Inspection·June 11, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few boots on either one of her feet. At 8:20 a.m. the aide, employee A, who was assigned to Resident #5, was interviewed about the feet soft boots/splints. Employee A revealed she knows Resident #5 and has had her on her assignment frequently. Employee A did confirm that Resident #5 did not have any soft boots/splints on her feet this a.m. and did not know why they were not on. Employee A did not know who's responsibility it was to put the boots/splints on Resident #5's feet, to include the 11-7 shift or current 7-3 shift staff. Employee A further revealed that Resident #5 has refused to wear the splints/boots on her feet at times. Employee A stated, I have not told any nurse staff of Resident #5 refusing to wear the boots/splints in the past. Employee A did not know why she would not tell the unit nurse or unit manager of this behavior. Employee A pointed out in Resident #5's room where the soft boots were located. They were pushed to the back of a shelf directly above the closet. She was not aware who maintained or cleaned the soft boots/splints either. On 6/11/2021 at 8:30 a.m. the 200/300 Unit Manager was interviewed and she revealed that staff had not told her that Resident #5 refused to wear feet soft boots/splints. The Unit Manager was aware Resident #5 was supposed to wear soft boots/splints on both of her feet while in bed and confirmed Resident #5 was not wearing the boots at this time. She revealed that the aides should be telling her if residents refuse care and services and treatments, so it could be reflected in the chart. The Unit Manager confirmed there was no indication in the chart of resident #5 refusing to wear the boots/splints on her feet, while in bed. Review of Resident #5's medical record to include the electronic record resident profile, advance directives section, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the diagnosis sheet revealed diagnoses to include: Dementia, Pressure ulcer Left heel unstageable, Osteoarthritis. Review of the current Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed, (Brief Interview Mental Score BIMS/Cognition - No score. Long Term/Short Term memory problem with Moderately impaired decision making skills); (Activities of Daily Living - Extensive assist with Transfers, Personal Hygiene, Bathing); (falls since admission - 1,) Review of the current Physician's Order Sheet dated for month 6/2021 revealed: Keep boots on both feet when resident is in bed, every shift for Skin Protection (order 5/25/2021) Bilateral ½ siderails up when in bed and as enabler Review of the nurse progress notes dated from 2/16/2021 to current 6/11/2021 revealed: 2/17/2021 04:40 - Resident in bed resting , bed low position, feet elevated on pillow. 3/30/2021 18:52 - Resting in bed with feet propped up on a pillow. Review of the current care plans with next review date 8/25/2021 revealed the following: Risk for falls and fall related injuries: generalized weakness, limited endurance, requires staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 2 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assist with transfers and ambulation. Has hx (history) of falls and indicated last fall on 5/15/2021, with interventions in place. Has potential for skin impairment/pressure ulcers r/t (related to) impaired mobility, requires staff assist to turn and reposition, incontinence of bowel and bladder functions, fragile skin, Hospice ongoing, with interventions in place to include but not limited to: Turn and reposition to promote offloading of pressure; Float heels when in bed (10/29/2020); Pressure reducing mattress to bed (10/29/2020). Is noted to have skin impairment as follows: Blackened area to L heel, ongoing Skin tear 3/28/2021 (Resolved), Skin tear right forearm 4/12/2021 4/14/2021 Pressure ulcer left heel Revised 4/14/2021 with interventions to include but not limited to: Use supportive devices to facilitate position changes/offloading (12/16/2020). On 6/11/2021 at 9:40 a.m. an interview with the Director of Nursing (DON) confirmed that if a resident is ordered and care planned to wear assistive devices to include foot boots, that the expectations are that staff follow the care plan interventions and orders. She did not know why staff have not been assisting the resident with the splint/boots the past few days during survey. On 6/11/2021 DON provided the (Medication Orders, and Care Plans, Comprehensive Person-Centered) Policy and procedure. Review of the Medication Orders Policy with revision date 2014 revealed; The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. The