Inspection·January 26, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to develop and implement a care plan to meet the resident's medical needs for 1 of 5 residents reviewed for unnecessary medications, Resident #28. Residents Affected - Few Findings include: Review of Resident #28's physician orders revealed Resident #28 was prescribed with Haloperidol Lactate Concentrate 1 milliliter by mouth every 6 hours as needed for mood/behaviors, and Prochioperazine Maleate Tablet by mouth every 6 hours as needed for nausea and vomiting, both starting on 1/1/2023. Review of Resident #28's care plan, initiated on 1/2/2023 through 1/17/2023, did not include any plan for the psychoactive medications Haloperidol Lactate Concentrate and Prochioperazine Maleate. Review of Resident #28's physician orders revealed Resident #28 was prescribed with Olanzapine Tablet 5 milligrams by mouth one time a day for bipolar related to unspecified dementia, unspecified severity with agitation, starting on 1/2/2023. Review of Resident #28's care plan, initiated on 1/17/2023, reads, Is receiving an antipsychotic Zyprexa/Olanzapine for and is at risk of undesired side effects such as neuroleptic malignant syndrome, abnormal gait, tachycardia, increased salivation, asthenia, personality disorder, akathisia, tremor, tardive dyskinesia and extrapyramidal events. The care plan did not include the reason or condition for which Resident #28 had been prescribed with the Zyprexa/Olanzapine. During an interview on 1/24/2023 at 12:31 PM, the Minimum Data Set Coordinator confirmed that Resident #28's care plan did not include a plan for the psychoactive medications, and the reason or condition for which Resident #28 had been prescribed the Zyprexa/Olanzapine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 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 105001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Eustis Healthcare and Rehabilitation Center 411 W Woodward Ave Eustis, FL 32726 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview, the facility failed to ensure the attending physician or prescribing practitioner documented their rationale to extend the use of as needed (PRN) psychotropic drugs with projected duration of use for 1 of 5 residents reviewed for unnecessary medications, Resident #28. Findings include: Review of Resident #28's physician orders showed Resident #28 was prescribed with Prochioperazine Maleate Tablet by mouth every 6 hours as needed (PRN) for nausea and vomiting on 1/1/2023. Review of Resident #28's records did not reveal any documentation indicating that the attending physician or prescribing practitioner documented their rationale in the resident's medical record and indicated the duration for the PRN order. During an interview on 1/24/2023 at 12:11 PM, the Director of Nursing confirmed that Resident #28's physician order for use of a psychotropic medication for nausea and vomiting was an as needed order with a start date of 1/1/2023 and agreed the order had exceeded 14 days as a PRN order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 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 105001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Eustis Healthcare and Rehabilitation Center 411 W Woodward Ave Eustis, FL 32726 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 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 ensure foods in the refrigerator, freezer, and storeroom were covered, dated, labeled, and placed to ensure safety and sanitation. Residents Affected - Many Findings include: On 1/23/2023 at 9:12 AM, during a walk-through of the kitchen with the Certified Dietary Manager (CDM), the surveyor observed the following: 1. Multiple food items in the walk-in cooler with no use by dates or identifier labels, just a current date, 2. The dry storage area had stock sitting on the floor, 3. Seventy seven 4 oz. health shakes on a sheet pan that were thawed without a pulled to thaw or use by date, 4. A box of partially thawed ground beef stored on the 2nd shelf next to a bag of fully cooked meatballs, 5. A partially opened gallon container milk, mayonnaise, and BBQ sauce with no opened or use by date, 6. Heads of cabbage and bags of carrots in a plastic grocery bag with no label or date, 7. Forty two glasses of apple and orange juice, all in the walk-in cooler with no date or label, 8. Two racks with three shelves being used for food storage of multiple items in the rear of the walk-in cooler that had broken shelves that were at an angle for food to fall, spill, or topple off, 9. Eight pieces of what appeared to be raw fish in an opened clear bag in the walk-in freezer with no label or date, and 10. Dirty and wet rags on the stainless steel table next to the microwave oven and laying on the rack