Health inspection·September 28, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to assure the accuracy of the Pre-admission Screening and Resident Review (PASRR) for two residents (#14 and #45) related to the diagnosis of a Serious Mental Illness (SMI) and/or an Intellectual Disability out of six sampled residents. Findings included: 1) Review of Resident #14's PASRR, dated 8/27/14, revealed no indication the resident had a mental illness or a related condition. A review of Resident #14's admission Record identified an original admission date of 2/27/15 and recently readmitted on [DATE]. The diagnoses information revealed the following diagnoses and onset dates: - Unspecified intractable epilepsy with status epilepticus, onset 4/29/22; - Unspecified schizophrenia, onset 4/30/16; - Unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, onset 3/29/16; - Unspecified psychosis not due to a substance or known physiological condition, onset 2/27/15; - Unspecified bipolar disorder, onset 2/27/15; - Unspecified anxiety disorder, onset 4/30/16; - Unspecified recurrent major depressive disorder, onset 10/1/15; - Unspecified mood (affective) disorder, 2/27/15. The mental illnesses and a neurological condition that was included on Resident #14's admission Record had onset dates on or later than the residents original admission date. 2) Review of Resident #45's PASRR, dated 7/14/20, revealed no indication the resident had a mental illness or a related condition. A review of Resident #45's admission Record identified an original admission date of 7/14/20 and a readmission on [DATE]. The diagnoses information revealed the following diagnoses and onset dates: - Unspecified severity vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, onset 7/14/20; - Unspecified recurrent major depressive disorder, onset 3/8/22; - Unspecified anxiety disorder, onset 10/28/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The mental illnesses and a neurological condition that was included on Resident #45's admission Record had onset dates on or later than the residents original admission date. On 9/28/23 at 10:51 a.m., the Interim Director of Nursing (DON) stated in the past the facility utilized the Assistant Director of Nursing (ADON) to submit PASRR's but currently did not have a ADON. The Interim DON reported having the ability to assess the PASRR and the Business Office Manager was also able to submit the information. She stated the facility reviews PASRR's during morning meetings and the screening should be provided to the facility prior to admission. She stated she would have to ask Regional Nursing Consultant to determine when a PASRR should be redone or a resident reassessed. The Interim DON reviewed Resident #45's medical diagnoses and PASRR and stated the PASRR should have been corrected as it does not contain any mental illness diagnoses. A review of policy and procedure entitled PASRR Requirements Level I and Level II Florida revealed the following: Preadmission screening for mental illness and intellectual disability is required to be completed prior to admission to a nursing home. The screening is reviewed by Admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. During the admissions process Admissions or Business Development will communicate with the facility regarding prospective admissions and confirm a Level 1 PASRR has been completed. Social Services or RN will review to determine if a Serious Mental Illness (SMI) and Intellectual Disability (ID) or both exist while reviewing the PASRR form. The existence of either or both conditions triggers the requirement for a level 2 review and will be provided to the appropriate state agency by the Social Service Director upon admission. The Social Service Director/Nursing Administration will review for completion and accuracy during the clinical meeting process. A resident review must be completed when there has been a significant change in a resident mental or physical condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon having a qualifying mental health diagnosis for two residents (#26 and #64) out of six residents sampled for PASARR Level II screenings. Residents Affected - Few Findings included: 1. A review of the admission Record showed Resident #26 was admitted on [DATE] with diagnoses of schizophrenia, major depressive disorder, and anxiety. Review of Resident #26's PASRR Level I Assessment, dated 07/14/20 revealed a qualifying mental health diagnosis of schizophrenia and no PASARR Level II was required. A review of Section I Active Diagnosis of the Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a diagnoses to include schizophrenia, major depressive disorder, and anxiety. On 09/28/23 