Inspection·January 27, 2022

F 0604 impairment. Level of Harm - Minimal harm or potential for actual harm The Care Plan for Resident #63 indicated that the resident had impaired cognitive function, was a risk for falls, and was at risk for elopement. The care plan did include an intervention that instructed staff to lock the residents' wheelchair when not assisting Resident #63 in transferring. Residents Affected - Few The Policy and Procedure, Resident Rights, effective February 2021, indicated that The facilty strives to assure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facilty must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 2 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #200 was originally admitted on [DATE] and re-admitted on [DATE]. The admission Record included the diagnoses not limited to unspecified chronic obstructive pulmonary disease, unspecified ashma with status asthmaticus, paroxysmal atrial fibrillation, cardiomegaly, and Type 2 Diabetes Mellitus without complications. A progress note, dated 01/05/22 at 8:30 a.m., reported that a Certified Nursing Assistant (CNA) called the nurse to Resident #200's room due to the resident was experiencing shortness of breath with an oxygen saturation of 77% while on a Continuous positive airway pressure (CPAP) machine. The note identified that the resident requested to be sent to the hospital and the physician and emergency contact was notified. A review of the Nursing Home Transfer and Discharge Notice indicated the resident name, Medicaid number, the Nursing Home information, location to which the resident was being transferred/discharged , and the date the notice was given (01/05/2022). The notice did not include the reason for the discharge or transfer, was not signed by the Nursing Home Administrator/designee or the resident/representative who received the notice. During an interview, on 1/27/22 at 11:31 a.m., the Director of Nursing (DON) reviewed Resident #200's Nursing Home Transfer and Discharge Notice and stated that the notice was not completed correctly. She stated that the nurse was responsible for completing the reason for the discharge or transfer if going to the hospital. Based on record reviews, interviews, and review of facility policy, the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and failed to notify the Office of the State Long-Term Care Ombudsman of a resident transfer for two (Resident #56 and Resident #200) of four residents sampled for hospitalizations. Findings included: A review of Resident #56's Medical Record revealed that Resident #56 was admitted to the facility on [DATE] with diagnoses of dementia, acute osteomyelitis of right ankle and foot, non-pressure chronic ulcer of the right heel and midfoot with necrosis of muscle. A review of Resident #56's Medical Record also revealed that Resident #56 was transferred to the hospital on [DATE] and 12/27/2021 during a visit with the wound care physician due to wound infections. A review of Resident #56's Nursing Home Transfer and Discharge Notice dated on 11/29/2021 revealed a reason for discharge/transfer listed as needs cannot be met in this facility. The Nursing Home Information, Location of transfer, and Date Notice is given sections were completed by facility staff. The Resident Representative portion of the form was not completed. The section of the form titled Brief explanation to support this action was left blank. Review of the second page of the Nursing Home Transfer and Discharge Notice revealed that sections Notice presented by, Notice received by, and Notice given to were left blank. Review of the Nursing Home Transfer and Discharge Notice did not reveal the date that the notice was given to Resident #56's representative or the date that the notice was given to the Office of the State Long-Term Care Ombudsman. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 3 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #56's Nursing Home Transfer and Discharge Notice dated on 12/28/2021 revealed a reason for discharge/transfer listed as needs cannot be met in this facility. The Nursing Home Information, Location of transfer, and Date Notice is given sections were completed by facility staff. The Resident Representative portion of the form was not completed. The section of the form titled Brief explanation to support this action was left blank. Review of the second page of the Nursing Home Transfer and Discharge Notice revealed that sections Notice presented by, Notice received by, and Notice given to were left blank. Review of the Nursing Home Transfer and Discharge Notice did not reveal the date that the notice was given to Resident #56's representative or the date that the notice was given to the Office of the State Long-Term Care Ombudsman. A telephone interview was attempted with Resident #56's representative on 01/27/2022 at 12:45 PM. The call was not answered and a message for call back was not returned. An interview was conducted on 01/27/2022 at 11:19 AM with the facility's Director of Nursing (DON). The DON stated that upon transfer to the hospital, the floor nurse fills out the Nursing Home Transfer and Discharge Notice and that the Social Services Director (SSD) was in charge of following up with the Office of the State Long-Term Care Ombudsman. The DON addressed that the Nursing Home Transfer and Discharge Notices for Resident #56 were not filled out and was not able to state if Resident #56's representative was given the notice or if the Office of the State