Inspection·May 28, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Review of Resident #7's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to nondisplaced fracture of greater trochanter of left femur subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus without complications, uncomplicated alcohol abuse, and unspecified protein-calorie malnutrition. The resident was transferred on 3/29/25 at 4:59 p.m. to the emergency room (ER) and did not return to the facility. Residents Affected - Few Review of Resident #7's admission inventory of personal effects showed the resident had top and bottom dentures. The form was not dated. Review of Resident #7's progress notes did not reveal documentation of the representative's concern involving missing dentures or any conversation the facility had with the representative in regard to any missing items. An interview was conducted on 5/28/25 at 9:33 a.m. with the BOM. The BOM reported having tried to contact Resident #7's spouse and said, should be in a note. She stated she tried to contact the spouse the day before on 5/27/25 at 4:37 p.m. regarding an invoice for dentures. The BOM reviewed documentation revealing she had last spoken with the family on 3/29/25, the day the resident left facility regarding missing dentures and missing clothing. She stated she did not know if anyone else had reached out to the family between 3/29/25 and the previous day. She stated the first time she had reached out to the family was on 5/27/25 for a follow-up. An interview was conducted on 5/28/25 at 9:39 a.m. with the current SSD. The SSD described the grievance procedure as when receiving a grievance, talked about in clinical meeting, makes a copy of it, and gives the copy to the relevant department head. She stated she believed the facility had 3 days to follow-up and resolve the concern and if not able to resolve it in the 3 days, she would speak with the NHA. The SSD stated after the resolution, she would go to either the resident and/or representative and have them sign the form or document a verbal resolution. She stated she would resolve the grievance after a month and would contact the family before resolving it. The SSD stated she would document conversations with the family but she does not know if her predecessor did the same. She reviewed Resident #7's record and confirmed there were no Social Service notes in the resident's record. The SSD reported being unaware of a grievance regarding Resident #7. Review of the policy and procedure - Grievance/Concern Management, effective November 2024, revealed Residents and their representative had the right to present concerns on behalf of themselves, and/ or others to the staff and/ or administrator of the facility, to government officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous. These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/ grievances with respect to the behavior of other residents. The procedure showed: (4.) The NHA is responsible for oversight of the concern process. (5.) The Social Services representatives/Grievance Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social services will monitor and document resident/representative satisfaction upon completion of the investigation in the summary of findings/conclusion. (7.) The facility leadership team will review and discuss concerns in the progress of an investigation(s) and resolution(s). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 2 of 16 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 05/28/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (8.) The department involved will document the concern and record the resident/ resident representative's satisfaction with the resolution to the concern. (13.) Complete a concern report investigation with summary and conclusion. (14.) Social services staff will provide information regarding compliance line information for unresolved concerns. Event ID: Facility ID: 105269 If continuation sheet Page 3 of 16 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 05/28/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility failed to have pain medication available per physician orders for one resident (#5) out of three residents sampled. Residents Affected - Few Findings Included: On 5/27/2025 at 1:49 p.m., an interview was conducted with Resident #5 with Staff A, Registered Dietician, for interpretation. Resident #5 stated getting her pain medication was an issue the last month and stated she went without getting her pain medication. A record review of Resident #5's Medication Administration Record (MAR) for the month of April 2025 showed a missed dose of Oxycodone HCL oral tablet 10 milligrams (mg) by mouth one time a day for nonacute pain on 4/26/2025. A record review of Resident #5's admission Record showed an original admit date of 02/14/2024 with a readmission date of 5/01/2025 with diagnoses included but not limited to spinal stenosis cervical region, neuralgia and neuritis unspecified, monoarthritis not elsewhere classified unspecified site and pain unspecified. A record