where the clean pans and lids were stored. During an interview on 1/23/2023 approximately at 9:30 AM, the CDM confirmed that the food items in the freezer and refrigerator should be labeled and dated. The CDM verified that health shakes should have a date when they were pulled from the refrigerator and were only good for 14 days after thawing. The CDM confirmed that there were 77 health shakes that were completely thawed and did not have a pulled or use by date. The CDM stated that raw ground beef should be stored on the bottom shelf and not ever placed next to fully cooked foods. The CDM confirmed that there was a gallon of milk, mayonnaise, and BBQ sauce that had been opened and did not have an opened date on either of the 3 items. The CDM verified that a clear opened bag of what she identified as raw fish in the freezer and should have an identifying label and date. The CDM confirmed that all dirty rags should be placed in a Santi-bucket with a sanitizing solution when not being used. The CDM verified that a dirty rag was found on the stainless-steel table by the microwave oven and a dirty rag was on the open shelving where clean pots, pans, and lids were stored. The CDM stated that all foods should be stored 6 inches off the floor and stock should be put away upon delivery and that there was stock observed on the floor of the storeroom. During the follow-up visit to the kitchen on 1/24/2023 at 7:00 AM, there were 53 dome lids and bases that had multiple deep scratches and discoloration. Approximately twelve bases were noted to be the type that were not insulated and that used heated metal inserts that were not available. During an interview on 1/24/2023 at 10:08 AM, the CDM confirmed that the dome lids and bases had multiple deep scratches and discoloration. The CDM confirmed that some bases were noted to be the type that were not insulated and used heated metal inserts that were not available and were being used during meal service. The CDM verified that two shelves in the walk-in cooler were broken but still being used to store food items. Review of the facility policy and procedure titled Food Safety and Sanitation dated 1/17/2019 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 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 105001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Eustis Healthcare and Rehabilitation Center 411 W Woodward Ave Eustis, FL 32726 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 - Many reads, Procedure . 8. Food Storage . Foods stored in the storeroom are placed on clean racks at least 6 inches above the floor . All leftovers are labeled, covered and dated when stored. Review of the facility policy and procedure titled Food Storage Dating & Labeling dated 1/17/2019 and revised on 12/09/22 reads, Procedure . 4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk food. All containers must be legible and accurately labeled . 14. Refrigerated Food Storage . e. Cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. f. All food should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded . i. All foods will be stored off the floor. Review of the facility policy and procedure titled Receiving and Storage Safety dated 1/17/2019 reads, Policy: Safety precautions should be followed when delivery containers, crates, or boxes are opened, and when food and supply items are stored. Procedure . 4. All supplies will be stored on well-constructed shelves and floor racks. Review of the facility policy and procedure titled Cleaning Instructions: Cloths, Pads, Mops, and Buckets dated 1/17/2019 reads, Procedure . Cleaning cloths should be kept in a container of clean sanitizing solution between uses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 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 105001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Eustis Healthcare and Rehabilitation Center 411 W Woodward Ave Eustis, FL 32726 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure all electrical equipment used for food service was maintained in a safe and working condition. Residents Affected - Some Findings include: During the tour of the kitchen on 1/24/2023 at 7:00 AM, the electric plate warmer was not working and all plates for meal services were at room temperature. During an interview on 1/14/2023 at 10:08 AM, the CDM confirmed that the electric plate warmer was broken and had not been working since 1/21/2023 and no backup heating source was being used. Review of the facility's Work Order #7740 dated 1/21/2023 reads, Plate warmer for the kitchen . Assigned to: nobody. Notes: Warmer was plugged into different areas not coming on . Priority: Medium. Comments: Plate warmer not getting hot. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 If continuation sheet Page 6 of 6