Long-Term Care Ombudsman was notified of the transfer. The DON stated that the SSD was out of the facility and was not available for interview. A review of the facility policy titled Resident/Family Care and Services (Transfer/Discharge Documentation Recommendations) effective in February 2021 revealed under the section titled Facility Initiate Discharge that a copy of the Transfer Discharge document must be sent to the State Ombudsman's Office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 4 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of facility policy, the facility failed to provide written notification of the Bed Hold Policy to Resident Representatives for for one (Resident #56) of four residents sampled for hospitalizations. Findings included: A review of Resident #56's Medical Record revealed that Resident #56 was admitted to the facility on [DATE] with diagnoses of dementia, acute osteomyelitis of right ankle and foot, non-pressure chronic ulcer of the right heel and midfoot with necrosis of muscle. A review of Resident #56's Medical Record also revealed that Resident #56 was transferred to the hospital on [DATE] and 12/27/2021 during a visit with the wound care physician due to wound infections. A request for documents was made on 01/26/2022 at 04:30 PM for Resident #56's Bed Hold and In-House Transfer Policy for the hospital admissions on 11/29/2021 and 12/27/2021 to the facility's Director of Nursing (DON). A review of Resident #56's Bed Hold and In-House Transfer Policy on 01/27/2022 at 11:19 AM revealed that the two notices provided by the DON were not dated and were not signed by Resident #56's representative. An interview was conducted following the review with the DON. The DON stated that upon transfer to the hospital, the floor nurse fills out the Bed Hold and In-House Transfer Policy and send it with the resident to the hospital. The DON addressed that the Bed Hold and In-House Transfer Policy forms were not completed for Resident #56 and stated that the forms should have been completed and that the nursing staff should be notifying the resident representative of the policy. The DON was not able to state how the policy is provided to resident representatives in writing. The DON was also not able to state if Resident #56's representative received the policy upon admission. A telephone interview was attempted with Resident #56's representative on 01/27/2022 at 12:45 PM. The call was not answered and a message for call back was not returned. A review of the facility policy titled Bed Hold and In-House Transfer effective in February 2021 revealed under the section titled Purpose that in case of emergency transfers, notice at the time of transfer means the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 5 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to maintain and store respiratory equipment in a sanitary manner for one (#57) out of 7 residents who utilized a continuous positive airway pressure (CPAP). Residents Affected - Few Findings included: Resident #57 was admitted on [DATE]. A review of the resident's Order Listing Report included an order, dated 1/20/22, Empty and Rinse CPAP humidifier chamber every a.m. (QAM) and allow to dry every day shift. Every day shift for Acute and Chronic Respiratory Failure with Hypercapnia. An observation was conducted, on 1/25/22 at 9:02 a.m., of Resident #57's continuous positive airway pressure (CPAP) machine in the bottom drawer of the bedside dresser. The observation revealed the tubing from the machine was lying out of the drawer, on the floor then looped back into the drawer with the uncovered mask lying on the other items in the drawer. The resident reported taking the mask off, the aides put it the drawer, and that staff fill it (humidifer) with water. On 1/26/22 at 10:36 a.m., an observation was made of Resident #57's CPAP mask lying uncovered in the bottom drawer, the water container was attached to the machine. The resident stated that staff do not clean the container but does fill it with water. A review of the residents' January Treatment Administration Record (TAR), on 1/26/22 at 11:27 a.m., did not indicate that the humidifer had been emptied and rinsed. The TAR did not indicate an order prior to 1/20/22 that instructed staff to empty and rinse the CPAP humidifer chamber. The TAR did not include an order prior to 1/19/22 that instructed staff to fill the CPAP humidifer chamber with distilled or sterile water. On 1/26/22 at 12:17 p.m., the Director of Nursing (DON) observed the CPAP and spoke with the resident and a family member, who was at bedside. The DON observed the CPAP stored in the bottom drawer and the mask that continued to lie uncovered atop other items in the bottom drawer of the bedside dresser. The DON stated, the CPAP mask should not be stored that way, it should be in a bag. Resident #57 reported that staff had not cleaned the mask or the chamber. On 1/26/22 at 12:35 p.m., Staff Member L, Registered Nurse (RN) stated he had not cleaned the mask before or the humidifer then immediately retracted and said he had cleaned both after reviewing the physician orders. The admission Minimum Data Set (MDS), dated [DATE], identified that Resident #57's Brief Interview of Mental Status (BIMS) score was 15 out of 15, indicative of an intact cognition. The MDS indicated that the resident utilized a non-invasive mechanical ventilator (BiPAP/CPAP) while a resident. The residents' care plan did not include the focus or inventions related to Resident #57's