review of Resident #5's Controlled Drug Declining Inventory Sheet with a 4/16/2025 received date showed on 4/25/2025 the count for oxycodone HCL (IR)10 mg (milligram) was zero. A review of a copy of the latest original prescription for Resident #5 for Oxycodone HCL oral tablet 10 mg to give one tablet by mouth one time a day for non-acute pain had an order date of 4/25/2025. On 5/27/2025 at 11:54 a.m. an interview was conducted with Staff H, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff H, LPN/UM stated the facility has one automated medication dispense machine available for medications used for emergencies. When asked if Oxycodone was available in the medication dispense machine, Staff H, LPN/UM stated there was an inventory sheet on the side of the machine. Upon entrance into the medication room with Staff H, an inventory sheet was not available. Staff H stated the process to pull narcotics for new admits is not the same for existing residents because the resident already has an existing prescription filled by the pharmacist. Staff H stated only when all the refills have been used up for the original prescription and the narcotic is not available for the resident in the medication cart, can the nurse call the ordering physician to obtain an order, confirm with the pharmacist, obtain an access code from pharmacy to then pull the narcotic from the medication dispense machine. Staff H stated the nurse can request to the pharmacy services a refill request for any medication through the electronic chart when a medication is low. Staff H stated, if the narcotic is getting low, the nurse should put the request in early to allow time for pharmacy to deliver the medication. Staff H stated the pharmacy will come for deliveries at least once a day but maybe twice a day, I'm not sure. Staff H stated if the medication is needed as a STAT (meaning immediately), the pharmacy will deliver within two to four hours. Staff H, stated if the medication was not ordered in time,we can get it from the medication dispensing machine, but it would have to be a different order and as a one-time order. On 5/27/2025 at 3:17 p.m., a telephone interview was conducted with a representative from the pharmacy. The pharmacy representative stated a prescription for Oxycodone 10 mg was placed on the morning of 4/26/2025 for Resident #5 with the prescription manually faxed over. The pharmacist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 4 of 16 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 05/28/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few representative stated the medication was delivered after 7:30 p.m. The pharmacist representative stated the nurse could have obtained a code from the pharmacist to obtain the missing narcotic and stated, I don't know what is in their inventory but if the medication is there, they can pull the medication. On 5/28/2025 at 9:50 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the only time a narcotic can be pulled for a long-term resident in the medication dispense machine would be if the prescription were to be new, or the physician either called the medication to the pharmacist or the prescription was faxed over to the pharmacy. The DON stated the expectation would be for the nurse to contact pharmacy when the medication is low. The DON stated nurses should re-order refill prescription when the count of the narcotic gets to a count of ten pills remaining. The DON stated there is a warning on the medication card when the prescription should be reordered to avoid running out of the medication. A review of the facility's policy titled, Physician Orders with an effective date of 10/ 2021showed the following policy statement: At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at the next physician visit. Nurses, therapists and pharmacists may take verbal and/or telephone orders as permitted by their state licensure board. 9. Communicate orders to the pharmacy based on facility established process period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 5 of 16 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 05/28/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide incontinence care for four ( #4, #5 #8 and #11) out of four residents sampled. Findings Included: During an interview on 05/27/2025 at 12:46 p.m., Resident #4 stated a few months ago she put her call light on, and a male staff member came into her room told her that he was not her aide and that he was going to get her aide. She stated he turned off her light and no one ever came back. She stated she had to wait for the next shift to come in and change her wet brief. She spoke with the facility at the time of the incident and told them that staff do not come into her room at night and they do not offer to change her. She reported she was told that this would change, and staff would come and check on her during the night. Resident #4 stated this has not happened. Staff still do not come into the room during the night and offer or check to see if she needs incontinent care. She stated