin incident. He stated that the 24-hour report should show any new orders. They review the lab results during the morning meeting. He stated he understood that the nurse clicked off that the lab was done, and the Coumadin restarted. He stated that the facility should have a tickler system to ensure labs were scheduled in the chart. If the lab was ordered on the 1st should have a tickler that it was scheduled say for the 5th. He stated that the facility spoke with him about Resident #3's elevated PT/INR and he told them to hold her Coumadin. The expectation was for the follow-up INR to be done. He stated he received the labs on 07/05/23 on his text / phone and told them to hold the Coumadin and recheck on Friday (07/07/23). The NHA stated that they had only focused on the Coumadin labs because that was the concern. Record review of the facility's policy, Laboratory Services and Reporting, revised 01/2023 showed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. 7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106138 If continuation sheet Page 4 of 4