at 11:00 a.m., the Director of Nursing (DON) stated the diagnoses should be listed on the PASSAR and the document was inaccurate. She stated she would get with the regional team to see when a Level II should be submitted. On 09/28/23 at 11:15 a.m., the DON stated when she resubmits the PASSR with corrections, then it would automatically tell them to submit a Level II. 2. A review of the admission Record showed Resident #64 was admitted on [DATE] with diagnoses of schizophrenia, and anxiety. Review of Resident #64's PASRR Level I Assessment, dated 04/06/2023 revealed a qualifying mental health diagnosis of schizophrenia and a Level II PASRR was not required. A PASRR Level II Assessment was not completed for Resident #64. On 09/28/23 at 10:52 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the diagnoses should be listed on the PASRR Level I and the PASRR was inaccurate. A Policy and Procedure for PASRR Requirements Level I and Level II - Florida, dated on the bottom, effective February 2021. Under the Procedure for a PASRR Level I revealed: 2. Social Services or RN (Registered Nurse) will review to determine if a Serious Mental Illness (SMI) and Intellectual Disability (ID) or both exist while reviewing the PASRR form. The existence of either, or both, condition (s) triggers the requirement for a Level II review and will be provided to the appropriate state agencies by the Social Services Director upon admission. The Social Services Director/Nursing Administration will review for completion and accuracy during the clinical meeting process. Recommendations will be implemented into the resident's plan of care then the document will be filed in the resident record. RN will review the Florida 3008 form for completion of all sections prior to submission of the PASRR Level II for review. Procedure for Level II: 3. Level II PASRR must be completed if the below are listed but not limited (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 0645 to: the resident has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion, or diagnosis of SMI, ID or both and . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to provide a physician-ordered and resident preferred diet to one resident (#45) out of three residents sampled for nutrition. Residents Affected - Few Findings included: An observation with Resident #45 was conducted on 9/26/23 at 10:05 a.m. revealed a clean sandwich baggie, undated, containing an unknown type of sandwich, an opened milk carton on the over-the-bed table. The resident was observed with arthritic-deformed bilateral hands and able to open the thumb and index fingers minimally. An observation on 9/26/23 at 12:29 p.m., with Resident #45 revealed the resident sitting up in bed with a plate of a vegetable blend of broccoli, carrots, and cauliflower and large-size helping of white rice with a feeding utensil in it, a dessert cup contained grapes and a peanut butter and jelly sandwich was in a clear plastic bag. The observation identified no staff was assisting the resident with eating. A full juice cup containing a red-colored liquid, without a lid was observed out of the residents arm reach, the cup did contain a plastic straw. The resident was repeating something this writer was unable to understand. Staff C, Certified Nursing Assistant (CNA), arrived to the room and reported really busy in this room, (only one other resident was in the room). The staff member reported being unable to understand the resident and Staff K, CNA, would be able to. Several sugar packets were observed on the meal tray and Staff C picked up the cup and commented it appeared to have sugar in it. Staff C reported rice was not a finger food and Resident #45 began laughing. Staff K arrived to the residents bedside and assisted the resident with the red-colored juice. Staff K stated rice was not a finger food and the resident did need assistance with eating at times. Resident #45's diet ticket, which was on the meal tray, identified the resident was to receive FINGER FOODS and an Alternate Starch. Staff C opened the sandwich and it contained a minimal smearing of peanut butter and jelly and was made with the heel of the bread loaf. (Photographic evidence was obtained) A review of Resident #45's Order Summary report, as of 9/27/23 at 4:29 p.m., revealed a physician order, dated 11/8/22 that the resident was to receive Finger Foods diet, regular texture, regular (thin) consistency for diet. The Nutrition Evaluation Comprehensive, dated 8/14/23, identified Resident #45 was to receive finger foods and staff were to refer to food preferences. A review of the Resident #45's care plan revealed Resident #45 had a potential for a nutritional problem and staff were to