she waits for the morning shift to be changed out of her wet briefs. Resident #4 stated this happens at least 3 or 4 nights a week. Review of Resident #4's admission record revealed an admission date of 04/10/2024. Resident #4 was admitted to the facility with diagnosis to include other lack of coordination, difficulty in walking, not elsewhere classified, muscle wasting and atrophy, not elsewhere classified, unspecified site, muscle weakness (generalized), other abnormalities of gait and mobility, need for assistance with personal care, unsteadiness on feet, and overactive bladder. Review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Section C. Cognitive Patterns a Brief Interview Mental Status (BIMS) of 15 out of 15 showing intact cognition. Review of Section GG. Functional Abilities revealed for toileting hygiene, substantial/maximal assistance, showing helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of Section H. Bladder and Bowel revealed Resident #4 is always Incontinent for bowel and bladder. Review of Resident #4's care plan 12/30/2019, revealed a Focus: Activities of Daily Living (ADL) showing Resident #4 has an ADL self-care performance deficit related to impaired mobility, chronic pain with pain management, and psychoactive med use. Initiated on 04/12/2024 and revised on 04/12/2024. The goal revealed - Resident #4 will have ADL needs anticipated and met by staff through the next review. Will maintain current level of self-performance with ADL's through next review date. Interventions showed Anticipate needs, Toileting: Bed Pan, Bladder: Continent with episodes of incontinence related to urgency, Bowel Incontinent at times, Toilet Use: Assist of 1, Toilet/Check and change upon arising, before and after meal, at bedtime and as needed with routine care. Apply Barrier cream after incontinent episode. Review of a second focus in the same care plan dated 12/30/2019 showed - Incontinence: Resident #4 is often incontinent of bladder and/or bowel related to diagnosis of overactive bladder and urgency. Date Initiated: 01/10/2023 and revised on: 09/17/2024. The goal indicated the resident will maintain dignity and will minimize the risk of infection. Interventions included: Check for incontinence with routine care, upon arising, before & after mealtime, at bedtime and as needed. Provide incontinent care as indicated, provide perineal care & apply barrier cream after incontinent episodes and as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 6 of 16 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 05/28/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed, utilize incontinent products as needed to provide dignity, observe condition of skin with each incontinent episode, observe for foul smelling urine, change in urinary output, mental status change, changes in bowel pattern and report as needed Certified Nursing Assistant (CNA). Review of Resident #4's tasks for bladder incontinence revealed no entries for the third shift (11 p.m.-7 a.m.) on 05/04/2025,05/18/2025, and 05/25/2025. No entries for the first shift (7 a.m.-3 p.m.) on 05/12/2025, 05/19/2025, and 05/25/2025. No entries for the second shift (3 p.m.-11 p.m.) on 04/30/2025, 05/04/2025, 05/12/2025, 05/26/2025. During an interview on 5/28/2025 at 9:25 a.m., Staff A, Dietary Manager interpreted for Resident #5 and stated her incontinence care response time is slow. Resident #5 stated she knows when she has the sensation to urinate, but the nursing staff are slow to answer, and therefore, she must urinate in her briefs. After she has urinated, Resident #5 stated she must wait for over forty-five minutes or more to be assisted in cleaning her up. Resident #5 said, It is like this every day. Review of Resident #5's admission record revealed an admission date of 05/01/2025 and an initial admission date of 02/14/2024. Resident #5 was admitted to the facility with diagnosis of unspecified fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, spinal stenosis, cervical region, other lack of coordination, difficulty in walking, not elsewhere classified, neuralgia and neuritis, unspecified, type 2 diabetes mellitus with diabetic nephropathy. Review of Resident #5's Quarterly MDS dated [DATE], revealed Section C -Cognitive Patterns, a BIMS of 15 out of 15 showing intact cognition. Review of Section GG. Functional Abilities, revealed Toileting hygiene, Supervision or touching assistance showing helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Review of Section H. Urinary Continence revealed Resident #5 is always incontinent for bladder and bowel. Review of Resident #5's Care Plan Dated: 02/15/2024 revealed a focus on ADL revealing Resident #5 has an ADL Self Care Performance Deficit. Date Initiated 02/15/2024 and revised on 02/15/2024. The goal showed the resident will improve level of self performance by next review. Interventions included: Two staff members to provide care at all times; Toilet Use: Assist of two; Toilet Use: Dependent bedside commode with 2 staff members; Toileting: Bathroom; Toileting: Bedpan; Toileting: Bedside Commode. Review of Resident #5's tasks for bladder incontinence revealed no entries for the third shift (11 p.m.