use of a CPAP. A request was made, on 1/26/22, for a policy regarding the storage of respiratory equipment and for the maintenance/care of respiratory equipment. The facility provided a policy, Disposable Equipment Change Schedule, dated May 2020. The policy identified that The facility requires that respiratory supplies are routinely changed or cleaned in order to prevent nosocomial infections. The procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 6 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated the change schedule for disposable items was that Humidified ventilator/BiPAP circuits weekly and as needed (prn). According to The Food and Drug Administration (FDA), dated 2/27/20, (https://www.fda.gov/consumers/consumer-updates/cpap-machine-cleaning-ozone-uv-light-products-are-not-fda-approved) the reason a CPAP machine needed to be cleaned was that, Germs from your lungs, throat, or mouth can get into the CPAP mask or hose as you breathe in and out during sleep, or germs on your skin may get transferred to the CPAP mask or hose. Dust, mold, or other allergens may also get into the CPAP mask or hose. All types of CPAP machines need to be cleaned regularly so that these germs and contaminants do not grow inside of your equipment and make you sick. The information indicated that the All detachable CPAP parts can generally be cleaned with mild soap and water unless the owner's manual says otherwise. Event ID: Facility ID: 105269 If continuation sheet Page 7 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to provide ongoing monitoring for complications before and after dialysis treatments for 2 (Resident #92 and Resident #35) of 2 resident sampled for dialysis care. Residents Affected - Some Findings included: A review of Resident #92's Medical Record revealed that Resident #92 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD). A review of Resident #92's Physician's Orders revealed an order, dated 04/19/2020, for Dialysis on Monday, Wednesday, and Friday with a chair time of 04:30 AM. A review of Resident #92's Care Plan revealed a problem, revised on 01/06/2020, that Resident #92 had actual risk for impaired renal function related to end-stage renal failure. Interventions included dialysis treatment on Monday, Wednesday, and Friday, observe dialysis catheter site for signs and symptoms of bleeding, and protect shunt site from injury. A review of Resident #92's Dialysis Communication Forms for the dates 12/01/2021 to 01/24/2022 revealed the following: - 12/01/2021: Assessment of access site was not documented prior to dialysis appointment. - 12/08/2021: Dialysis Communication Form was not completed for the dialysis appointment. - 12/15/2021: Assessment of access site was not documented prior to dialysis appointment. - 12/14/2021: Assessment of dialysis access site for bruit/thrill was not assessed following dialysis appointment. - 12/17/2021: Assessment of access site was not documented prior to dialysis appointment. - 12/29/2021: Dialysis Communication Form was not completed for the dialysis appointment. - 01/05/2022: Assessment of access site was not documented prior to dialysis appointment. - 01/07/2022: Assessment of access site was not documented prior to dialysis appointment. - 01/10/2022: Assessment of access site was not documented prior to dialysis appointment. - 01/12/2022: Dialysis Communication Form was not completed for the dialysis appointment. - 01/14/2022: Dialysis Communication Form was not completed for the dialysis appointment. - 01/17/2022: Dialysis Communication Form was not completed for the dialysis appointment. - 01/19/2022: Assessment of access site was not documented prior to dialysis appointment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 8 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 - 01/24/2022: Assessment of access site was not documented prior to dialysis appointment. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 01/26/2022 at 11:42 AM with the facility's Director of Nursing (DON). The DON stated that the dialysis communication sheets for Resident #92's dialysis appointments on 12/08/2021, 12/29/2021, 01/12/2022, 01/14/2022, and 01/19/2022 were not able to be found. The DON also stated that the Dialysis Communication Form should be completed fully by the nurse upon leaving the facility for dialysis and upon return from dialysis. Residents Affected - Some A review of the facility policy titled Dialysis Management (Hemodialysis), dated October 2021, revealed under the section titled Guidelines staff are to complete the Dialysis Communication Tool before and after dialysis and following up on any special instructions from the dialysis center. On 01/25/22 at 10:12 a.m. Resident #35 was observed in his room. Resident #35 was not interviewable. An aide was assisting Resident #35 who was being transported to Dialysis for his appointment. Review of an admission record for Resident #35 printed on 01/26/22 showed an admission date of 08/06/21 and a diagnosis of end stage renal disease. An MDS (minimum data set) for Resident #35 showed resident was unable to complete the brief interview for minimum status, (BIMS) indicating severe cognitive impairment. A functional status assessment showed Resident #35 required extensive assistance with 2 staff assistance for activities of daily living. (ADL's) A care plan for Resident #35 dated 08/10/21 showed a focus related to hemodialysis. Resident #35 attends dialysis on Tuesdays, Thursdays, and Saturday. Physician orders for Resident #35 