offer Diet as ordered (Refer to POS for current order). An interview was conducted on 9/26/23 at 12:47 p.m. with Staff L, cook. The staff member reported a piece of meatloaf (menu item) would be placed on a piece of bread and cut up for a finger food diet. Staff L reported rice was considered a finger food then stated rice is not what she would consider a finger food but California-blend vegetables are finger foods. On 9/27/23 at 1:21 p.m., the Registered Dietician (RD) described finger food as easy to pick up for people who can't eat with utensils or adaptive equipment isn't appropriate. The RD stated rice is not an appropriate finger food and believed therapy screened for use of a 2-handle cup for Resident #45. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A therapy referral, dated 5/12/23, identified a referral was made to Occupational Therapy due to a diagnosis of Rheumatoid Arthritis (RA) and decreased intake of meals was noted. The Director of Rehab (DOR) stated on 9/27/23 at 2:18 p.m., Resident #45 had been screened for adaptive equipment in August by the previous Occupational Therapist. The facility failed to provide the Occupational Therapist notes per request. The Speech Therapist stated on 9/27/23 at 2:19 p.m., Resident #45 had been screened twice recently and needed a Occupational Therapy evaluation regarding the possible use of a two-handled cup for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review the facility failed to accurately follow up on pharmacy recommendations for two residents (#81 and #9) of five residents sampled for unnecessary medications. Residents Affected - Few Findings included: 1. Review of the admission record revealed Resident #81's date of admission was 11/1/2022 with diagnoses to include metabolic encephalopathy, cognitive deficit, unspecified dementia with severe agitation and other behavioral disturbance, restlessness, and agitation. Review the document titled, Note to Attending Physician/Prescriber, dated 8/1/2023, documented: [Resident #81's] condition was stable and attempt dose reduction to Seroquel 100 mg (milligram) at bedtime to 75 mg at bedtime and Depakote 1000 mg at bedtime to 750 mg at bedtime. Review of the document titled, Consultant Pharmacist's Medication Review Recommendations Pending a Final Response, dated 9/1/2023 and 9/4/2023, revealed Resident # 81 recommendations dated 8/1/2023 for a decrease in Seroquel 100 mg at bedtime to Seroquel 75 mg at bedtime and Depakote 1000 mg at bedtime to 750 mg at bedtime as still pending. Review Resident # 81's active physician orders, dated 9/1/2023 to 9/27/23, revealed orders for Quetiapine Fumarate (Seroquel) 100 mg in the evening for bipolar and Depakote ER 500 mg 2 tablets (tabs) in the evening for bipolar. Review of Medication Administration Record (MAR) for August 2023 and September 1-27, 2023, showed resident received Seroquel 100 mg at bedtime and Depakote ER 500 mg 2 tabs at bedtime as ordered. 2. Review of the admission record revealed Resident # 9 date of admission was 11/25/22 with diagnoses to include Type 2 Diabetes Mellitus, muscle wasting, quadriplegia, and hyperlipidemia. Review of the document titled, Note to Attending Physician/Prescriber, dated 8/1/2023, documented: [Resident # 9] is currently receiving Lantus/Basaglar 20 Units SQ (subcutaneous) HS (bedtime). The document revealed the resident was receiving sliding scale insulin and per the recommendations included in the CMS (Centers for Medicare and Medicaid) guidelines identified continued or long-term need for sliding scale insulin for non-emergency coverage may indicate inadequate blood sugar control. The recommendation was to increase the basal insulin dose by 2 units to a total of 22 units SQ daily at HS. Review of the document titled, Consultant Pharmacist's Medication Review Recommendations Pending a Final Response, dated 9/1/2023 and 9/4/2023, revealed [Resident #9's] recommendation for increase in basal insulin to 22 units SQ daily at HS as still pending. Review Resident # 9's active physician orders, dated 9/1/2023 to 9/27/23, revealed orders for Lantus/Basaglar 20 units SQ at HS for diabetes. Review of MAR for August 2023 and September 1-27, 2023, showed resident received Lantus/Basaglar 20 units SQ at HS for diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 An interview was conducted on 9/27/2023 at 2 PM with the DON and Regional Nurse Consultant (RNC). The DON responded to the incompletion of recommendations within 30 days from the pharmacy. Per the DON the consultant pharmacist sends a document called Consultant Pharmacist's Medication Review Recommendations Pending a Final Response to the DON. On 9/28/2023 at 12:30 p.m. a voice mail was left with the