Health inspection·May 25, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy and procedures titled Lab and Diagnostic Test Results - Clinical Protocol with an approval date of 1/19/2022 reads, Identifying Situations that Warrant Immediate Notification. 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: . Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors) . Options for Physician Notification. 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how and to whom the information was provided and the response. This can be done in the Progress Notes section of the medical record. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the facility policy and procedures titled Change in a Residents Condition or Status with an approval date of 1/19/2022 reads, Policy Statement. Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy interpretation and Implementation. 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . g. need to transfer the resident to a hospital/treatment center . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . b. There is a significant change in the resident's physical, mental, or psychosocial status; . e. It is necessary to transfer the resident to a hospital/treatment center. Based on observation, interview, and record review, the facility failed to notify the resident's physician and the resident representative of a significant change in condition for 3 of 4 sampled residents, Residents #13, #51, and #86, in a total sample of 34 residents. Findings include: 1. Review of the medical records for Resident #51 documented the resident was admitted to the facility on [DATE] with the diagnoses to include unspecified dementia, unspecified atrial fibrillation (an irregular heartbeat), chronic embolism and thrombosis of unspecified deep veins of left lower extremity (a blood clot in the legs), protein calorie malnutrition, major depressive disorder, and anxiety disorder. Review of Resident #51's laboratory results for a urine culture and sensitivity dated 5/13/2022, reported on 5/17/2022, reads, Final Report. Critical Result called to [Staff A's name] on 5/17/2022 12:20 PM by [Laboratory Personnel's Name]. Results were read back to caller. Site: Clean Catch. Result > 100,000 CFU/ML [Colony Forming Units/Milliliter] Gram Negative Rods Escherichia Coli. This isolate is Extended Spectrum Betalactamase (ESBL) producing organism (isolate 1). Klebsiella Pneumoniae (isolate 2). This isolate is Extended Spectrum Betalactamase (ESBL) producing organism. Review of the physician orders for Resident #51 dated 5/18/2022 reads, Insert/maintain midline with 1% lidocaine. Review of the physician orders for Resident #51 dated 5/20/2022 reads, Ertapenem Sodium Solution Reconstituted 1 gm [gram]. Use 1 gram intravenously one time a day for Klebsiella pneumoniae ssp (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 2 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0580 pneumoniae and E Coli related to Urinary Tract Infection, site not specified for 14 days. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes for Resident #51 revealed no note notifying the resident's representative or physician of the critical laboratory results. Residents Affected - Some During an interview on 5/23/2022 at 2:05 PM, Staff A, Licensed Practical Nurse (LPN), stated, I did receive the critical lab results call about [Resident #51's name]. I did not call her physician or her family. I guess I should have. 2. Review of the medical records for Resident #86 documented the resident was admitted to the facility on [DATE] with the diagnoses to include quadriplegia, hypothyroidism, traumatic brain injury, dysphagia (difficulty swallowing food and liquids), constipation, right hand contracture, left hand contracture, sacral pressure ulcer unstageable, ESBL resistance, UTI (Urinary Tract Infection), aphasia (a language disorder that affects a person's ability to speak). Review of the progress notes dated 5/17/2022 at 12:22 AM for Resident #86 reads, Laboratory Note. Note text: Resident has an abnormal urinalysis, temperature of 101.7 @ [at] 2345 [11:45 PM], DR [doctor] being notified and sending the order in. Review of Resident #86's laboratory results report dated 5/17/2022 reads, Final Report . Critical Result called to [Staff D, LPN's name] on 5/17/2022 at 12:27 PM by [Laboratory Staff's Name] Results were read back to caller. Result > 100,000 CFU/ML gram negative rods. Escherichia Coli. This isolate is extended spectrum betalactamase (ESBL) producing microorganism. Review of the nursing progress notes for Resident #86 revealed no notification of the resident's physician or family of the critical lab results. Review of the progress notes dated 5/18/2022 at 10:01 PM for Resident #86's reads, Laboratory Note. Note Text: U/A [Urinalysis] reviewed. Results => 100,000 CFU/ML Gram negative Rods Escherichia Coli. This isolate is extended spectrum betalactamase (ESBL) producing microorganism. ESBL production may predict therapeutic failure in some patients treated with drugs such as Penicillins, Ceftazidime, Cefotaxime, Ceftriaxone and Aztreonam ESBL producing strains may be resistant to other agents including aminoglycosides. Result. Escherichia Coli (Isolate 1). Resident started on Nitrofurantoin [an antibiotic]. Review of the physician orders dated 5/20/2022 for Resident #86 reads, Macrobid Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule via G-tube [Gastrostomy Tube] four times a day related to Urinary Tract Infection, site not specified. Review of the progress notes for Resident #86 revealed no family notification of the resident starting an antibiotic. During an interview on 5/24/2022 at 11:20 AM, the Director of Nursing (DON) stated, There is no progress note that states that family was notified of the urine culture results or the start of an antibiotic. I did not document that family was notified when I wrote the progress note. It is our policy to call family and physicians. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 3 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 - Some 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** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident for 2 of 3 sampled residents, Residents #23 and #27, in a total sample of 34 residents. Findings include: 1. During an observation on 5/22/2022 at 11:45 AM, Resident #23 was being administered oxygen at 3 liters per minute via nasal cannula. During an observation on 5/23/2022 at 8:28 AM, Resident #23 was being administered oxygen at 3 liters per minute via nasal cannula. Review of admission records for Resident #23 documented the resident was admitted on [DATE] with the diagnoses to include chronic obstructive pulmonary disease. Review of the physician orders dated 9/23/2021 for Resident #23 reads, Oxygen @ [at] 2 LPM [liters per minute] via NC [nasal cannula] continuous every shift. Review of Section O- Special Treatments, Procedures, and Programs of Resident #23's Minimum Data Set (MDS) dated [DATE], revealed that the resident received supplemental oxygen at the time of assessment. Review of Resident #23's care plan dated 3/12/2022 documented a focus area of potential for complications of respiratory distress, and an intervention to administer oxygen as ordered. During an interview on 5/23/2022 at 8:30 AM, Staff E, Registered Nurse (RN), confirmed Resident #23 had an order to be administered oxygen at 2 liters per minute via nasal cannula, and Resident #23 was currently being administered oxygen at 3 liters per minute via nasal cannula. 2. During an observation on 5/22/2022 at 10:00 AM, Resident #27 was being administered oxygen at 2.5 liters per minute via nasal cannula. During an interview on 5/22/2022 at 10:00 AM, Resident #27 stated he had chronic obstructive pulmonary disease (COPD) and a heart condition, which required him to be on oxygen at all times. Review of the physician order dated 3/28/2022 for Resident #27 reads, Oxygen at 3.5 liters/minute. Review of Resident #27's care plan dated 12/22/2021 documented a focus area of potential for complications of respiratory distress r/t (related to) dx (diagnosis) of COPD (Chronic Obstructive Pulmonary Disease), emphysema, and an intervention to administer oxygen as ordered. During an observation on 5/23/2022 at 8:30 AM, Resident #27 was being administered oxygen at 2.5 liters per minute via nasal cannula. During an interview on 5/23/2022 at 8:45 AM, Staff F, Licensed Practical Nurse (LPN), confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 4 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 - Some Resident #27's oxygen order was for 3.5 liters per minute via nasal cannula, and the current oxygen was running at 2.5 liters per minute. During an interview on 5/23/2022 at 9:00 AM, the Director of Nursing stated it was her expectation that if a physician wrote an order for a resident to receive oxygen at a certain rate, the nursing staff would administer the oxygen at the prescribed rate. Review of the facility policy and procedures titled, Oxygen Administration with revised date of January 2022, reads, Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Review of the facility policy and procedures titled Care Plans, Comprehensive Person-Centered with a revision date of January 2022, reads, Policy Statement. A comprehensive, person-centered care plan that includes measurable objectives and timetables to measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 5 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for peripherally inserted central catheters for 4 of 7 residents with central venous catheters, Residents #22, #51, #70, and #287, in a total sample of 34 residents. Residents Affected - Some Findings include: 1. During an observation of Resident #51 on 5/22/2022 at 9:25 AM, there was a left upper arm midline catheter covered with a transparent dressing with a piece of gauze over the insertion site. The dressing was lifting up and pulling away from skin on the side of the dressing closest to the resident. The dressing was dated 5/19/2022. During an observation Resident #51 on 5/23/2022 at 8:23 AM, there was a left upper arm midline catheter with a dressing date of 5/19/2022. The transparent dressing had a piece of gauze under the dressing. The dressing was lifting up at the edges and pulling away from the skin with the insertion site exposed. Review of the medical records for Resident #51 documented the resident was admitted to the facility on [DATE] with the diagnoses to include unspecified dementia, unspecified atrial fibrillation (an irregular heartbeat), chronic embolism and thrombosis of unspecified deep veins of left lower extremity (a blood clot in the legs), protein calorie malnutrition, major depressive disorder, and anxiety disorder. Review of Resident #51's laboratory results for a urine culture and sensitivity dated 5/13/2022, reported on 5/17/2022, reads, Site: Clean Catch. Result > 100,000 CFU/ML [Colony Forming Units/Milliliter] Gram Negative Rods Escherichia Coli. This isolate is Extended Spectrum Betalactamase (ESBL) producing organism (isolate 1). Klebsiella Pneumoniae (isolate 2). This isolate is Extended Spectrum Betalactamase (ESBL) producing organism. Review of the physician orders for Resident #51 dated 5/18/2022 reads, Insert/maintain midline with 1% lidocaine. Review of the physician orders for Resident #51 dated 5/20/2022 reads, Ertapenem Sodium Solution Reconstituted 1 gm [gram]. Use 1 gram intravenously one time a day for Klebsiella pneumoniae ssp pneumoniae and E Coli related to Urinary Tract Infection, site not specified for 14 days. Review of the physician orders for Resident #51 revealed no additional orders for midline care and dressing changes. Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #51 documented no dressing changes ordered or completed. During an interview on 5/23/2022 at 8:23 AM, Staff A, Licensed Practical Nurse (LPN), stated, I am not IV [Intravenous] certified, so I cannot change her dressing, but it is pulling up and away and needs to be changed. I will get someone to change it. I see there are no orders in her chart for any dressings. We should put those in as soon as we have an order for a PICC [Peripherally Inserted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 6 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0684 Central Catheter) or a midline. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/23/2022 at 1:26 PM regarding Resident #51's catheter care, the Director of Nursing (DON) stated, When we get a PICC or midline, we should put in orders for dressing changes right away. Any dressing with gauze under it should be changed every 48 hours. I think that this is her initial dressing and should have been changed in twenty-four hours. Residents Affected - Some 2. During an observation of Resident #287 on 5/22/2022 at 1:30 PM, there was a right upper arm double lumen PICC line covered with a transparent dressing with the date of 5/9/2022 on the transparent dressing. During an interview on 5/22/2022 at 1:30 PM, Resident #287 stated, Oh, that hasn't been changed since I was in the hospital. During an observation of Resident #287 on 5/23/2022 at 12:45 PM, the right upper arm double lumen PICC line was covered with a transparent dressing dated 5/9/2022. Review of the medical records for Resident #287 documented the resident was admitted to the facility on [DATE] with the diagnoses to include arthritis due to bacteria, right knee, osteoarthritis right knee, Methicillin Resistant Staphylococcus Aureus (MRSA) infection, malignant neoplasm (cancer) of prostate, unspecified atrial fibrillation, chronic kidney disease unspecified, malignant neoplasm of tonsil, and essential (primary) hypertension. Review of the physician orders dated 5/15/2022 for Resident #287 reads, Change transparent catheter site dressing as needed for soiling or loosening of dressing. Change transparent catheter site dressing every night shift every 7 day(s) . Maintain double lumen PICC to RUE [Right Upper Extremity] every shift for IV [intravenous] ABX [antibiotics] . Measure external catheter length on admission, with each dressing change and PRN [as needed]. Observe site for signs/symptoms of infiltration, extravasation/infection with each dressing change . Measure arm circumference every night shift every 7 day(s) with dressing change. Measure external catheter length every night shift every 7 day(s) with dressing change . Daptomycin solution reconstituted 500 MG [milligram], Use 750 mg intravenously one time a day for right knee related to Methicillin Resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere for 29 days. During an observation of Resident #287 with the DON on 5/23/2022 at 12:47 PM, the DON confirmed that the PICC line dressing date was 5/9/2022. During an interview on 5/23/2022 at 12:47 PM, the DON stated, He [Resident #287] was admitted on [DATE] and it is policy to change the dressing on admission and every 7 days. I can't tell you why it isn't being done. We cannot evaluate the site if the dressing is not changed. We cannot measure the catheter length or the arm circumference without following the physician orders for PICC line care. 3. During an observation of Resident #70 on 5/23/2022 at 9:10 AM, there was a right upper arm midline catheter with a 2 x 2 gauze under a transparent dressing dated 5/19/2022. Review of the medical records for Resident #70 documented the resident was admitted to the facility on [DATE] with the diagnoses to include chronic obstructive pulmonary disease, type 2 diabetes mellitus with complications, morbid obesity due to excessive calories, peripheral vascular disease, non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, unspecified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 7 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some atrial fibrillation, unspecified combined systolic and diastolic heart failure, chronic kidney disease, major depressive disorder, recurrent, moderate and urinary tract infection, site not specified. Review of the physician order dated 5/19/2022 for Resident #70 reads, May insert midline for IV antibiotic therapy . Meropenem Solution reconstituted 1 GM, use 1 gram intravenously every 12 hours for bacterial infection, UTI related to cellulitis of unsuspected part of limb. Review of the medical records for Resident #70 revealed no additional orders related to the midline catheter for dressing changes or flushes. Review of the MAR for Resident #70 documented no dressing changes or flush orders. During an observation of Resident #70 on 5/23/2022 at 1:20 PM, there was a right upper arm midline catheter transparent dressing with a 2 x 2 gauze under the dressing dated 5/19/2022. During an interview on 5/23/2022 at 1:20 PM, Resident #70 stated, That dressing hasn't been changed since they put it in. During an interview on 5/23/2022 at 1:55 PM, the DON confirmed that the midline catheter transparent dressing was dated 5/19/2022 and had gauze under the transparent dressing. During an interview on 5/23/22 at 1:55 PM, the DON stated, [Resident #70's name] did not have orders placed for midline care or dressing changes until yesterday. The staff should have placed the orders when the midline was placed on the 19th. I cannot tell you why they didn't. We change the dressing after the first 24 hours and wouldn't put any gauze under the dressing. We should use a biopatch. I can't tell you why it isn't being done. 4. During an observation of Resident #22 on 5/22/2022 at 10:08 AM, there was a left upper arm midline catheter with one port and clear transparent dressing with a gauze under the dressing. There was no date on the dressing. All four edges of the dressing were curling up. During an observation of Resident #22 on 5/23/2022 at 11:18 AM, there was a left upper arm midline catheter with a clear transparent dressing with a piece of gauze under the dressing. There was no date on the dressing. All four edges of the dressing were curling up. Review of the medical records for Resident #22 documented the resident was admitted to the facility on [DATE] with the diagnoses