Inspection·July 31, 2025

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 interview, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was accurately completed for 2 of 6 residents reviewed (Residents #11, and #19). Residents Affected - Few Findings include: 1) Review of Resident #11’s admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to residual schizophrenia (onset date: 3/26/2019), unspecified mood (affective) disorder (onset date: 3/26/2019), adjustment disorder with mixed anxiety and depressed mood (onset date: 3/26/2019), major depressive disorder (onset date: 1/31/2024), generalized anxiety disorder (onset date: 1/31/2024), paranoid schizophrenia (onset date: 3/26/2019), and other specified persistent mood disorders (onset date: 3/26/2019). Review of Resident #11’s PASSR dated 7/10/2025 did not show persistent mood disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making. Review of Resident #11’s psychiatry subsequent note dated 7/1/2025 read, “Chief complaint: Depression, anxiety, mood disorder, schizophrenia and TD [Tardive Dyskinesia].” Review of Resident #11’s quarterly Minimum Data Set assessment dated [DATE] showed unspecified mood (affective) disorder under Section I- Active Diagnoses. During an interview on 7/31/2025 at 1:45 PM, the Director of Nursing (DON) stated, “[Resident #11’s name] PASSR needed to be updated. I did not know we could add diagnosis in the other section.” 2) Review of Resident #19’s medical record showed the resident was originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included but not limited to brief psychotic disorder (onset date: 10/12/2024), major depressive disorder (onset date: 10/12/2024), other specified persistent mood disorders (onset date: 10/12/2024), generalized anxiety disorder (onset date: 10/12/2024), cerebral ischemia, and urinary tract infection. Review of Resident #19’s PASRR dated 10/9/2025 did not show brief psychotic disorder, major depressive disorder, and other specified persistent mood disorders under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making. Review of Resident #19’s psychiatry subsequent note dated 7/8/2025 read, “Chief complaint: Depression, anxiety, dementia, mood disorder, psychosis, and Parkinson’s disease.” Review of Resident #19’s quarterly Minimum Data Set assessment dated [DATE] showed depression, psychotic, and anxiety as part of the active diagnosis under Section I- Active Diagnoses. During an interview on 7/30/2025 at 2:45 PM, the DON stated, “[Resident #19’s name] PASRR needs to be updated to include the diagnosis that were missing.” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105346 If continuation sheet Page 2 of 9 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 105346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Montgomery Health and Rehabilitation Center 1270 SW Main Blvd Lake City, FL 32055 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 record review and interview, the facility failed to ensure medications were administered as ordered by physician for 2 of 7 residents reviewed for medication management (Residents #5 and #11). Findings include: 1) Review of Resident #5's physician order dated 9/2/2024 read, Metoprolol Tartrate Oral Tablet 50 MG [Milligram] (Metoprolol Tartrate), Give 50 mg by mouth every 12 hours for Beta Blocker. Review of Resident #5's Medication Administration Record (MAR) for June 2025 for administration of Metoprolol Tartrate Tablet 50 mg showed code 4 (vitals outside of parameters for administration) was documented on 6/4/2025 at 9:00 PM for the blood pressure of 115/60 and pulse of 66, on 6/7/2025 at 9:00 PM for the blood pressure of 109/65 and pulse of 80, on 6/8/2025 at 9:00 PM for the blood pressure of 111/69 and pulse of 70, on 6/19/2025 at 9:00 PM for the blood pressure of 107/61 and pulse of 66, and on 6/21/2025 at 9:00 PM for the blood pressure of 111/69 and pulse of 62. Review of Resident #5's MAR for July 2025 for administration of Metoprolol Tartrate Tablet 50 mg showed code 4 was documented on 7/19/2025 at 9:00 AM for the blood pressure of 110/66 and pulse of 60 and at 9:00 PM for the blood pressure of 112/61 and pulse of 59, and on 7/22/2025 for the blood pressure of 105/43 and pulse of 67. During an interview on 7/30/2025 at 8:30 AM, the Director of Nursing (DON) stated, The nurses were holding the medication without an order. If they have questions, they should contact the provider and let him about their concern. During an interview on 7/30/2025 at 4:05 PM, the Medical Doctor #1 stated, Nurses should not be holding medications that do not have parameter. If they have any questions, they need to call me. This was not reported to me. No medical concerns have been reported to be recently in regards to [Resident #5's name] related to his medication. During an interview on 7/31/2025 at 3:55 PM, Staff E, Licensed Practical Nurse (LPN), stated, I held [Resident #5's name] blood pressure medication because it was low. I did not let the provider know. 2) Review of Resident #11's physician order dated 5/8/2025 read, Insulin Glargine Solution 100 UNIT/ML [milliliter], Inject 20 unit subcutaneously two times a day for diabetes if blood sugar is less than 150 hold Lantus. Review of Resident #11's MAR for July 2025 showed Lantus was administered at on 7/2/2025 at 6:00 AM for the blood sugar of 77; on 7/4/2025 at 6:00 AM for the blood sugar of 75 and at 9:00 PM for the blood sugar of 100; on 7/8/2025 at 6:00 AM for the blood sugar of 120; on 7/9/2025 at 6:00 