Consultant Pharmacist requesting a return call, no response had been received by the survey exit date of 9/28/2023. A review of the policy titled Changes to Long Term Care Pharmacy Services 483.45, effective 11/18/2016, identified the following: Requirement 2: 1. Irregularities are reported to the medical director, attending physician and director of nursing 2. Response to monthly drug regimen should be completed within 30 calendar days 3. Response to irregularities requiring urgent action will include prompt notification to direct care nurse for immediate action. A review of the document Organizational Aspects Consultant Pharmacist Services Provider Requirements section 1.3 revised 11/2016 identified the following: 1. 4 c. Review and follow-up to previous month's recommendations with the nursing care staff, 2. 4 d. Medication Regimen Reviews (MRR) for each skilled Nursing (SNF) resident at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards 3. 4 w. Exit with the nursing care center's director of nursing, and administrator or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 the medication error rate was less that 5.00%. Thirty-two medication administration opportunities were observed and three errors were identified for two residents (#51 and #83) of five residents observed. These errors constituted a 9.38% medication error rate. Residents Affected - Few Findings included: 1. On 9/26/23 at 8:45 a.m., an observation was made of Staff I, Licensed Practical Nurse (LPN), the nurse dispensed the following medications for Resident #51: - Acidophillus capsule - Gabapentin 300 milligram (mg) capsule - Carvedilol 3.125 mg tablet - Eliquis 5 mg tablet - Furosemide 20 mg tablet - Fluoxetine 20 mg tablet Staff I confirmed six tablets/capsules had been dispensed prior to entering Resident #51's room. The staff member administered the dispensed medications to the resident then left the room. A review of Resident #51's September Medication Administration Record (MAR) identified the resident was also scheduled at 9:00 a.m. to receive Lisinopril 5 mg tablet and Metformin 1000 mg tablet, both of which Staff I documented had been administered at the same time as the observed six medications. 2. On 9/26/23 at 9:07 a.m., an observation was made of Staff J, Licensed Practical Nurse (LPN), The nurse dispensed the following medications for Resident #83: - Oyster Shell Calcium 500 mg over-the-counter (otc) tablet - Multi Vitamin with mineral otc tablet - Probiotic (sacc boulardii) 500 mg otc tablet - Iron 325 mg otc tablet - Carbamazepine Extended Release (ER) 100 mg - 2 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 - Carbamazepine ER 400 mg tablet Level of Harm - Minimal harm or potential for actual harm - Levetiracetam 750 mg tablet - Topiramate 50 mg tablet Residents Affected - Few - Sertraline 150 mg capsule - Spiriva 1.25 microgram (mcg) activation inhaler - Flonase nasal spray Staff J confirmed 10 tablets/capsules, one inhaler, and one nasal spray had been dispensed for Resident #83. The staff member administered the oral medications, educated the resident to exhale all air then administered one inhalation of the Spiriva inhaler. Staff J encouraged the resident to drink water after the administration which the resident refused. The staff member administered the nasal spray for the resident. A review of Resident #83's September Medication Administration Record (MAR) identified the resident was ordered to be administered, Spiriva Respimat Inhalation Aerosol Solution 1.25 mcg/act - 2 puff inhale orally one time a day for Chronic Obstructive Pulmonary Disease (COPD). The observation conducted with Staff J revealed Resident #83 had been administered one puff of Spiriva and not the two that had been ordered and Staff J had documented had been given. The policy - Medication Administration General Guidelines, dated 09/18, included the following: Medications are administered as prescribed in accordance with manufacturer specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they are familiarized themselves with the medication. Prior to administration, review, and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and the MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber orders are checked for the correct dosage schedule. Medications are administered in accordance with written orders of the prescriber. Verify medication is correct three (3) times before administering the medication: when pulling medication package from Med cart, when doses prepared, (and) before dose is administered. During an interview on 9/28/23 at 1147 a.m., the Interim Director of Nursing (DON) and the Staff Developement Coordinator, Staff H, stated medications are administered per following the five (5) rights: right time, right drug, right patient, right route, and right dose. The DON stated staff should not be documenting a medication was given when it wasn't. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. 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 record review, the facility failed implement an effective performance improvement plan for resident concerns voiced at resident council meetings related to diet accuracy and timeliness of meal service. Residents Affected - Some Findings included: A review of the facility' Resident Council Meeting Minutes dated 9/13/2023, 8/30/2023, 6/14/2023, and 4/12/2023 revealed the residents were voicing complaints regarding the delivery time of the meal services during the meetings. An interview was conducted with the facility Resident Council President (RCP) on 9/25/23 at 1:16 PM . The RCP stated, Its terrible man. It comes late, it comes early. Day to day you don't know what your going to get. An observation of the facility' breakfast meal service was conducted on 9/26/2023. The observation revealed the following related to meal deliveries for residents: Cart Times Scheduled Time Actual Time 100 Hallway 7:05 - 7:20 AM 7:38 AM 200 Hallway 7:20 - 7:35 AM 7:57 AM Dining room [ROOM NUMBER]:35 - 7:50 AM 8:14 AM 400 Hallway 7:50 - 8:05 AM 8:29 AM 300 Hallway 8:05 - 8:20 AM 8:47 AM An interview was conducted with the facility's Dietary Manager on 09/26/23 at 09:10 AM. The Dietary Manager (DM) acknowledged the delivery times and stated, The staff were really nervous this morning and I don't know why . I will do a quick in-service on my expectation and will be ready for lunch. I just think everyone was nervous and was shocked to see you this early. An interview was conducted with the facility Administrator on 9/27/23 at 3:18 PM. The Administrator stated, Yes, I'm aware of this [late tray deliveries at breakfast]. We have identified that as a concern .But we have been consistently in-consistent and therefore we have extended our audits by 3 months. On 9/28/2023 at 1:40 PM, during an interview with the Nursing Home Administrator (NHA), the NHA stated on 5/15/23, they implemented a Performance Improvement Plan (PIP) to ensure accuracy of diets, temperature of food, presentation, and timeliness of trays. The NHA stated education was started on 5/16/23 with the dietary staff for tray accuracy and timeliness of meals and started random audits of 5 trays per month. The NHA stated the audits for June 2023 showed temperature improvement, however, accuracy and timeliness had no improvement. The NHA stated the facility educated the dietary staff on accuracy and timeliness on 6/26/2023 and no other changes were implemented. In July 2023, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some audits revealed temperature remained good, however, there was no change in accuracy or timeliness. In August 2023 audits revealed no change for accuracy and timeliness. The NHA stated the facility had not implemented any other interventions to try to improve the accuracy or timeliness of dietary tray deliveries. The NHA stated they only extended the timeframe for audits. Review of the facilities Policy and Procedure titled Quality Assurance Performance Improvement (QAPI) Plan, dated effective October 2017, revealed the following: Policy: The facility will develop a QAPI Plan to describe how the facility will track and measure performance; establish goals and thresholds for performance measurement; identify and prioritize deviations for performance and other problems and issues; systematically investigate and analyze to determine underlying causes of systemic problems and adverse events; develop and implement corrective actions or performance improvement activities; monitor/evaluate the effects of corrective actions performance activities The QAPI Plan is reported to QA&A compliance committee with regular updates regarding progress with improvement activity, or corrective actions when there is unplanned or unexpected response to such activities. It is the responsibility of the QA&A compliance committee to consider all data presented by the improvement teams and to direct the teams to continue, change or conclude the assignment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to implement an effective infection control program as evidence by 1) failure to handle, store, process, and transport all linens and laundry in accordance with appropriate infection control practices to produce hygienically clean laundry for 104 out of 104 residents, and 2) failure to ensure appropriate hand hygiene was completed after delivering a meal tray to one isolation room (room [ROOM NUMBER]) of one isolation