to include type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, other idiopathic peripheral autonomic neuropathy, morbid obesity, hypothyroidism, GERD (Gastroesophageal Reflux Disease), major depressive disorder, ESBL resistance. Review of the physician order dated 5/5/2022 for Resident #22 reads, May insert midline IV using 1% lidocaine one time only for IV ABX for 1 day. Review of the physician order dated 5/6/2022 for Resident #22 reads, Ertapenem Sodium solution reconstituted 1 GM, use 1 gram intravenously one time a day related to Extended spectrum beta lactamase (ESBL) resistance for 10 days. Review of the physician orders for Resident #22 revealed no additional orders for midline care or dressing changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 8 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the MAR for Resident #22 revealed the midline was inserted on 5/6/2022 at 1:43 AM. There were no dressing changes documented on the MAR. Review of the TAR for Resident #22 revealed no dressing changes documented. During an interview on 5/23/2022 at 11:25 AM, Staff E, Registered Nurse (RN), stated, Oh, she [Resident #22] doesn't have a line. That is no longer in. During an interview on 5/23/2022 at 1:20 PM, the DON stated, I don't know why her [Resident #22] midline is still in. It is not being used. The dressing is not dated, and the dressing is compromised. There are no orders for central line care, and I don't see any dressing changes have been completed. It is a standard for dressings to be changed when they are compromised and every 7 days and PRN. During an interview on 5/25/2022 at 7:25 AM, the DON stated, It is a standard that we get orders to change PICC and midline catheter dressings when a resident is admitted , or we get one placed when they need one. All IV certified nurses and RNs know this. They should have gotten the orders and then changed them according to our policies. Review of the facility policy and procedures titled Central Venous Catheter with an effective date of 2/2009, and approval date of 1/19/2022, reads, Purpose: To provide a general procedure regarding central venous catheters. Procedure: I. Site care. 1. Obtain physicians order for dressing change. Refer to Appendix B IV line maintenance . 18. Label dressing with nurse date and your initials . Appendix B. IV Line Access Chart. Effective Date: February 7, 2020. Midline. Site Maintenance. Transparent Dressing Changes. On admission or 24 post insertion, then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change and PRN. PICC. Site Maintenance. Transparent Dressing Changes. On admission or 24 post insertion, then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change and PRN . Dressing change: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed q [every] 2 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 9 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were maintained accurately documented for 3 residents reviewed for medication administration, Residents #137, #138 and #139, in a total sample of 34 residents. Findings include: 1. Review of the medical records for Resident #137 documented the resident was admitted to the facility on [DATE] with the diagnoses to include sepsis unspecified organism, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, anxiety disorder, unspecified, hypothyroidism, anemia, unspecified dementia without behavioral disturbances, major depressive disorder, and essential (primary) hypertension. Review of the physician order dated 5/12/2022 for Resident #137 reads, Ampicillin Sodium Solution reconstituted 2 GM [gram], Use 1 application intravenously six times a day for sepsis until 06/06/2022. Review of the physician order dated 5/14/2022 for Resident #137 reads, Saline Flush Solution (Sodium Chloride Flush) use 10 ml [milliliters] intravenously every shift for SASH [Saline Administration Saline Heparin] flush non-valved central line catheter with 10 ml normal saline before medication, then 5 ml heparin 10 units/ml, observe site for signs and symptoms of infection, infiltration, extravasation. Review of the MAR for Resident #137 documented Staff A, Licensed Practical Nurse (LPN), administered Saline flush solution (Sodium Chloride Flush) use 10 ml intravenously every shift for SASH flush non valved central line catheter with 10 ml normal saline before medication, then 5 ml heparin 10 units/ml, observe site for signs and symptoms of infection, infiltration, extravasation on 5/16/2022 day shift, on 5/18/22 day shift, on 5/21/22 day shift and evening shift, on 5/22/22 day shift, on 5/23/22 day shift, and on 5/25/22 day shift. Review of the MAR for Resident #137 documented Staff A, LPN, administered Ampicillin Sodium Solution reconstituted 2 GM use 1 application intravenously six times a day for sepsis until 6/6/2022 on 5/15/22 at 8:00 AM, on 5/16/2022 at 8:00 AM and 12:00 PM, on 5/17/2022 at 8:00 AM and 12:00 PM, on 5/18/2022 at 12:00 PM, on 5/20/2022 at 8:00 AM and 12:00 PM, on 5/21/2022 at 8:00 AM, 12:00 PM and 4:00 PM, on 5/22/2022 at 8:00 AM and 12:00 PM, on 5/23/2022 at 8:00 AM, and on 5/25/1022 at 8:00 AM. During an interview on 5/25/2022 at 12:30 PM, Staff A, LPN, stated, I am not IV [intravenous] certified and I did not administer the IV medications. I did sign for them. I didn't know that I wasn't supposed to sign for them. I asked other nurses to administer these. I had [Staff B, Registered Nurse (RN)'s name] do this. It is wrong. I did not administer these medications I can't. It's wrong to have signed for them. During an interview on 5/25/2022 at 12:50 PM, Staff B, Registered Nurse (RN), stated, I did administer [Resident #137's name] Ampicillin both doses today and [Resident #138's name] Vancomycin. I guess I can't tell you how I preserved the patients' rights to medication administration. I see now that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 10 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it is wrong. I should have verified the doses of the medication to the orders on the