AM for the blood sugar of 78; on 7/11/2025 at 6:00 AM for the blood sugar of 85; on 7/12/2025 at 9:00 PM for the blood sugar of 121; on 7/13/2025 at 9:00 PM for the blood sugar of 121; on 7/18/2025 at 6:00 AM for the blood sugar of 87 and at 9:00 PM for the blood sugar of 98; on 7/22/2025 at 6:00 AM for the blood sugar of 90; and on 7/27/2025 at 6:00 AM for the blood sugar of 112, and at 9:00 PM for the blood sugar of 148. During an interview on 7/30/2025 at 9:54 AM, the DON stated, [The Medical Doctor #2's name] will be taking off the parameters and she actually said [Resident #11's name] A1C [Glycated Hemoglobin] has improved. I also spoke to the medical director and he said no harm was done to the patient. I also spoke to the medical director about [Resident #5's name] blood pressure and there were no concerns with the blood pressure. He was going to discontinue one of the blood pressure medications because he had two. Nurses should always follow doctor's orders. During an interview on 7/30/2025 at 11:11 AM, Staff B, Registered Nurse (RN), stated, Usually long-acting medication is never stop and this order probably was new. I was not reading it. I read the order that shows up on the screen. I feel I should have been more careful and read the order. Also, I should contact the provider if I have any questions about the orders. We should always follow doctor's parameters. It is our obligation. During an interview on 7/30/2025 at 12:21 PM, Staff C, LPN, stated, If he [Resident #11] has parameters to hold medication, I would have definitely held it. I don't recall those days. It might have been an error, because I would hold the medication if he has parameters. During Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105346 If continuation sheet Page 3 of 9 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 105346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Montgomery Health and Rehabilitation Center 1270 SW Main Blvd Lake City, FL 32055 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 FORM CMS-2567 (02/99) Previous Versions Obsolete an interview on 7/30/2025 at 12:23 PM, Staff D, RN, stated, I don't recall. I will say this Lantus is a 24-hour insulin that would be my only reason for giving it. That is a terrible mistake. Orders should show the parameters. I know there is parameters for other insulins, and he does have some issues with blood sugar. I should have followed parameters. During an interview on 7/30/2025 at 1:01 PM, the Medical Doctor #1 stated, I have a standard for my parameters. I have not been notified of any medical concerns. I plan to stop [Resident #11's name] insulin depending on the next A1C results. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/31/2025 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Event ID: Facility ID: 105346 If continuation sheet Page 4 of 9 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 105346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Montgomery Health and Rehabilitation Center 1270 SW Main Blvd Lake City, FL 32055 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Findings include: During an observation on 7/28/2025 at 9:39 AM, nurse staffing information dated 7/27/2025 was posted immediately after entering the residential area (Photographic evidence obtained). During an interview on 7/29/2025 at 2:39 PM, the Director of Nursing stated, The scheduler is the one responsible for updating the staff posting daily. She arrives around 6 AM and by 8 AM, the posting should be updated. During an interview on 7/31/2025 at 8:19 AM, the Scheduler stated, I will normally update the staff posting when I get to the facility that is around 8 to 8:30 AM. I had it ready in the backroom on Monday [7/28/2025] and was trying to still get the numbers correct during the morning routine. I don't have access to the census. I have to wait on payroll or the Business Office Manager. During an interview on 7/31/2025 at 12:45 PM, the Business Office Manager stated, I had no delays on Monday that I recall that would have not allowed me to provide the census in a timely manner. During an interview on 7/31/2025 at 12:46 PM, the Administrator stated, There is no policy for the posting of the federal staffing, but my expectation would be that by 9:00 AM, it is posted. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105346 If continuation sheet Page 5 of 9 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 105346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Montgomery Health and Rehabilitation Center 1270 SW Main Blvd Lake City, FL 32055 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to provide laboratory services to meet the needs of the residents for 1 of 5 residents reviewed for medication management (Resident #19). Findings include: Review of Resident #19's progress note dated 7/7/2025 at 5:19 PM read, Resident daughter came to nursing reporting that mother is hallucinating, talking to someone that is not there and thinking someone is watching here. Will notify MD [Medical Doctor] and Psych [Psychiatrist]. Review of Resident #19's psychiatry subsequent note dated 7/8/2025 read, Chief complaint: Depression, anxiety, mood disorder, psychosis, and Parkinson's disease. Reason for Today's encounter: Today I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. History of present illness . Today I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. As per collected information, staff reported increased anxiety. Patient come to front lobby and pray all the