showed the following: Resident to have Dialysis on days Tuesdays, Thursdays, and Saturdays at [dialysis center] chair time 11:15 a.m. Dialysis AV shunt monitor every shift for bruit and thrill. shunt is located at RUC Monitor every shift for signs and symptoms of bleeding. Cath site RUC (right upper chest) monitor every shift for signs and symptoms of bleeding. Catheter site RUC monitor every shift for signs and symptoms of infection. Transport: [NAME]. Document vital signs upon resident returning from dialysis every day and evening shift every Tuesday, Thursday, and Saturday. Review of treatment administration record (TAR) for Resident #35 dated 12/01/21 to 12/31/21 and 01/01/22 to 01/26/22 showed a physician order error with vitals documentation monitoring shown for Monday, Wednesday, and Friday and not Tuesday, Thursday and Saturday as ordered. The documentation showed post vitals tracking missed during the months of December 2021 and January 2022. Catheter site monitoring every shift was also noted missing during the two months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 9 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Review of dialysis communication forms dated November 2021 to January 2022 Level of Harm - Minimal harm or potential for actual harm showed missed documentation related to access site assessment, check for Bruit / thrill, post dialysis vitals dates noted missing documentation included dates: 01/22/22, 01/06/22, 12/23/21, 12/21/21, 12/16/21, 12/04/21, undated document, 11/24/21, 11/20/21, undated document and 01/11/22. Residents Affected - Some On 01/26/22 at 12:33 p.m., an interview was conducted with Staff J, RN Unit Manager. Staff J stated that when a dialysis resident comes back, the expectation is to check the site, monitor for bleeding and take vitals. Staff J stated that the expectation is to document in dialysis communication form and in the TAR. Staff J stated that if concerns are noted, they are to notify the physician. Staff J, RN said, yes, the form should be completely filled out. An interview was conducted on 01/26/22 at 12:45 p.m. with Staff S, LPN stated that she takes care of Resident #35. Staff S said, when he [Resident #35] comes home, I check his vitals per orders. My communication forms are fully completed. Staff S stated that if the dialysis nurse does not do their part, she calls them and asks them to complete and fax it back. Staff S said, I do know there was a problem with the order not matching the TAR. Staff S stated that she had notified the unit manager. Staff S stated that dialysis orders stated to go to dialysis on Tuesday, Thursday, Saturday and the TAR reads to monitor post dialysis vitals on Monday, Tuesday and Wednesday. Staff S confirmed that documentation was missed because of the order confusion. On 01/26/22 at 12:50 p.m., an interview was conducted with Staff L, RN unit Manager. Staff L stated that he did not know that the order in the TAR did not match the physician orders. Staff L said, I don't recall anyone alerting me. I will review the physician orders and address the issue. Staff L stated that the documentation should show the nurse's initials to confirm the treatment was provided. Staff L said, if it is not documented it did not happen. The expectation is for post dialysis care to be fully completed. Staff L stated that post dialysis care was critical to the resident's quality of care. A follow -up was conducted on 01/26/22 at 10:54 a.m. with the director of nursing (DON). The DON said, if it was not documented, it did not happen. The DON stated that the nurses should follow physician's orders. The DON confirmed that the order stated to monitor the shunt site daily. The DON stated that monitoring should be completed as ordered. The DON stated that some dialysis communication orders were missing because they switched [Resident #35's] schedule but his orders in the TAR were not updated. The DON said, the TAR should match the physician's order. There were many moving parts and we dropped the ball. On 01/26/22 at 10:54 a.m., the DON stated that the facility did not have a documentation policy. Review of a facility's order titled, physician orders, dated October 2021, stated that each time a resident is admitted , the facility will have physician orders for their immediate care. #12. Confirm the accuracy of orders. Review orders daily in the clinical meeting to confirm accuracy in transcription and identify errors of omission. #16. When the physician's order changes an order that is currently in place, discontinue the original physician's order . Assure the new order reflects the change and order components required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 10 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to act upon a pharmacy recommendation in a timely manner for one (Resident #59) of six residents sampled for unnecessary medications. Findings included: A review of Resident #59's Medical Record revealed that Resident #59 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #59's Physician's Orders revealed an order, dated 01/19/2022, for Fludrocortisone Acetate 0.1 milligrams (mg) by mouth one time a day for orthostatic hypotension. A review of Resident #59's Medication Regimen Review, dated 11/05/2021, revealed a recommendation from the Consultant Pharmacist (CP) to Resident #59's Attending Physician to indicate a diagnosis to be added to the Medication Administration Record for fludrocortisone. No response was recorded by Resident #59's Attending