-7 a.m.) on 05/04/2025, and 05/18/2025. No entries for the second shift (3 p.m.-11 p.m.) on 05/04/2025, 05/25/2025, 05/26/2025, and 05/27/2025. During an interview on 05/27/2025 at 6:40 a.m., Resident #8, stated when she puts her call button on, staff takes a while to come in to answer. She stated she was not sure how long she had to wait. resident #8 said, It happens the most during the night shift. I hold my bladder, because I am in briefs and don't want to be wet. Review of Resident #8's admission record revealed an admission date of 10/21/2022. Resident #8 was admitted to the facility with diagnosis to include cerebral infarction, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, epilepsy, unspecified, not intractable, with status epilepticus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 7 of 16 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 05/28/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #8's Quarterly MDS dated [DATE], revealed Section C. Cognitive Patterns, a BIMS of 06 out 15 showing Severe cognitive impairment. Review of section GG. Functional Abilities revealed for Toileting hygiene, and Toilet transfer Resident #8 is dependent showing helper does all the effort. Resident does none of the effort to complete the activity, Or the assistance of 2 or more helpers is required for the residents to complete the activity. Review of Section H. Bladder and Bowel revealed Resident #8 is always incontinent for bladder and bowel. Review of Resident #8's Care Plan Dated 06/01/2022 revealed an ADL focus showing Resident #8 has an ADL Self Care Performance Deficit related to history of Cerebral infarction with right sided weakness. Peripheral vertigo, muscle atrophy. Date Initiated 10/24/2022 and revised on 03/27/2025. The goal showed the resident will maintain current level of self performance with ADL's through next review. Interventions included - Anticipate Needs; Bladder: Incontinent; Bowel: Incontinent; Toilet Use: Assist of one; Toilet Use: Toilet/Check and change upon arising, before and after meal, at bedtime and as needed with routine care. Apply barrier cream after incontinent episode; Toileting: Bedpan; Toileting: Resident prefers to utilize adult briefs as well. Review of a second focus in the same care plan dated 06/01/2022 showed, Incontinence - the resident is incontinent of Bladder/ Bowel and is not a candidate for a toileting program related to lack of sensation of need to void or control. Date initiated 10/24/2022 and revised on 03/27/2025. The goal showed the resident will minimize the risk of skin breakdown. Interventions showed: check for incontinence with routine care, upon arising, before and after mealtime, at bedtime and as needed; Provide incontinence care as indicated; Provide perineal care and apply barrier cream after incontinent episodes and as needed. Utilize incontinent products as needed to provide dignity. Review of Resident #8's tasks for bladder incontinence revealed no entries for the third shift (11 p.m.-7 a.m.) on 05/25/2025. No entries for the first shift (7 a.m.-3 p.m.) on 05/18/2025. No entries for the second shift (3 p.m.-11 p.m.) on 05/04/2025, 05/25/2025, and 05/27/2025. During an interview on 05/27/2025 at 02:00 p.m., Resident #11 stated staff was slow with answering call lights. He stated on average it takes twenty to thirty minutes after he has soiled himself for staff to answer his call light. There have been a few times he has had to wait up to an hour. This happens mostly in the afternoon and at midnight. Resident #11 said, It is especially long, any time after 05:00 p.m. to morning. He stated on the morning of 05/27/2025, he waited an hour and a half with a soiled brief. He stated he had turned on the call light and someone turned the call light off. Resident #11 said, I told the person not to do that if they are not going to provide the care. He said this was the second time he had been left in a soiled brief and had to wait for someone to answer his call light. He said, They are typically short staffed, which is why it took so long for the staff to get to me on 05/27/2025. Review of Resident #11's admission record revealed an admission date of 04/09/2025. Resident #11 was admitted to the facility with diagnosis of non-displaced commuted fracture of shaft of right tibia, muscle wasting and atrophy, difficulty in walking, need for assistance with personal care, benign prostatic hyperplasia without lower urinary tract symptoms, post procedural urethral stricture. Review of Resident #11's 5 Day MDS dated [DATE], revealed Section C. Cognitive Patterns, a BIMS of 14 out 15 showing intact cognition. Review of section GG. Functional Abilities revealed for Toileting hygiene Resident #11 is dependent on showing helpers do all the effort. Residents does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the residents to complete the activity. For Toilet transfer Resident #11 needs substantial/maximal assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 8 of 16 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 05/28/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showing helpers do more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of section H. Bladder and Bowel revealed resident #11 is occasionally incontinent for bladder and bowel. Review of Resident #11's Care Plan Dated 04/10/2025 revealed an ADL focus showing an ADL Self Care Performance Deficit. Initiated on 04/10/2025 and revised on 04/10/2025. The goal showed: Will have ADL needs anticipated and met by staff through next review. Will achieve functional level by the next review date. Interventions included Bladder: Occasional incontinent-uses urinal; Bowel: Incontinent; Toilet Use: Assist of one. Review of Resident #11's tasks for bladder incontinence revealed no entries for the first shift (7 a.m.-3 p.m.) on 05/18/2025, 05/21/2025, and 05/24/2025. No entries for the second shift (3 p.m.-11 p.m.) on 05/26/2025, and 05/27/2025. During an interview on on 5/27/25 at 6:30 a.m. Staff J, Certified Nursing Assistant (CNA), who was crying throughout the interview, stated her and another aide had the 100-200 halls by themselves with twenty-something residents. Staff J, CNA reported a resident had complained about the care received and she had explained she had not seen the call light on and the nurse was providing 1:1 care with a roommate and someone had shut the call light off twice. Staff J reported the nurses working on 5/27/25 had not assisted with care. During an interview on 5/27/25 at 7:57 a.m. Staff L, CNA, reported working 11 p.m. -7 a.m. shift (last night) and stated they had some run-ins down there nodding head to end of 400-hall. The staff member stated some residents needed to be changed and that they could not leave it for the 7 a.m. - 3 p.m. shift. During an interview on 5/27/25 at 8:11 a.m. with Staff E and K, CNA, reported 1-2 times a week thing are left over from the 11 p.m. - 7 a.m. shift. Staff K reported they had informed management of the need for additional staff. The staff members stated even the 7 a.m. - 3 p.m. shift was heavy, it was just the 2 of them for the hallway and everyone was totally dependent. They stated they had to shower residents, feed them, and get them ready for appointments. Staff E and K stated they were not blaming 11-7 shift for things being left because one aide could not do it all. During an interview on 05/28/2025 at 11:40 a.m., Staff F, CNA stated she helps residents with hygiene care daily. She has a few residents on her assignment who are incontinent. These residents need their briefs changed and help with toileting care. Residents usually put their call lights on to let me know when they need to be changed. I check on the residents through out my shift when I have the time. During an interview on 05/28/2025 at 11:55 a.m., Staff G, CNA stated she helps residents with getting dressed and out of bed. She stated residents who needed incontinence care ring their call light when they need to be changed. Staff G said, I check on residents periodically throughout my shift. During an interview on 05/28/2025 at 1:02 p.m., Director of Nursing (DON), stated she was not aware of resident not getting incontinent care. When she started in November 2024, they had an issue with residents not receiving care during the night shift. The DON stated after these incidents the Assistant Director of Nursing (ADON) did education on walking rounds, and nurse to nurse reporting. She stated the walking rounds are for staff to ensure residents are clean and dry, and making sure their needs are being met. The DON stated the CNAs should be documenting when they provide care in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 9 of 16 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 05/28/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm documentation software, under the task tab. She stated there should be documenting from each shift. The DON stated the residents should be checked every 2 hours to see if they are soiled and if they need to be changed. She reviewed the bladder incontinence task for Resident #4 and stated there should be documentation for each shift. The DON said, We are struggling with staff because we have a lot of people on 1 to 1 care. Residents Affected - Few Review of the facility's policy titled Bowel and Bladder Continence Program, dated October 2021 revealed: Overview - To evaluate incontinent resident/patient to determine the appropriate continence program. To assist individual residents/patient in regaining continence to their maximum functional potential. To promote skin integrity. To reduce the potential for urinary tract infections. To promote independence and self-esteem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 10 of 16 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 05/28/2025 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 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** 2. Residents Affected - Some On 5/27/25 at 7:52 a.m. an observation