computer and signed that I administered them. I suppose it would be inaccurate documentation if I administer it and someone else signs for it. I shouldn't have done that. During an interview on 5/25/2022 at 1:15 PM, the Director of Nursing (DON) stated, It is not correct documentation, and it is against our medication administration policies, and it shouldn't have been done. 2. Review of the medical records for Resident #138 documented the resident was admitted to the facility on [DATE] with the diagnoses to include unspecified psychosis, osteomyelitis, major depressive disorder. Review of the physician order dated 5/13/2022 for Resident #138 reads, Vancomycin HCL [Hydrochloride] solution use 1000 mg intravenously two times a day related to osteomyelitis unspecified (M86.9) until 06/14/2022. Review of the physician order dated 5/14/2022 for Resident #138 reads, Saline Flush Solution (Sodium Chloride Flush) use 10 ml intravenously every shift for SASH, Flush non-valved central line catheter with 10 ml normal saline before medication, 10 ml normal saline after medication, then 5 ml Heparin 10 units/ml, observe site for signs and symptoms of infection, infiltration, extravasation. Review of the MAR for Resident #138 documented Staff A, LPN, administered Vancomycin HCL solution use 1000 mg intravenously two times a day related to osteomyelitis unspecified until 6/14/2022 on 5/13/2022, 5/16/2022, 5/18/2022, 5/20/2022, 5/21/2022, 5/22/2022 and 5/23/2022, all at 12:00 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered Saline flush solution [Sodium Chloride Flush] use 10 ml intravenously every shift for SASH flush non valved central line catheter with 10 ml normal saline before medication, 10 ml normal saline after medication, then 5 ml heparin 10 units/ml, observe site for signs and symptoms of infection, infiltration, extravasation on 5/16/2022, 5/17/2022, 5/18/2022, 5/20/2022, 5/21/2022, 5/22/2022, and 5/23/2022 for day shift, and on 5/21/2022 on evening shift. During an interview on 5/25/2022 at 12:45 PM, Staff A, LPN, stated, Those are my initials, but I did not administer these. I got another nurse to do them. I just signed the MAR. During an interview on 5/25/2022 at approximately 1:00 PM, Resident #138 stated, The nurse on the cart today did not hang my medication. The dark haired one did. She has not hung any medications or flushed my PICC. I guess she can't do it. 3. Review of the medical records for Resident #139 documented the resident was admitted to the facility on [DATE] with the diagnoses to include osteomyelitis (an infection of the bone), peripheral vascular disease unspecified, and diabetes mellitus due to underlying condition with diabetic neuropathy. Review of the physician order dated 5/13/2022 for Resident #139 reads, RUE single lumen PICC line. Review of discontinued physician order for Resident #139 reads, Heparin Lock Flush solution 10 Unit/ml. Use 10 ml intravenously every shift for IV ABT, observe site for signs and symptoms of infection, infiltration/extravasation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 11 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MAR for Resident #139 documented Staff A, LPN, administered Heparin Lock Flush solution 10 Unit/ml Use 10 ml intravenously every shift for IV ABT observe site for signs and symptoms of infection, infiltration/extravasation on 5/2/2022, 5/3/2022, and 5/4/2022 for day shift, During an interview on 5/25/2022 at 12:45 PM, Staff A, LPN, stated, I did not administer the heparin flushes on [Resident #139's name]. I had another IV certified nurse do those. During an interview on 5/25/2022 at 1:30 PM, the DON stated, Nurses should never document medications that they did not administer. It is not following facility policy and procedures for administering medications. She should not be documenting medications if she [Staff A] didn't administer them and the nurses who do administer them need to complete the documentation. Review of the facility policy and procedures titled Administering Medications with an approval date of 1/19/2022 reads, Policy Statement. Medications are administered in a safe a timely manner, and as prescribed. Policy Interpretation and Implementation. 1. Only persons licensed and permitted by this state to prepare administer and document the administration of medications may do so . 24. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: . g. The signature and title of the person administering the drug. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 12 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure peripherally inserted central catheter (PICC) dressings were changed in accordance with professional standards of practice for 6 of 7 residents with central venous catheters, Residents #22, #51, #70, #137, #138 and #287, and hand hygiene was performed during medication administration in 6 of 7 observations of medication administration. Residents Affected - Many Findings include: 1. During an observation of Resident #138 on 5/22/2022 at 12:22 PM, there was a double lumen PICC line in the right upper arm dated 5/22/2022, with gauze under the transparent dressing. During an observation of Resident #138 on 5/23/2022 at 9:10 AM, the right upper arm PICC line dressing had 4 unsecured edges to the dressing and was lifting off of the skin. During an interview on 5/23/2022 at 9:10 AM, Resident #138 stated, I told them about this last night. During an interview on 5/23/2022 at 9:15 AM, Staff A, Licensed Practical Nurse (LPN), stated, I will get another nurse to change his dressing. I can't. I am not IV [Intravenous} certified to do that. Review of the medical records for Resident #138 documented the resident was admitted to the facility on [DATE] with the diagnoses to include unspecified psychosis, osteomyelitis, major depressive disorder. Review of the physician order dated 5/13/2022 for Resident #138 reads, Vancomycin HCL [Hydrochloride] solution use 1000 mg intravenously two times a day related to osteomyelitis unspecified (M86.9) until 06/14/2022. Review of the physician order dated 5/14/2022 for Resident #138 reads, Change transparent catheter site dressing as needed for soiling or loosening of dressing. Change transparent catheter site dressing every night shift every 7 day(s), Measure external catheter length on admission, with each dressing change and PRN [as needed]. Observe site for signs/symptoms of infiltration/extravasation/infection with each dressing change. During an interview on 5/23/2022 at 1:42 PM, Resident #138 stated, I have been trying to get this PICC line dressing changed all day now. It needs to be changed. During an interview on 5/23/2022 at 1:57 PM, the Director of Nursing (DON) stated, We need to get that dressing changed. It has been compromised. 