Inspection·May 31, 2024

F 0641 [patient/caregiver education]. Level of Harm - Minimal harm or potential for actual harm Review of Resident #32's physician order dated 9/22/2023 read, Restorative nursing program for PROM [Passive Range of Motion] right upper extremity and right elbow splint as tolerated. Residents Affected - Few Review of the facility policy and procedure titled MDS 3.0 Completion with the last review date of 4/1/2024 read, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an intradisciplinary care plan . Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 If continuation sheet Page 2 of 7 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 05/31/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #57's admission record showed the resident was most recently admitted on [DATE] with diagnosis including epilepsy, unspecified, not intractable, without status epilepticus. Review of Resident #57's physician order dated 3/27/2024 read, Levetiracetam Oral Tablet 500 mg [milligram], Give 1 tablet by mouth every 12 hours related to epilepsy unspecified, not intractable, with status epilepticus. Review of Resident #57's care plan showed no focus and intervention for seizure disorder. During an interview on 5/30/2024 at 2:41 PM, the MDS/Care Plan Coordinator stated, [Resident #57's name] has a diagnosis of epilepsy and is taking anticonvulsants. I do not see that he was care planned for epilepsy. This focus should be included. During an interview on 5/30/2024 at 9:50 AM, the Director of Nursing stated, [Resident #57's name] is diagnosed with seizures and has anticonvulsant medication order. He should have been care planned for seizures. Review of the facility policy and procedure titled Care Plan Meeting last reviewed in April 2024 showed that it read, Policy: The facility will ensure that the residents, families, or representatives understand the comprehensive care planning process which includes the care plan meetings. Procedure . Each team member responsibilities include . c. Follow through on assigned tasks . Format of the care plan conference (meeting) . 3. Review the triggers indicated on the MDS review, 4. Discuss problems, issues, interventions related to triggers and any other concerns raised at the resident's last care plan conference. 6. Discuss new problems or concerns and identify goals and interventions to be used. 7. The facilitator will summarize the problems and identify who is responsible for the implementation of new interventions or modifications made to the care plan. Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan for 1 of 3 residents reviewed for falls, Resident #58, and failed to develop a comprehensive care plan for 1 of 3 residents reviewed for accidents, Resident #57. Findings include: 1. Review of Resident #58's admission record showed the admission date of 3/12/2024 and diagnoses including chronic kidney disease, muscle weakness, lack of coordination, dementia, altered mental status, anxiety disorder, depression, neuromuscular dysfunction of bladder, tremor, syncope and collapse, and repeated falls. During observations on 5/28/2024 at 9:30 AM, 11:15 AM, and 1:50 PM, there were no bilateral floor mats on the floor on either side of Resident #58's bed or in the room while the resident was in bed. During observations on 5/29/2024 at 9:10 AM, 12:50 PM, and 1:20 PM, there were no bilateral floor mats on the floor on either side of Resident #58's bed or in the room while the resident was in bed. During observations on 5/30/2024 at 8:00 AM, there were no bilateral floor mats on the floor on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 If continuation sheet Page 3 of 7 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 05/31/2024 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 0656 either side of Resident #58's bed or in the room while the resident was in bed. Level of Harm - Minimal harm or potential for actual harm Review of Resident #58's care plan dated 1/18/2024 showed that it read, Focus: [Resident #58's name] is at risk for falls r/t [related to] past history of falls, impaired balance, weakness, noncompliance with asking for assistance, not easily redirected, he is spontaneous, poor safety awareness, dementia, and the need for extensive assistance with transfers and ambulation . Interventions . Bilateral floor mats. Residents Affected - Few Review of Resident #58's physician order dated 4/30/2024 showed that it read, Bilateral floor mats when in bed. During an interview on 5/30/2024 at 9:24 AM, Staff B, Certified Nursing Assistant (CNA), stated, He [Resident #58] is a fall risk. I don't know why he doesn't have fall mats on the floor or in his room. During an interview on 5/30/2024 at 9:28 AM, Staff C, Registered Nurse, stated, He [Resident #58] is a fall risk. His bed is in a low position for falls. They may have taken them [the fall/floor mats] out of the room to clean them. During an interview on 5/30/2024 at 9:38 AM, the Director of Nursing stated, I expect the nurse assigned to him [Resident #58] and the Unit Manager to be checking that the floor mats are in place. The CNAs should be checking the Kardex for the task. If the floor mats are not in place the CNAs or nurses should let someone know and let me know they are not following the plan [care plan]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 