rooms, and 5 rooms (room [ROOM NUMBER], 308, 310, 311 and 313)out of 15 rooms observed for meal service. Residents Affected - Many Findings included: On 9/28/2023 at 8:03 AM an observation occurred in the central laundry room, of two washing machines. One machine had the front cover removed permitting the motor to be seen, with no clothes in the drum. The second machine was filled with pads (for placement underneath the resident), sheets and towels. The front of the machine had a rectangular blue and white box, with the Vendor name on it and the display showed, 04 Personals. (Photographic evidence was obtained) During an interview on 9/28/2023 at 8:04 AM, in front of the washing machines Staff F, Laundry Aide (LA), and Staff E, Floor Tech (FT) (who assists in the laundry if needed) confirmed one washer was broken. The other washer was filled with pads, sheets, and towels. The linens were being washed on the 04 Personals setting. Staff F, LA stated the 04-Personal cycle takes less time than the 02 Whites. They need to be able to keep up with the need for linen, and this saves time. Staff F, LA continued to state all we must do is push these arrows on the blue rectangle box to add different chemicals, such as bleach, softener, and vinegar. Staff F, LA started pressing the arrow to add 1 soap and 2 bleach. Staff E, FT was not able to state what order the arrows needed to be pushed. During an interview on 9/28/2023 at 8:24 AM, the Housekeeping and Laundry Account Manager (HLAM) stated the chemicals are set to disinfect the laundry based on what is being washed. HLAM was shown the picture of the washing machine with the sheets, pads and towels being washed on the 04-Personal cycle. HLAM stated this should not have occurred, and he would have to investigate. During an interview on 9/28/2023 at 2:06 PM, the Vendor Territory Representative (VTR) for the chemical disbursement system stated, The facility called earlier this morning and requested an equipment check of the chemical disbursement system. The system is usually checked once per month to ensure the equipment is working and dispensing properly. The VTR continued to state the Vendor company had just been out to validate the equipment last week and the equipment was functioning properly. The equipment was found to be functioning properly today, as well. The VTR stated the 04 Personal formula does not disburse bleach as compared to the 02 Whites. The cycle formulas are designed differently according to what is being washed for proper disinfection. The cycle chemical composition takes into account, time and amounts of chemical needed to ensure proper disinfection. The VTR stated personals should be kept separate as this is how formula is designed for disinfection. The VTR stated the facility staff are unable to change the formulas. The formulas are preset and only someone from the Vendor company has the ability to alter the formulas. The staff are not able to add additional chemicals by pushing buttons on any of the equipment or machines. The only way they could possibly add chemicals is by pouring them into the machine directly. On 9/28/2023 at 8:10 AM, an observation occurred in the clean laundry room, in front of the dryers. Staff G, Housekeeping Aide (HA) was observed to be folding a resident's t-shirt by utilizing her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many body as a folding table. The t-shirt was against her smock/scrub top. Staff G, HA's smock/scrub top appeared to have dried stains along the abdomen area. During an interview on 9/28/2023 at 8:13 AM, Staff G, HA confirmed folding the t-shirt against the body and not utilizing the folding table. Staff G, HA stated she had been in and out of resident's rooms earlier in the morning, as she was cleaning them. Staff F, LA informed Staff G, HA, folding needed to occur on the clean folding table and clean linens should not touch our clothes. Staff G, HA stated I did not know this, I don't recall this from my training. During an interview on 9/28/2023 at 8:24 AM, the HLAM stated the expectation for folding clean linen is to utilize the folding table or hold the item away from your person. The clean linen should not touch the staff's clothing. HLAM was not sure why this was happening. During an interview on 9/28/23 at 2:30 PM, the Nursing Home Administrator (NHA) was unclear on the process for linen handling and would need to check with the facilities regional staff to determine the appropriate action to take next. During an interview on 9/28/2023 at 3:00 PM, the Director of Nursing (DON) stated, if no additional chemical could be added to the washing cycle, then there would be an Infection Control concern. The facility should rewash all