was made of Resident #9's doorway which showed Contact precautions were to be followed for the resident' roommate. The observation did not reveal any Personal Protective Equipment (PPE) available in the hallway near the resident's room. An interview and observation was conducted on 5/27/25 at 8:11 a.m. with Staff E, Certified Nursing Assistant (CNA) who entered Resident #9's room and pulled the privacy curtain back then reached behind the door partially closing door and obscuring view from hallway. Staff E did not don PPE. An interview was conducted on 5/27/25 at 9:10 a.m. with Staff D, Registered Nurse (RN) in the hallway near Resident #9's room. The staff member stated the resident was on contact precautions due to bacteremia. Review of the floor map provided by the facility on 5/27/25 showed Enhanced Barrier Precautions for B-bed in Resident #9's room. Review of Resident #9's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to bacteremia and methicillin resistant staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere. Review of Resident #9's Order Summary Report, active as of 5/28/25 at 4:26 p.m., showed an order, dated 5/22/25 for Enhanced Barrier Precautions (EBP) related to (r/t) intravenous (IV) access and wounds every shift for infection prevention and control. The report included an order, dated 5/27/25, for Contact Precaution for Bacteremia and Extended-Spectrum Beta-Lactamase (ESBL) in the wound every shift. The Order Summary included the following orders: - Ceftaroline Fosamil Intravenous solution reconstituted 600 milligram (mg) - Use 600 mg intravenously three times a day for bacteremia for 23 days. 600 mg in sodium chloride 0.9% 100 milliliter (ml) intravenous piggyback (IVPB), start date 5/23/25 - end date 6/15/25. - Daptomycin Intravenous solution reconstituted 500 mg - Use 500 mg intravenously one time a day for bacteremia for 21 days, start date 5/24/25 - end date 6/15/25. The Order Report included orders for wound care to right inner thigh, right side of abdomen (inside wound), wound on right side abdomen, and sacrum. Review of Resident #9's 3008-5000 form, dated on 5/15/25 with a fax date of date of 5/22/25 at 8:45 a.m. showed the resident had Infection control Issues of Methicillin-Resistant Staphylococcus aureus (MRSA) in the nares and ESBL in wound, requiring Contact Isolation Precautions. Review of Resident #9's care plan report revealed the following focuses and interventions: - Infection: (Resident #9) has an infection, Blood Infection/Bacteremia, initiated on 5/22/25. The interventions included Enhanced Barrier Precautions - dated 5/22/25 and Contact Precaution initiated 5/27/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 11 of 16 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 05/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Actual Wound: The resident has an ACTUAL wound to right side abdomen, right inner thigh, sacrum, (and) right lower abdomen, initiated on 5/22/25 and revised on 5/27/25. The interventions included: Enhanced Barrier Precaution - initiated on 5/27/25. An observation on 5/27/25 at 12:48 p.m. revealed a sign for Enhanced Barrier Precautions had been posted on the door frame of Resident #9's room. The sign showed both Resident #9 and B bed were to be cared for utilizing Enhanced Barrier precautions. The observation showed a white mesh bag hanging behind the door without evidence of Personal Protection Equipment (PPE). The hallway outside of the resident's room did not have PPE available nearby. An observation was conducted on 5/27/25 starting at 12:48 p.m. of rooms posted with precaution signs (Enhanced and Contact). The following rooms were posted with no available PPE: 5/27/25 at 12:48 p.m. room [ROOM NUMBER], EBP posted for A and B beds. No PPE in white mesh bag hanging from back of door. 5/27/25 at 12:53 p.m. room [ROOM NUMBER], EBP posted for A and C beds. No PPE in white mesh bag hanging from back of door. 5/27/25 at 12:54 p.m. room [ROOM NUMBER], EBP posted for A and B beds. No PPE in white mesh bag hanging from back of door. 5/27/25 at 1:02 p.m. room [ROOM NUMBER], EBP posted for A and B beds. No PPE in white mesh bag hanging from back of door. Not shown as EBP or Contact on map provided by the facility. An interview was conducted on 5/28/25 at 3:04 p.m. with the Infection Preventionist (IP) and the Director of Nursing (DON). The IP described EBP as a barrier to protect the resident from us when they have a port of entry. Contact was if the resident had a multi-drug resistant organism (MDRO), MRSA, when we make sure to prevent cross infections. The IP reported looking at the form 3008 (to see) if they have skin issues, wound issues, or any type of lines, looks at the whole 3008. The DON stated there was only one person on contact precautions (not Resident #9). The ADON stated the same color of signs for EBP and Contact was causing issues and nobody on the 400-hall should be on contact precautions. The IP stated Resident #9 was on EBP and did not know what type of bug the resident had. Resident #9's 3008 diagnoses