time. Dementia is persisting, but no other behaviors noted. Assessment and plan: I feel the symptoms are occurring due to exacerbation of underlying depression and anxiety disorder. The symptoms occur almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms Plan of action: I have decided to continue Buspirone along with Clonazepam for anxiety and Donepezil to treat dementia. Medication rationale and adverse effects: Dry mouth, headache, drowsiness, fatigue, constipation, diarrhea, decreased appetite, increased sweating, dizziness, and insomnia. Review of Resident #19's progress note dated 7/10/2025 at 5:51 PM read, res [Resident] noted to be having conversations with past relatives. md [Medical Doctor] made aware and ua [urine analysis] ordered. vitals at baseline. plan of care continues. Review of Resident #19's physician order dated 7/11/2025 read, UA w [with]/culture and sensitivity STAT [immediately] for lab. Review of Resident #19's progress note dated 7/11/2025 at 8:36 AM read, Resident observed sitting up front by the doors and claims to be waiting on her brother. After speaking to daughter she says her mother prays and that family members talk to her through it. Her brother lives out of state and does not come down to visit. Review of Resident #19's lab result report dated 7/14/2025 showed invalid result for urinalysis w/reflex to culture. Review of Resident #19's progress note dated 7/19/2025 at 12:29 AM read, Behavior Monitoring- Observe for (specify resident's behavior). Document: 'Y' if the resident is exhibiting behaviors. 'N' if resident is not exhibiting behaviors. If 'Y' document in the PN's [progress notes]. every shift. Was a behavior observed? YES. Resident sitting in front lobby believing family is coming. Review of Resident #19's progress note dated 7/20/2025 at 7:35 AM read, Behavior Monitoring- Observe for (specify resident's behavior). Document: 'Y' if the resident is exhibiting behaviors. 'N' if resident is not exhibiting behaviors. If 'Y' document in the PN's. every shift. Was a behavior observed? YES. Resident sat up in front lobby and refused to go to bed, insisted that her brother was coming to pick her up. Review of Resident #19's progress note dated 7/21/2025 at 2:59 PM read, Resident has been sitting up front by the door. She refused to eat or take a shower. MD notified and orders put in regarding her UA. Will continue to monitor. Review of the text message conversation with the Director of Nursing (DON) dated 7/21/2025 at 12:54 PM read, [Resident #19's last name] has been refusing to eat and leave from in front of the front door for the past 3-4 days. She says she is waiting on family members who talk to her through her prayers. Her daughter says she progressed this same way at the last facility before she started attempting to leave. The U/A results show no bacteria seen but elevated WBC [White Blood Cell] leukocytes, and hyaline casts. I am trying to look into the c/s [culture and sensitivity] now. It's shown being ordered but no results are here. The C/S was invalid. We will reorder and it will go out in the morning. Can she get something in the mean time to hold over until the results come back? Review of Resident Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105346 If continuation sheet Page 6 of 9 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 105346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Montgomery Health and Rehabilitation Center 1270 SW Main Blvd Lake City, FL 32055 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #19's progress note dated 7/22/2025 at 1:26 PM read, Resident taking antibiotic treatment of UTI [Urinary Tract Infection] started on 7/21/2025. Resident continues sitting front entrance periods of times during the shift, however she has participated in meals and activities today. Resident took a nap in her bed after lunch. No s/s [signs and symptoms] of adverse reactions noted. Review of Resident #19's progress note dated 7/23/2025 at 2:55 PM read, Resident has been sitting up front by the door since I came onto shift at approx. [approximately] 8 am. She is refusing to come to bed or eat claiming she is not hungry. She is getting agitated when asked to lay down. MD notified. Daughter says she will be in after work to try and talk to her. Review of Resident #19's progress note dated 7/24/2025 at 12:11 AM read, Continues on ABT [Antibiotic Therapy] for UTI. No adverse reactions noted. temp [temperature] 97.3. Resting in bed with eyes closes. Review of Resident #19's progress note dated 7/24/2025 at 12:34 AM read, Due to the poor vitals, 911 was called. They assessed her and the resident was discharged to the hospital. Review of Resident #19's progress note dated 7/24/2025 at 1:25 PM read, patient aggressive behavior, attempting to hit at staff and push staff to stand up, educated on unsteadiness and being careful not to fall, patient replies I no fall, behavior inappropriate at this time. notified [Medical Doctor #1's name] that patient has not changed with cipro treatment for uti, asked [Medical Doctor #1's name] for a broad spectrum abt [antibiotics] while we wait for culture due to not noticing a change with patient since treatment started. new order Augmentin 500 mg bid [milligram twice a day] for 7 days. Review of Resident #19 progress note dated 7/24/2025 at 2:09 PM read, Resident was walking to the bathroom and fell from generalized weakness and fatigue. She has not been sleeping or eating well. Daughter and MD have been notified. She then refused to