2. During an observation of Resident #137 on 5/22/2022 at 1:38 PM, there was a single lumen PICC line in the left upper arm with gauze under the dressing and a date of 5/21/2022. The edges were curling up on the left side of the dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 13 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 5/22/2022 at 1:50 PM, Staff A, LPN stated, The dressing needs to be changed. I will get a nurse to do it. Review of the medical records for Resident #137 documented the resident was admitted to the facility on [DATE] with the diagnoses to include sepsis unspecified organism, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, anxiety disorder, unspecified, hypothyroidism, anemia, unspecified dementia without behavioral disturbances, major depressive disorder, and essential (primary) hypertension. Review of the physician order dated 5/14/2022 for Resident #137 reads, Change transparent catheter site dressing as needed for soiling or loosening of dressing. Change transparent catheter site dressing very night shift every 7 day(s). Measure external catheter length on admission, with each dressing change and PRN [as needed]. Observe site for signs/symptoms of infiltration/extravasation/infection with each dressing change. During an observation of Resident #137 on 5/23/2022 at 9:10 AM, there was a single lumen PICC line with gauze under the transparent dressing, dated 5/21/2022. The edges of the dressing were pulling away from the skin and curling up at the edges. During an interview on 5/23/2022 at 4:22 PM, the DON acknowledged that the dressing had gauze under the transparent dressing and the dressing was compromised. 3. During an observation of Resident #51 on 5/22/2022 at 9:25 AM, there was a left upper arm midline catheter covered with a transparent dressing with a piece of gauze over the insertion site. The dressing was lifting up and pulling away from skin on the side of the dressing closest to the resident. The dressing was dated 5/19/2022. During an observation Resident #51 on 5/23/2022 at 8:23 AM, there was a left upper arm midline catheter with a dressing date of 5/19/2022. The transparent dressing had a piece of gauze under the dressing. The dressing was lifting up at the edges and pulling away from the skin with the insertion site exposed. Review of the medical records for Resident #51 documented the resident was admitted to the facility on [DATE] with the diagnoses to include unspecified dementia, unspecified atrial fibrillation (an irregular heartbeat), chronic embolism and thrombosis of unspecified deep veins of left lower extremity (a blood clot in the legs), protein calorie malnutrition, major depressive disorder, and anxiety disorder. Review of the physician orders for Resident #51 dated 5/18/2022 reads, Insert/maintain midline with 1% lidocaine. Review of the physician orders for Resident #51 dated 5/20/2022 reads, Ertapenem Sodium Solution Reconstituted 1 gm [gram]. Use 1 gram intravenously one time a day for Klebsiella pneumoniae ssp pneumoniae and E Coli related to Urinary Tract Infection, site not specified for 14 days. Review of physician orders indicated there were no additional orders for Midline care and dressing changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 14 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #51 documented no dressing changes ordered or completed. During an interview on 5/23/2022 at 8:23 AM, Staff A, Licensed Practical Nurse (LPN), stated, I am not IV [Intravenous] certified, so I cannot change her dressing, but it is pulling up and away and needs to be changed. I will get someone to change it. I see there are no orders in her chart for any dressings. We should put those in as soon as we have an order for a PICC [Peripherally Inserted Central Catheter) or a midline. During an interview on 5/23/2022 at 1:26 PM regarding Resident #51's catheter care, the Director of Nursing (DON) stated, When we get a PICC or midline, we should put in orders for dressing changes right away. Any dressing with gauze under it should be changed every 48 hours. I think that this is her initial dressing and should have been changed in twenty-four hours. 4. During an observation of Resident #287 on 5/22/2022 at 1:30 PM, there was a right upper arm double lumen PICC line covered with a transparent dressing with the date of 5/9/2022 on the transparent dressing. During an interview on 5/22/2022 at 1:30 PM, Resident #287 stated, Oh, that hasn't been changed since I was in the hospital. During an observation of Resident #287 on 5/23/2022 at 12:45 PM, the right upper arm double lumen PICC line was covered with a transparent dressing dated 5/9/2022. Review of the medical records for Resident #287 documented the resident was admitted to the facility on [DATE] with the diagnoses to include arthritis due to bacteria, right knee, osteoarthritis right knee, Methicillin Resistant Staphylococcus Aureus (MRSA) infection, malignant neoplasm (cancer) of prostate, unspecified atrial fibrillation, chronic kidney disease unspecified, malignant neoplasm of tonsil, and essential (primary) hypertension. Review of the physician orders dated 5/15/2022 for Resident #287 reads, Change transparent catheter site dressing as needed for soiling or loosening of dressing. Change transparent