Physician for the recommendation. A review of Resident #59's Medication Regimen Review, dated 01/10/2022, revealed a recommendation from the CP to Resident #59's Attending Physician to indicate a diagnosis to be added to the Medication Administration Record for fludrocortisone. Resident #59's Attending Physician agreed with the recommendation and signed the response on 01/12/2022. An interview was conducted on 01/26/2022 at 11:20 AM with the facility's Director of Nursing (DON). The DON was not able to state why the pharmacy recommendation for Resident #59 on 11/05/2021 was not acted upon until 01/12/2022 and stated I wasn't here. The DON stated that she receives e-mails from the CP with the medication regimen review recommendations, prints them out, and divides them by units. The Unit Managers request for the Attending Physician to respond to the recommendation and the Physician either agrees or disagrees with the recommendation. The Physician then signs the recommendation and returns them so the appropriate changes can be made in the medical record. The DON stated that pharmacy recommendations should be responded to by the Attending Physician within thirty days of the recommendation. A telephone interview was conducted on 01/27/2022 at 04:31 PM with the CP. The CP stated that she writes the pharmacy recommendations monthly and sends them to the DON by e-mail. During the next month's review, if thirty days have passed, the recommendation will be transferred to the monthly review as pending. The CP stated that the recommendations should be responded to within thirty days per the facility policy. A review of the facility policy titled Medication Regimen Review and Reporting, dated September 2018, revealed that the nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within thirty calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 11 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure proper monitoring for psychotropic medication use was consistently implemented for two (Resident #59 and Resident #68) of six residents sampled for unnecessary medications. Findings included: A review of Resident #59's Medical Record revealed that Resident #59 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #59's Physician's Orders revealed the following orders: - An order dated 01/15/2022 for Olanzapine 2.5 milligrams (mg) by mouth one time daily and 5 mg by mouth at bedtime for mood disorder. - An order dated 01/04/2022 for behavioral monitoring of antipsychotic medication use every shift. - An order dated 01/04/2022 for side effect monitoring of antipsychotic medication use every shift. A review of Resident #59's Care Plan revealed a problem revised on 01/04/2022 that Resident #59 used psychotropic medications. Interventions included to administer medications as ordered, observe/document for side effects and effectiveness, and psychological services per MD order. A review of Resident #59's Minimum Data Set (MDS) assessment dated [DATE] revealed under Section N Medications, that Resident #59 received antipsychotic medications for seven days out of the seven day assessment period. A review of Resident #59's Behavior Monitoring record for January 2022 revealed that behavioral monitoring for antipsychotic medication use was not recorded on 01/11/2022, 01/12/2022, 01/15/2022, and 01/26/2022 on the 7 AM to 3 PM shift. A review of Resident #68's Medical Record revealed that Resident #68 was admitted to the facility on [DATE] with diagnoses of mood disorder, anxiety disorder, vascular dementia, and major depressive disorder. A review of Resident #68's Physician's orders revealed the following orders: - An order dated 07/26/2021 for behavioral monitoring of mood stabilizer use every shift. - An order dated 07/26/2021 for side effect monitoring of mood stabilizer use every shift. - An order dated 01/01/2022 for Depakote Sprinkles Delayed Release 125 mg by mouth three times a day for mood stabilizing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 12 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 - An order dated 01/01/2022 for Quetiapine Fumarate 25 mg by mouth three times a day for mood disorder. Level of Harm - Minimal harm or potential for actual harm A review of Resident #68's Care Plan revealed a problem revised on 08/21/2015 that Resident #68 had a mood problem related to depression. Interventions included to administer psychotropic medications as ordered, observe/document for side effects and effectiveness, and observe for changes in mood. Residents Affected - Few A review of Resident #68's MDS assessment dated [DATE] revealed under Section N - Medications, that Resident #68 received antipsychotic medications for seven days out of the seven day assessment period. A review of Resident #68's Behavior Monitoring record for December 2021 revealed that behavioral monitoring for mood stabilizer use was not recorded on 12/07/2021, 12/10/2021, 12/14/2021, 12/16/2021, 12/24/2021, 12/27/2021, 12/28/2021, and 12/30/2021 on the 7 AM to 3 PM shift. A review of Resident #68's Behavior Monitoring record for January 2022 revealed that behavioral monitoring for mood stabilizer use was not recorded from 01/12/2022 to 01/15/2022 on the 7 AM to 3 PM shift and on 01/16/2022 and 01/21/2022 on the 11 PM to 7 AM shift. A telephone interview was conducted on 01/27/2022 at 04:31 PM with the facility's Consultant Pharmacist (CP). The CP stated that psychotropic medication monitoring is reviewed during monthly medication regimen reviews and recommendations are