sit down and walk away from the winding saying she was waiting on someone. She then became combative. MD changed antibiotics for uti. No s/s or adverse reactions observed. Review of Resident #19's hospital note dated 7/25/2025 read, In the ED [Emergency Department], CT [Computed Tomography] abdomen pelvic shows no acute findings except for distended bladder, creatinine of 5.7, BUN [Blood Urea Nitrogen] 118, urinalysis with leuko esterase, concerning of mild UTI. Review of Resident #19's lab results with the collection date of 7/24/2025 and report date of 7/28/2025 documented urine culture with no growth after 48 hours. Review of laboratory order history for Resident #19 showed pending status for urinalysis w/reflex to culture on 7/11/2025, and on pending collection status on 7/14/2025 and on final status on 7/24/2024. During an interview on 7/30/2025 at 4:00 PM, the Medical Doctor #1 stated, We were in the process of finding out the reason behind [Resident #19 name] altered mental status since she was having signs of confusion. I gave the order [Urinalysis and culture and sensitivity] as a stat order. It should have been done as stat if not the same day the next day if possible. I ordered a broad-spectrum antibiotic while we were waiting for the results of the labs. From 7/14/2025 to 7/24/2025 is 10 day. The culture and sensitivity should have been done quicker. During an interview on 7/30/2025 at 4:25 PM, the DON stated, [Laboratory's name] comes Tuesday and Thursdays. They first started saying they come every day and now they only come Tuesdays and Thursdays. We have lots of problems with them. They came in on 7/11/2025 and collected the urine. The staff kept calling and they did not have the results. That is why we recollected on 7/14/2025. We have not done a performance improvement plan. The nurses kept calling to find out. Usually, the order will be placed once the urine is collected. During an interview on 7/30/2025 at 4:53 PM, Laboratory Medical Records Representative stated, Per our contract, we will collect STAT orders any day. We are not able to do cultures and sensitivity as a stat order. They have to be ordered as a regular run. The order was a stat order and the urine analysis was drop off at the hospital. Cultures take 72 hours and we are not allowed to leave it at the hospital. We let the nurses know they have to do a new order and collect for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105346 If continuation sheet Page 7 of 9 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 105346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Montgomery Health and Rehabilitation Center 1270 SW Main Blvd Lake City, FL 32055 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete regular run. We will communicate this information via the chat when the nurse is placing the order. I see an order placed on 7/14/2025 and no new order or communication with us from the facility until 7/24/2025. During an interview on 7/31/2025 at 8:23 AM, the DON stated, The urine was collected and showed no bacteria, but we were awaiting the culture and sensitivity. [Resident #19's name] was having signs and symptoms and we got psych involved also. We thought it would be psych and they saw her and adjusted her medication. There was no bacteria in the urine. That is why the doctor did not order anything until we called and requested antibiotics to be ordered while we waited for the lab results. During an interview on 7/31/2025 at 10:04 AM, Staff F, Registered Nurse, stated, The culture and sensitivity was collected and it was invalid. On 7/21/2025, I reached out to the provider and started to try to get a urine specimen to send to the lab to get a culture and sensitivity. She shares a bathroom and even though we were trying, we were able to collect it on Wednesday night [7/23/2025] and the lab came that next Thursday morning [7/24/2025]. The urine culture came back with no growth. We reached out to the provider and kept waiting on the lab. Since she had behaviors mixed with UTI, we were trying to figure out what was the underlying cause. She was ordered antibiotics, but not all worked. Review of the facility policy and procedure titled Laboratory Services and Reporting with the last review date of 1/31/2025 read, Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for timeliness of the services. Event ID: Facility ID: 105346 If continuation sheet Page 8 of 9 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 105346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Montgomery Health and Rehabilitation Center 1270 SW Main Blvd Lake City, FL 32055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was properly stored in 1 of 2 nourishment rooms. Findings include: During an observation of the nourishment room on C Hall on 7/28/2025 at 9:35 AM, there were two unlabeled and undated plastic bags containing unknown food items in the freezer. There was unlabeled and undated cloth lunch box containing unknown food item in the refrigerator drawer. During an interview on 7/28/2025 at 9:37 AM, the Dietary Manager stated the food should have been labeled and dated. Review of the facility policy and procedure titled Use and Storage of Food Brought in by Family or Visitors with the last review date of 1/31/2025 read, Policy: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the residents. Policy Explanation and Compliance Guidelines. 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. Event ID: Facility ID: 105346 If continuation sheet Page 9 of 9