of MRSA in nares and ESBL in wounds were revealed to the staff members, the IP stated the resident should be on Contact precautions with PPE available outside of the room and inside the room for EBP. The DON stated nursing and central supply were responsible for stocking PPE and the facility had used the mesh bags (for storing PPE) hanging inside the door since before she came to the building. Review of the Centers of Disease Control Prevention website, dated 4/11/2024, linked here: https://www.cdc.gov/esbl-producing-enterobacterales/ showed Extended-spectrum beta-lactamase (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 12 of 16 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 05/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm (ESBL)-producing Enterobacterales are resistant to common antibiotics and may require complex treatments and good infection prevention practices can help reduce infection risk. ESBL- producing Enterobacterales can spread through dirty hands and surfaces from person to person. Review of the policy and procedure - Barrier Precautions, effective April 2024, described the following: Residents Affected - Some - Contact Precautions are used when the employee expects to be in direct or indirect contact with a patient in/ or his or her environment including the person's room or objects in contact with the person, that has an infection with an Organism transmitted fecal-orally, such as Clostridium difficile, or wound and skin infections, or multi-drug resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). PPE required before entering a contact precaution designated rim is always gloves and a gown. Mask and eye protection are additionally required of contact with bodily secretions is possible. - Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission or multi-drug resistant organisms that employ targeted gown and glove use during high contact resident activities. EBP Are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP Is indicated for residents with any of the following: -1. Infection or colonization with a Centers of Disease Control and Prevention (CDC)- targeted multi-drug resistant Organism when contact precautions do not otherwise apply or, -2. Wounds and/ or indwelling medical and devices even if the resident is not known to be infected or colonized with a multi-drug resistant Organism. Based on observations, interviews and record review, the facility did not ensure appropriate isolation precautions were initiated for two residents ( #10 and #9 ) of three residents sampled and failed to ensure personal protective equipment (PPE) was supplied for residents on isolation precautions for five rooms (101,409, 413, 408 and 305) out of twenty rooms observed. On 5/27/2025 at 8:32 a.m., an observation was made in front of room [ROOM NUMBER] with a blue sign outside the door and Contact Precautions was indicated for resident in bed A. There was no PPE observed outside the door. An interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B, LPN stated the resident in bed B was on Contact Isolation for having a peripherally inserted central catheter (PICC) line. Staff B stated the PPE was located behind the door inside the residents' room. Staff B stated any resident with wounds, catheters, central lines, dialysis and catheters are placed on Contact Isolation. The Contact Isolation sign was read out loud to Staff B related to wearing gown and gloves before entering the room and the sign indicated the resident in the A bed was on Contact Isolation. Staff B, LPN stated the resident in the B bed was on the Contact Isolation for the PICC line. On 5/27/2025 at 9:04 a.m., an observation was made of Resident #10 with a blue Enhanced Barrier Precaution sign. On 5/28/2025 at 9:10 a.m., an observation was made outside Resident #10's room with a white sign with a red stop sign and the words Contact Precautions and a cart in front of the room in the hallway (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 13 of 16 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 05/28/2025 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 0880 with PPE supplies. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #10's admission Record showed an admit date of 5/16/2025 with diagnoses to include but not limited to osteomyelitis of vertebra, cervical region and Klebsiella pneumoniae as the cause of diseases classified elsewhere. Residents Affected - Some A record review of Resident #10's Minimum Data Set (MDS), Section I-Diagnoses, dated 5/20/2025, under Infections I1700 showed Multidrug-Resistant Organism (MRDO) checked YES as a diagnosis for the resident. A review of current physician orders showed an order dated 5/27/2025 for Contact Isolation related to MRSA (Methicillian Resistant Staphylococcus Aureus) in surgical wound every shift. A review of Resident #10's care plan showed a Focus area of Infection- the resident has an infection initiated on 5/16/2025. Interventions include but are not limited to: Contact Precaution initiated on 5/27/2025. Enhanced Barrier Precaution