provided to the facility if needed to add psychotropic medication monitoring. The CP stated that she would expect for psychotropic medication monitoring for behaviors and side effects be documented on every shift. An interview was conducted on 01/27/2022 at 05:16 PM with the facility's Director of Nursing (DON). The DON reviewed the Behavior Monitoring documentation for Resident #59 and Resident #68 and addressed that some of the documentation was missing from both resident records. The DON stated that she would expect for monitoring of behaviors and side effects related to psychotropic medication use to be documented as ordered by the physician. A review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring revised in December 2016 revealed under the section titled Monitoring that if a resident is being treated for alter behavior or mood the Interdisciplinary Team will seek and document any improvements or worsening in the individual's behavior, mood, or functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 13 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and three errors were identified for two (#74 and #15) of four residents observed. These errors constituted a 12.00% medication error rate. Residents Affected - Few Findings included: 1. On 1/25/22 at 8:20 a.m., an observation of medication administration with Staff Member T, Registered Nurse (RN) was conducted with Resident #74. Staff T was observed dispensing the following medications: - Enteric coated Aspirin 81 milligram (mg) tablet orally - Calcium Carbonate 2 tablets orally - Vitamin D 25 microgram (mcg) tablet orally - Metformin 1000 mg tablet orally - Repaglinde 2 mg tablet orally - Memantine 5 mg tablet orally - Losartan 50 mg tablet orally - Celecoxib 400 mg tablet orally - Levemir 10 units subcutaneously - Sertraline 50 mg tablet orally During dispensing of the medication, Staff Member T stated she had previously checked for Resident #74's Levemir in the refrigerator in the medication room and that the resident did not have any so she was observed drawing up 10 units from a vial labeled for Resident #96. Despite encouragement from the RN, Resident #74 refused the oral and subcutaneous medications. 2. On 1/25/22 at 8:37 a.m., an observation of medication administration with Staff Member T, Registered Nurse (RN) was conducted with Resident #15. Staff T was observed dispensing the following medications: - Enteric coated Aspirin 81 mg tablet orally - Vitamin D 25 mcg, 2 tablets orally - Multi Vitamin tablet orally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 14 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - Escitalopram 10 mg tablet orally Level of Harm - Minimal harm or potential for actual harm - Gabapentin 600 mg tablet orally - Atenolol 25 mg tablet orally Residents Affected - Few - Divaloproex 125 mg sprinkles, 2 capsules orally - Novolog 70/30, 30 units subcutaneously - Novolog (Insulin Aspart) 4 units subcutaneously During the dispensing, Resident #15 was observed propelling self in wheelchair in the midst of the 100-hallway. The observation indicated that the medication profile for the resident's Novolog 70/30 insulin was in red, indicative of the medication was late. Staff T obtained a blood glucose level or 244 from the middle finger of the residents right hand. The resident stated that breakfast was same as always. The staff member lifted the shirt of Resident #15 and injected the 30 units of Novolog 70/30 into the right upper abdominal quadrant. The staff member then injected 4 units of Insulin Aspart into the residents middle right abdomen. A review of Resident #15's January Medication Administration Record indicated the following: - Novolog Mix 70/30 Suspension 100 unit/milliliter - Inject 30 unit subcutaneously two times a day for diabetes. Give with meals. - Guaifenesin 400 mg tablet - Give one tablet by mouth two times a day for cough for 10 days. Order date 1/16/2022. The observation indicated that Novolog 70/30 was administered after the resident had eaten breakfast and the Guaifenesin tablet due at 9 am. was not observed as being administered. On 1/2622 at 5:38 p.m., the Director of Nursing (DON) stated she was aware of the nurse using insulin for another resident, we don't share the insulin, we call the physician, we call the pharmacy. She stated that unless a resident asks to be given medication in a public space it should not be given but never an injectable. The DON stated she didn't know why the Guaifenesin was not given and identified that if the over-the-counter medication was not available she would have walked to the nearby chain pharmacy and have gotten it. On 1/27/22 at 4:30 p.m., an interview was conducted with the Consultant Pharmacist. She stated that no medications cannot be borrowed and that she felt that the Novolog 70/30 being administered late, as it was a mixture of short and long lasting but they (staff) should follow physician orders. The policy, Medication Administration - General Guidelines, dated 09/18, indicated Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The policy identified the following: - b. Medications to be given with meals are to be scheduled for administration at the residents' meal times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 15 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - 6. Provide for privacy as appropriate. Level of Harm - Minimal harm or potential for actual harm - 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Residents Affected - Few - 16. Medications supplied