If continuation sheet Page 4 of 7 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 05/31/2024 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 food was safely stored, labeled, or discarded in the areas of the kitchen walk-in cooler. Residents Affected - Some Findings include: During an observation while conducting a walk-through tour of the kitchen on 5/28/2024 at 9:06 AM with the Dietary Manager (DM), in the walk-in cooler, there were an unlabeled and undated large clear container containing food items, a container of food that had pork written on the label with a use by date of 5/25/2024, and a sheet pan with 72 Styrofoam bowls containing food items with lids with no label or date on the individual bowls or the sheet pan holding the individual bowls. During an interview on 5/28/2024 at 9:28 AM, the DM confirmed that the products had no label or date and identified the large clear container with no label or date as leftover rice and the 72 bowls with no label or date as fruit cocktail. The DM stated that the products should be labeled and dated before storing in the cooler, and the container labeled as pork with a use by date of 5/25/24 should have been discarded on 5/25/24 as labeled. Review of the facility policy and procedure titled Food Safety and Sanitation dated 1/17/2019, read, Procedure . 4. Food Storage . b. Among the food protection measures that are performed by the food services department are . All leftovers are labeled, covered, and dated when stored . Foods with expiration dates are used prior to the date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 If continuation sheet Page 5 of 7 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 05/31/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff used appropriate PPE (Personal Protective Equipment) while providing direct care to the residents who were on enhanced barrier precautions to help prevent the possible development and transmission of communicable diseases and infections. Residents Affected - Few Findings include: During an observation on 5/30/2024 at 10:20 AM, Resident #49's room door was closed and there was an enhanced barrier precaution signage on the door with personal protective equipment outside of the room in a plastic bin. Staff A, Certified Nursing Assistant (CNA), was assisting Resident #59 to get dressed and changing the bed linen. Staff C was wearing gloves, but no gown. The Wound Care Nurse entered the resident's room, wearing gloves and gown, and asked Staff A to hold Resident #49's leg while she provided wound care. The Wound Care Nurse exited the room and Staff A continued to dress Resident #49 and assisted the resident to transfer to his wheelchair without wearing a gown. Review of Resident #49's physician order dated 3/24/2024 read, Enhanced barrier precautions r/t [related to] wound R [right] lateral ankle every shift for wound. During an observation on 5/30/2024 at 10:36 AM, Staff A, CNA, entered Resident #53's room. Resident #53 stated she needed help and needed to be changed. Staff A wore gloves and provided incontinence care to the resident. Staff A did not wear a gown. There was an enhanced barrier precautions signate on the resident's room door. Review of Resident #53's physician order dated 2/19/2024 read, Enhanced barrier precautions r/t wound right leg every shift. During an interview on 5/30/2024 at 12:15 PM, the Director of Nursing (DON) stated, Staff are expected to wear gloves and a gown when providing high contact care for residents with indwelling devices, wounds and certain infections. [Resident #49's name] and [Resident #53's name] both are under enhanced barrier precautions. During an interview on 5/30/2024 at 12:21 PM, Staff A, CNA, stated, If a resident has enhanced barrier precautions, I will wear gloves and a gown when providing direct care. I did not wear a gown when assisting [Resident #49's name] or [Resident #53's name] because I did not know they were under enhanced barrier precautions. Normally they will have signage on the door, and I did not see the signs before entering. Review of the facility policy and procedure titled Isolation Steps: Categories of Transmission Based Precautions with the last review date of 4/1/2024 read, Types of Transmission-Based Precautions . Enhanced Barrier Precautions. Enhanced Barrier Precautions expand the use of PPE [Personal Protective Equipment] beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug-resistant organisms (MDRO) to staff hands and clothing . Examples of infections requiring Enhanced Barrier Precautions, but are not limited to . All residents with any of the following conditions should use enhanced barrier precautions . Open wounds and/or indwelling medical devices . Personal Protective Equipment (PPE): Wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment. Donning PPE upon room entry and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 If continuation sheet Page 6 of 7 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 05/31/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm properly discarding before exiting the patient room is done to contain pathogens. High-contact care activity: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Therapy, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105001 If continuation sheet Page 7 of 7