catheter site dressing every night shift every 7 day(s) . Maintain double lumen PICC to RUE [Right Upper Extremity] every shift for IV [intravenous] ABX [antibiotics] . Measure external catheter length on admission, with each dressing change and PRN [as needed]. Observe site for signs/symptoms of infiltration, extravasation/infection with each dressing change . Measure arm circumference every night shift every 7 day(s) with dressing change. Measure external catheter length every night shift every 7 day(s) with dressing change . Daptomycin solution reconstituted 500 MG [milligram], Use 750 mg intravenously one time a day for right knee related to Methicillin Resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere for 29 days. During an observation of Resident #287 with the DON on 5/23/2022 at 12:47 PM, the DON confirmed that the PICC line dressing date was 5/9/2022. During an interview on 5/23/2022 at 12:47 PM, the DON stated, He [Resident #287] was admitted on [DATE] and it is policy to change the dressing on admission and every 7 days. I can't tell you why it isn't being done. We cannot evaluate the site if the dressing is not changed. We cannot measure the catheter length or the arm circumference without following the physician orders for PICC line care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 15 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 5. During an observation of Resident #70 on 5/23/2022 at 9:10 AM, there was a right upper arm midline catheter with a 2 x 2 gauze under a transparent dressing dated 5/19/2022. Review of the medical records for Resident #70 documented the resident was admitted to the facility on [DATE] with the diagnoses to include chronic obstructive pulmonary disease, type 2 diabetes mellitus with complications, morbid obesity due to excessive calories, peripheral vascular disease, non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, unspecified atrial fibrillation, unspecified combined systolic and diastolic heart failure, chronic kidney disease, major depressive disorder, recurrent, moderate and urinary tract infection, site not specified. Review of the physician order dated 5/19/2022 for Resident #70 reads, May insert midline for IV antibiotic therapy . Meropenem Solution reconstituted 1 GM, use 1 gram intravenously every 12 hours for bacterial infection, UTI related to cellulitis of unsuspected part of limb. Review of the medical records for Resident #70 revealed no additional orders related to the midline catheter for dressing changes or flushes. Review of the MAR for Resident #70 documented no dressing changes or flush orders. During an observation of Resident #70 on 5/23/2022 at 1:20 PM, there was a right upper arm midline catheter transparent dressing with a 2 x 2 gauze under the dressing dated 5/19/2022. During an interview on 5/23/2022 at 1:20 PM, Resident #70 stated, That dressing hasn't been changed since they put it in. During an interview on 5/23/2022 at 1:55 PM, the DON confirmed that the midline catheter transparent dressing was dated 5/19/2022 and had gauze under the transparent dressing. During an interview on 5/23/22 at 1:55 PM, the DON stated, [Resident #70's name] did not have orders placed for midline care or dressing changes until yesterday. The staff should have placed the orders when the midline was placed on the 19th. I cannot tell you why they didn't. We change the dressing after the first 24 hours and wouldn't put any gauze under the dressing. We should use a biopatch. I can't tell you why it isn't being done. 6. During an observation of Resident #22 on 5/22/2022 at 10:08 AM, there was a left upper arm midline catheter with one port and clear transparent dressing with a gauze under the dressing. There was no date on the dressing. All four edges of the dressing were curling up. During an observation of Resident #22 on 5/23/2022 at 11:18 AM, there was a left upper arm midline catheter with a clear transparent dressing with a piece of gauze under the dressing. There was no date on the dressing. All four edges of the dressing were curling up. Review of the medical records for Resident #22 documented the resident was admitted to the facility on [DATE] with the diagnoses to include type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, other idiopathic peripheral autonomic neuropathy, morbid obesity, hypothyroidism, GERD (Gastroesophageal Reflux Disease), major depressive disorder, ESBL (Extended Spectrum Beta-Lactamase) resistance. Review of the physician order dated 5/5/2022 for Resident #22 reads, May insert midline IV using 1% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 16 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 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 lidocaine one time only for IV ABX for 1 day. Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated 5/6/2022 for Resident #22 reads, Ertapenem Sodium solution reconstituted 1 GM, use 1 gram intravenously one time a day related to Extended spectrum beta lactamase (ESBL) resistance for 10 days. Residents Affected - Many Review of the physician orders for Resident #22 revealed no additional orders for midline care or dressing changes. Review of the MAR for Resident #22 revealed the midline was inserted on 5/6/2022 at 1:43 AM. There were no dressing changes documented on the MAR. Review of the TAR for Resident #22 revealed no dressing changes documented. During an interview on 5/23/2022 at 11:25 AM, Staff E, Registered Nurse (RN), stated, Oh, she [Resident #22] doesn't have a line. That is no longer in. During an interview on 5/23/2022 at 1:20 PM, the DON stated, I don't know why her [Resident #22] midline is still in. It is not being used. The dressing is not dated, and the dressing is compromised. There are no orders for central line care, and I don't see any dressing changes have been completed. It is a standard for dressings to be changed when they are compromised and every 7 days and PRN. During an interview on 5/25/2022 at 7:25 AM, the DON stated, It is a standard that we get orders to change PICC and midline catheter dressings when a resident is admitted , or we get one placed when they need one. All IV certified nurses and RNs know this. They should have gotten the orders and then changed them according to our policies. Review of the facility policy and procedures titled Central Venous Catheter with an effective date of 2/2009, and approval date of 1/19/2022, reads, Purpose: To provide a general procedure regarding central venous catheters. Procedure: I. Site care. 1. Obtain physicians order for dressing change. Refer to Appendix B IV line maintenance . 