initiated on 5/27/2025. Resolved: Type of Isolation required: (Specify)initiated on 5/16/2025 with a revision date of 5/20/2025 and a resolved dated of 5/20/2025. Resolved: Standard Precautions with an initiated date of 5/20/2025, revised on 5/27/2025 and resolved on 5/27/2025. A review of Resident #10's care plan showed a Focus area of IV (intravenous) Medications related to ESBL (Extended-Spectrum Beta-Lactamase) cervical fluid initiated on 5/20/2025. Interventions include but are not limited to: Enhanced Barrier Precautions initiated on 5/20/2025. On 5/28/2025 at 3:03 p.m., an interview was conducted with the Assistant Director of Nursing/Infection Control Preventionist (ADON/ICP). The ADON/ICP stated residents are placed on Enhanced Barrier Precaution when a resident has a means of an entry such as wounds and catheters of any kind. The ADON/ICP stated residents should be placed on Contact Precautions if there is a multi-resistant bacterium such as MRSA, ESBL and other MDROs for the protection of others. The ADON/ICP stated she will review discharge hospital orders, 3008 and labs to determine isolation precautions. The ADON/IPC stated Resident #10 was initially placed on Enhanced Barrier Precaution 5/20/2025 but agreed she should be on Contact Isolation secondary to her diagnosis of MDRO. The ADON/ICP stated the resident in room [ROOM NUMBER]-A should be on EBP and not Contact Isolation and corrected the confusion. The ADON/ICP stated the resident in the B bed does not require isolation precaution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 14 of 16 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 05/28/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to ensure their pest control program was effective during two (05/27/2025 and 05/28/2025) of two days of survey. Residents Affected - Some Findings included: During multiple facility tours on 05/27/2025 and 05/28/2025, observations were made of live insects in the dining hall/activity's area in 400 and 100 halls as follows: On 05/27/2025 at 06:30 a.m., a live insect was observed in the 400-hall, near the conference room. The insect was live and crawling across the floor. On 05/27/2025, at 06:48 a.m. live insects were observed in the dining hall/activity area. The insects were small flying insects observed landing on surfaces around the dining area. During this observation residents were observed in the area. On 05/28/2025 at 09:25 a.m. a live insect was observed near the 100-hall of the facility. The insect was observed crawling. There were various levels of staff near the area at the time. On 05/28/2025 at 02:29 p. m. an interview was conducted with a resident in room [ROOM NUMBER]. The resident stated there were roaches in their room and staff was notified. The resident could not recall who was notified, nor the day the report was made. The resident reported the drawers were cleaned out and everything was sprayed but there were still roaches in the room. Review of facility documents titled Service Inspection Reports (invoices) showed pest sightings were documented with on-going treatments for flies, rats, ants, and roaches. On 05/28/2025 at 03:10 p.m. an interview was conducted with the Director of Maintenance (DOM). He stated there were no roaches, however, there are similar bugs (a named Florida bug). He stated they typically come after the rain. He stated it was a Florida thing, and that there isn't much that can be done about it. He stated a pest control vendor does treat the bugs. He stated he was not aware of any complaints in regarding to pests in the building. During an interview on 05/28/2025 at 11:47a.m., the Nursing Home Administrator (NHA) stated he took care of the roach that was found this morning in the common area. He stated he called the Pest control company, and they will be out tomorrow. He stated Pest control was just here on Monday, and they come out weekly. He stated if he had an emergency that took place and needed pest control to come out he would call. The NHA sated he does not call pest control for single incidents. The NHA confirmed they have had roaches since he started in May. Review of a facility policy titled Pest/Insect Control, effective August 2024 showed the facility strives to protect residents, staff, and visitors from insects and other pest by controlling infestation through contracts with outside pest control agencies. Each facility will contract with a pest control agency. 1. Contract with a pest control agency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 15 of 16 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 05/28/2025 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 0925 2. Maintain a copy of the contract in a designated file in the facility. Level of Harm - Minimal harm or potential for actual harm 3. Maintain a log of services provided. 4. Evaluate effectiveness of services and contact pest control agency if additional services are needed. Residents Affected - Some (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105269 If continuation sheet Page 16 of 16