the linen that was washed improperly, to ensure disinfection occurred. On 9/27/2023 at 12:08 PM, Staff A, Licensed Practical Nurse (LPN), was observed assisting with meal tray service. Staff A, LPN was observed removing a resident tray from the meal cart of the 200 unit. Staff A, LPN, approached room [ROOM NUMBER]. room [ROOM NUMBER] was observed with an Infection Control supply cart hanging on the resident door, with the sign showing Contact Isolation. Staff A, LPN walked right past the infection control supply cart and did not place any personal protective equipment on. Staff A, LPN was observed moving room [ROOM NUMBER]B's over bed table, picked up the resident's bed controller and adjusted the resident's bed sheets. Staff A, LPN exited the room. Staff A, LPN was not observed completing any hand hygiene. On 9/27/2023 at 12:47 PM, an observation occurred in the dining room of Staff C, Certified Nursing Assistant (CNA), touching a resident while assisting with setting up their tray, proceeding to the meal cart and retrieving another resident's tray without completing hand hygiene. On 9/27/2023 at 12:50 PM an observation of the Activity Director (AD) assisting with meal tray service on the 300-hallway occurred. The AD was observed exiting room [ROOM NUMBER] and proceeded directly to the meal cart to retrieve another tray. No hand hygiene was observed. The AD removed a resident meal tray from the cart, walked to room [ROOM NUMBER]. The AD entered room [ROOM NUMBER], placed the tray down on the resident's over the bed table, adjusted the table to the resident's preference and exited the room. No hand hygiene observed. The AD continued to the meal cart, removed another tray, and proceeded to room [ROOM NUMBER]. Entered room [ROOM NUMBER], assisted the resident with tray set up, including moving the over bed table. AD exited the room without completing hand hygiene. An interview occurred on 9/27/2023 with Staff C, CNA confirming no hand hygiene occurred after touching the resident and retrieving the next tray. Staff C, CNA stated, I just want to get the trays passed. I forgot to complete hand hygiene. An interview occurred on 9/27/2023 at 12:57 PM, with AD who stated, I only was helping get the trays passed, I don't usually assist. I am usually only in the main dining room. I know to complete hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hygiene each time. AD stated hand hygiene was occurring although she did not have any alcohol-based hand sanitizer on her person, nor did resident rooms have dispensers inside the doors. AD stated some rooms have sinks but not all of them. An interview occurred on 9/27/2023 at 5:01 PM with Staff A, LPN. Staff A, LPN confirmed room [ROOM NUMBER] had a physician order for contact isolation. Staff A, LPN continued to state if a resident is on contact isolation, any person entering the room would need to wear the proper PPE: gown and gloves. Staff A, LPN, confirmed when entering room [ROOM NUMBER] during meal tray service, proper PPE was not donned (put on). Staff A, LPN stated, I was rushing to assist passing trays and did not notice the sign or the infection control supply cart on the door. I should have gowned up and defiantly completed hand hygiene. I was just trying to help. During an interview on 9/27/2023 at 12:30 PM, the DON stated the expectation for entry into a contact isolation room is to have the proper PPE donned; gown and gloves, and when exiting to complete hand hygiene. The DON continued to state, hand hygiene should occur during meal tray service upon exiting of the resident room. Review of the facilities Policy and Procedure, titled Laundry Operations HCSG, with the dated 3/12/2020, revealed the following: There are six steps in the laundry process: 1) pick-up or a collection of soiled linen, 2) sorting soiled linen, 3) washing (a) washing cycle, 4) drying, 5) folding, 6) Delivery. Under section 2) Sorting Soiled Linen: Sorting soiled linen properly makes the wash cycles more effective. Soiled laundry can be broken down into an almost unlimited number of categories. In the long-term care industry, laundry handles 4 categories of soiled linen: whites (sheets, bath towels), personal clothing, kitchen work, diapers and under pads. 3) Washing Soiled Linen . The wash cycle has one purpose; to get the linens clean. There are several factors that impact the ability to get linens clean: D. The amount of time the linens spend in the wash cycles. D. Time: Cycles that run too short may not produce the results required. No other policy and procedures were produced for review by the time the survey team exiting on 9/28/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 If continuation sheet Page 16 of 16