18. Label dressing with nurse date and your initials . Appendix B. IV Line Access Chart. Effective Date: February 7, 2020. Midline. Site Maintenance. Transparent Dressing Changes. On admission or 24 post insertion, then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change and PRN. PICC. Site Maintenance. Transparent Dressing Changes. On admission or 24 post insertion, then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change and PRN . Dressing change: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed q [every] 2 days. 7. During an observation of medication administration on 5/24/2022 at 8:45 AM, Staff D, Licensed Practical Nurse (LPN), was observed exiting a room after administering medications without performing hand hygiene. Staff D returned to the medication cart, unlocked the cart, and began to prepare medications for Resident #10 without performing hand hygiene. During an observation of medication administration on 5/24/2022 at 8:51 AM, Staff D, LPN, locked the medication cart, did not perform hand hygiene when entering Resident #10's room, moved an overbed table, picked up a cup of water and administered the medications to the resident. Staff D exited the room without performing hand hygiene, returned to the medication cart and began preparing medications for another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 17 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an observation of medication administration on 5/24/2022 at 8:59 AM, Staff D, LPN, returned to the medication cart and without performing hand hygiene prepared medications for Resident #54. Staff D entered the resident's room without performing hand hygiene and administered the medications. Staff D picked up the resident's meal tray and used napkin, placed a lid over the plate on the tray, exited the room, and placed the meal tray on the delivery cart before returning to the medication cart to prepare medications for another resident without performing hand hygiene. During an observation of medication administration on 5/24/2022 at 9:05 AM, Staff D, LPN, prepared medications for Resident #35, entered the resident's room without performing hand hygiene, elevated the residents head with the bed controls that were next to the resident on the bed, and administered the medications after handing the resident a cup from the overbed table. Staff D did not perform hand hygiene when exiting the room and returned to the medication cart and began preparing medications for another resident. During an interview on 5/24/2022 at 9:08 AM, Staff D, LPN, stated, I did not wash my hands. I should have. We have hand sanitizer right on the cart and in every room. During an observation of medication administration on 5/24/2022 at 9:10 AM Staff E, Registered Nurse (RN), poured medications for Resident #46. Staff E did not perform hand hygiene, locked the medication cart and entered the resident's room without performing hand hygiene. Resident #46 was not available, and Staff E returned to the medication cart without administering the medications and began preparing medications for another resident. Staff E did not perform hand hygiene when leaving the resident's room and returning to the medication cart. During an observation of medication administration on 5/24/2022 at 9:15 AM, Staff E, RN, prepared medications for Resident #67 without performing hand hygiene and entered the resident's room without performing hand hygiene. Staff E removed a cup of water from the resident's meal tray and handed it to the resident and administered the medications. Staff exited the room without performing hand hygiene and began preparing another resident's medications. During an observation of medication administration on 5/24/2022 at 9:20 AM, Staff E, RN, prepared medications for Resident #60 without performing hand hygiene and entered the resident's room without performing hand hygiene. Staff E moved the residents overbed table, removed a cup from the resident's meal tray and administered the medications to the resident. Staff E exited the room without performing hand hygiene, returned to the medication cart and began preparing medications for another resident. During an interview on 5/24/2022 at 9:37 AM, Staff E, RN, stated, I did not wash my hands or use hand sanitizer when I poured meds [medications], went into the resident's rooms or left. I guess I was distracted. Review of the facility policy and procedures titled Administering Medications, with an approval date of 1/19/2022 reads, Policy Statement. Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation . 26. Staff follows established infection control procedures (e.g., handwashing, aseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy and procedures titled Hand washing/Hand hygiene, with an approval date of 1/19/2022 reads, Policy Statement. This facility considers hand hygiene the primary means to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105196 If continuation sheet Page 18 of 19 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 105196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lodge Healthcare and Rehabilitation Center 635 SE 17th Street Ocala, FL 34471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents; c. Before preparing or handling medications . m. After contact with objects (e.g., medical equipment) in the resident's immediate vicinity of the resident. Event ID: Facility ID: 105196 If continuation sheet Page 19 of 19