for one resident are never administered to another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 16 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure medications were stored appropriately in three of four medication carts and one of two medication preparation rooms. Findings included: On 1/26/22 at 11:14 a.m., an observation of the 100-hall medication cart was unlocked and left unattended. Staff Member L, Registered Nurse (RN) came out of room [ROOM NUMBER], on 1/26/22 at 11:17 a.m., and confirmed that the cart was unlocked and should have been locked. Photographic evidence was obtained. On 1/27/21 at 10:39 a.m. an observation of the 400-hall medication cart was conducted with Staff Member U, Registered Nurse (RN). The observation revealed an unopened bottle of Novolog, which the label indicated had been delivered on 1/24/22. The staff member stated the bottle was ok to be in the cart, then stated. no that it should be in the refrigerator. On 1/27/21 at 10:45 a.m., an observation of the 100-hall medication cart was conducted with Staff Member T, RN. The observation revealed an undated open bottle of ProStat Sugar-Free liquid protein. Staff T turned the bottle over and reported the expiration date as the manufacturer date printed on the bottom. The staff member stated the bottle might have been opened two (2) weeks ago. She wiped off the bottle and began to put back into the drawer. The label of the ProStat indicated that users were to discard 3 months after opening. Staff T stated she would get another bottle. On 1/27/21 at 10:54 a.m., an observation of the 200-hall medication cart was conducted with Staff Member V, RN. The observation revealed a box of Salonpas Pain Relieving Patches stored in the same divided section of the bottom drawer as inhalation medications. The staff member stated that no the box should not be in there. On 1/27/21 at 1:12 p.m., an observation of the West-wing medication preparation room was conducted with Staff Member U, RN. The bottom cabinet contained a large opaque bag of blister cards containing medications for a resident that had been filled by a pharmacy other than the current pharmacy. The observation of the bottom cabinet identified two Ampicillin intravenous vials with bags of normal saline. A review of the prescribed resident indicated that the resident had been discharged on 7/12/21. Staff Member J, Unit Manager, confirmed that the resident was no longer at the facility and stated that the facility had had the current pharmacy since she had stated eight (8) months ago. On 1/27/22 at 4:30 p.m., the Consultant Pharmacist stated that medications were to be stored by route, the procedure is to date (the Novolog) and count the days starting when it comes out of the refrigerator. The policy, Medication Storage - Storage of Medication, dated 09/18, indicated that Medications and biological's are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The procedure identified that: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 17 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. - 4. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories. - 11. Medications requiring refrigeration or temperatures between 2 celsius (C) (36 Fahrenheit (F)) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. - 12. Insulin products should be stored in the refrigerator unit opened. The Director of Nursing (DON) stated, on 1/27/22 at 5:34 p.m., it was not good related to the medication cart being left unlocked, and stated, the ProStat should have been dated the moment we opened it, and different routes of medication should not be stored together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 18 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to conduct ongoing COVID-19 outbreak testing in accordance with testing frequency parameters for four (Resident #68, Resident #30, Resident #13, and Resident #79) of five residents sampled for COVID-19 testing requirements. Residents Affected - Some Findings included: A request was made on 01/26/2022 at 04:30 PM to review the last COVID-19 testing results for Resident #68, Resident #30, Resident #13, and Resident #79 to the facility's Director of Nursing (DON). A review of Resident #68's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. A review of Resident #30's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. A review of Resident #13's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. A review of Resident #79's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. An interview was conducted on 01/27/2022 at 02:37 PM with the DON. The DON stated that the facility was testing residents every 5 to 7 days in response to the COVID-19 outbreak in the facility. The DON also stated that resident's should have been tested on [DATE] but they were not. The DON was not able to explain why COVID-19 testing was not completed for residents on 01/25/2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 19 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that the call light was functioning properly for Resident's #17 and #89 during 4 of 4 days of survey. Residents Affected - Few Findings included: Resident #89's admission Record revealed she was admitted to the facility on [DATE] with a primary diagnosis of muscle wasting atrophy. A review of the Minimum Data Set (MDS) assessment Section G: Functional Status, dated 01/11/22, indicated that the resident had extensive limitation and required the assistance of at minimum one person for Activities of Daily Living (ADL's). A review of the Care Plan with a revision date of 08/05/21, revealed that Resident #89 had an ADL self-care performance deficit related to the following: weakness, incontinence, impaired mobility, balance and cognition. Interventions included call bell within reach while in room/bathroom/ shower room and remind to use. Resident #17's admission Record revealed she was admitted to the facility on [DATE] with a primary diagnosis of encephalopathy. A review of the Minimum Data Set (MDS) assessment Section G: Functional Status, dated 10/22/21, indicated that the resident required total dependence of at minimum one person for Activities of Daily Living (ADL's). A review of the Care Plan with a revision date of 09/12/21, revealed that Resident #17 had an ADL self-care performance deficit as evidenced by: Cannot complete ADL tasks independently and requires individualized interventions related to dementia and impaired mobility. Interventions included call bell within reach while in room/bathroom/ shower room and remind to use. On 01/24/22 at 12:56 p.m., an observation was made of Resident #89. She was observed lying in bed with a call light attached to her blanket. The call light was observed missing the red button that is pressed to activate the call system (photographic evidence obtained). An interview was immediately conducted with Staff H, Certified Nursing Assistant (CNA) she confirmed that the call light was broken and has been that way for at least a month. She stated that Resident #89 was not able to use the call light but should have had a call light that was functioning. On 01/25/22 at 11:47 a.m., an observation was made of Resident #89. She was observed lying in bed with the call light attached to the blanket. The red button remained missing from the inside of the call light (photographic evidence obtained). On 01/26/22 at 11:02 a.m., an observation was made of Resident #89. She was observed lying the bed with the call light attached to the blanket. The red button remained missing from the inside of the call light (photographic evidence obtained). On 01/26/22 at 03:31 p.m., an interview was conducted with Staff I, CNA. She was asked about the call light and if it was working. Staff I attempted to press the inside of the call light. The call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 20 of 21 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groves Center 512 S 11th St Lake Wales, FL 33853 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few light did not turn on. Staff I stated that she was not aware that the call light was broken. She then stated that Resident #89 was not able to use or operate the call light anyway. The process at the facility was to notify the nurse that the light was not working, and she would then log it in the book for the Maintenance Director. Since the Maintenance Director was nearby in the hallway, she would notify him verbally. On 01/26/22 at 03:35 p.m., an interview was conducted with the Regional Maintenance Director. He was called to the room and confirmed that the call light was broken. He unplugged the call light cord from the wall and placed it into the garbage as he was leaving Resident #89's room. He stated that he would have it fixed right away. On 01/26/22 at 03:36 p.m., an interview was conducted with the Staff J, Unit Manager. She stated that she was not aware that the call light was broken because it was not reported to her. She reached into the garbage, removed the call light cord and confirmed that it was broken. She stated that if they would have stopped putting her on the cart all the time, she could have performed her Unit Manager duties. On 01/27/22 at 03:05 p.m., an interview was conducted with Staff H, CNA. She stated that she noticed that the call light had been repaired in Resident #89's room. She then notified the surveyor that there was another resident (#17) with a broken call light. The surveyor inquired about the room number. Staff H informed the surveyor of the room number referenced. The surveyor immediately went into the room to observe the broken call light cord (photographic evidence obtained). On 01/27/22 at 03:18 p.m., the Director of Nursing (DON) was notified of the issues with the broken call lights for Resident #89 and Resident #17. A policy on call light/equipment maintenance and repair was requested. On 01/27/22 at 03:30 p.m., an interview was conducted with the DON. She stated that she did not have the policy that was requested. The DON stated The resident's call light should have been working. There are Department heads that go around to the resident's room to make sure things are functioning properly. The room had not been checked today because they had been running around since the state was there. She said the Nursing Home Administrator was responsible to maintain the list of issues found during their rounds. She stated, the CNA should have notified the nurse of the broken call light. The Maintenance Director was going to repair the call light immediately. They were going to complete an audit of all the call light cords in the facility. The DON confirmed if they would have done so yesterday when they were notified of the issue with Resident #89's broken call light, they would have caught the broken call light in Resident #17's room. On 01/27/22 at 05:38 p.m., the DON stated that the call light audit had been completed by the Nursing Home Administrator and the Maintenance Director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 21 of 21