Recording Orders section of the policy to include #6., revealed, Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. Review of the Care Plans, Comprehensive Person-Centered Policy with revision date 2016 revealed; A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation section #4., revealed; Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: g. Receive the service and/or items included in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 3 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure one (#53) out of one resident sampled for pressure ulcers received wound care in a sanitary manner. Residents Affected - Few Findings included: The admission Record for Resident #53 indicated that the resident was initially admitted on [DATE] and more recently on 5/19/21. The record included diagnoses not limited to unstageable pressure ulcer of sacral region, stage 4 pressure ulcer of left buttock, and dependence on renal dialysis. The 5-day Minimum Data Set, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 indicating an intact cognition. The MDS indicated that Resident #53 had one stage 3 pressure ulcer and two stage 4 pressure ulcers. An observation was conducted, on 6/10/21 at 10:20 a.m., of Staff Member G, Licensed Practical Nurse (LPN) performing wound care for Resident #53's three pressure ulcers. The LPN placed a paper towel barrier on the over-the-bed table, returned to the treatment cart, placed a couple of 4x4 gauze in a drinking cup and poured Dakins Solution over the gauze. She returned to the treatment cart, removed more 4x4 gauze from an open sleeve and four vials of normal saline (ns). After donning an isolation gown and gloves the staff member assisted Resident #53 onto his right side where three dressings were observed on the sacral and buttock area. Staff G removed the larger upper sacrum dressing, she ungloved, washed hands, and re-gloved then removed with her left hand the packing material from the wound which was colored with sanguineous exudate. The staff member removed the left hand glove, re-gloved (without hand hygiene), and used a gauze soaked in Dakins solution to wipe the outside of the wound then with the same gauze she cleaned the wound bed. While pat drying the wound the staff member partially removed the dressing from the middle wound. After ungloving and regloving (without hand hygiene) she used skin prep to wipe the peri-wound . Staff G ungloved, re-gloved and used the Dakin soaked gauze to pack the large wound, then placed a Dakin gauze over the packing. She ungloved. opened a 6 x 6.5 foam dressing, donned gloves, and used the dressing to cover the large sacral wound, again partially removing the lower wounds dressing. She ungloved and washed hands. After leaving the room to retrieve another box of gloves, the staff member washed her hands, opened a package of Calcium Alginate and two (2) island dressings. She donned gloves, without performing hand hygiene, removed the dressings on left ischium and left posterior thigh, ungloved, washed hands, and re-gloved. She opened one of the four vials of normal saline, wet gauze and wiped left thigh wound then patted it dry. She ungloved, re-gloved (without hand hygiene), opened second vial of ns, squirted it on gauze, cleaned inside ischium wound then the periwound, with the same normal saline gauze used to clean the ischium wound the staff member wiped over the thigh wound which was previously cleaned. The staff member ungloved, washed hands, donned gloves, used a 4x4 gauze to pack the ischium wound, and covered it with an foam dressing. She ungloved, cut an approximately 1.5 x 1.5 corner of Calcium Alginate with scissors, re-gloved, covered the thigh wound with the Alginate then covered it with a 3x3 dressing. Immediately following the wound observation Staff G stated that the scissors had been taken from the treatment cart and cleaned with an alcohol pad, which was not observed. She confirmed that hand hygiene was to be done after removing gloves, and confirmed that she had not sanitized or washed hands after removing gloves at times. The staff member confirmed wiping across the ischium and thigh wounds with the same gauze. Staff Member G stated that it had been awhile since she had done wound care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 4 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0686 and the observation should have been done with the Wound Care Nurse who was not at the facility. Level of Harm - Minimal harm or potential for actual harm A review of Resident #53's Order Summary Report included the following orders: Residents Affected - Few - Coccyx: Clean with normal saline, pat dry. Apply skin prep to periwound, apply wet gauze with Dakins Solution, and cover with foam dressing every day and evening shift related to unstageable Pressure Ulcer of Sacral region. - Left Ischium: Clean with normal saline, pat dry. Apply skin prep to periwound, apply wet gauze with Dakins Solution, and cover with foam dressing every day and evening shift related to Stage IV Pressure Ulcer of Left buttock. - Left Posterior Thigh: Clean with normal saline, pat dry. Apply Calcium Alginate and cover with foam dressing every day and evening shift related to Stage IV Pressure Ulcer of Left Buttock. The observation indicated that Staff G had cleaned the coccyx (sacral) wound with Dakins Solution soaked gauze and not the physician ordered normal saline. The Specialty Physician Wound Evaluation Summaries included the following: - 6/7/21: -- Stage IV Pressure Wound of the Left Ischium : 2.8 x 2.8 x 0.8 centimeter (cm). -- Stage III Pressure Wound of the Left Posterior Thigh: 3.2 x 0.9 x 0.1 cm. -- Stage IV Pressure Wound of Sacrum: 5.9 x 6.4 x 1.5 cm. Review of the resident's medical record showed a document, Unavoidable Skin Breakdown, 5/25/21, indicated that Resident #53 had Chronic/End Stage Renal Disease and Chronic/End Stage Pulmonary Disease and received Renal Dialysis and received drugs that increased the risk of skin breakdown. The care plan for Resident #53 indicated that the resident was admitted with pressure wounds to the Left Ischium, sacrum, and Left posterior thigh. The related interventions instructed staff to perform wound treatments as ordered. The Centers of Disease Control and Prevention, Introduction to Hand Hygiene for Healthcare Providers, identified multiple opportunities for hand hygiene may occur during a single care episode. The guidance indicated that healthcare providers should utilize Alcohol-Based Hand Sanitizer immediately after glove removal. (https://www.cdc.gov/handhygiene/providers/index.html) The facility's Clinical Protocol - Pressure Ulcers/Skin Breakdown, revised April 2018, did not identify the procedure for completing wound care for residents but did acknowledge that the nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 5 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility did not ensure accident hazards were addressed to prevent bruising to a resident's legs for 1 (Resident #30) out 6 residents sampled in hall 400. Findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses to include history of falling, Parkinson's disease, Type 2 diabetes, Unspecified Dementia without behavioral disturbance and peripheral vascular disease. During a facility tour on 06/08/21 2:29 p.m., Resident #30 was observed in room lying in bed. Resident #30 did not respond to questions as to whether he was in pain. On 06/09/21 09:59 a.m., Resident #30 was observed in bed, bed noted high, leaning to the left. his left arm heavily bruised. A review of the admission MDS (minimum data set) dated 03/20/21 revealed: Section C: BIMS (brief interview for mental status) 05 indicating severe cognitive impairment. Section D: Resident did not have any documented concerns with mood, feelings of sadness or trouble sleeping. Section E: Resident did not have reported behavior related to psychosis, delusions, or hallucinations. Section G: Functional status: Resident requires extensive assistance, he was a two person assist for all transfers, locomotion, dressing, eating, showers, personal hygiene, and bathing. A review of Resident #30's physician's orders revealed an order to perform skin checks weekly on Wednesdays for preventative skin care. A review of Resident #30's chart revealed an admission skin check assessment dated [DATE]. The assessment noted old dry scabs on both arms and old bruises different size and stages. Review of a weekly skin check dated 5/9/21 showed new skin impairments that included, Right lower leg (front) scabs and bruises, Left lower leg (rear) scabs and bruises, RT (right) and LT (left) arms bruises and scabs, RT and LT toes scabs and bruises. An interview was conducted with Staff L, RN, Unit Manager on 06/09/21 at 02:18 p.m. regarding the observation of dark blue bruising on the resident's arms and legs. Staff L stated that Resident #30 has been injuring himself in the Geri chair. Staff L stated that the nurses had been using blankets as padding to prevent injuries. When asked if Resident #30 had been assessed for safety with the use of the chair, Staff L stated that she did not know. An interview was conducted with Staff O, RN wound care nurse on 06/09/21 at 02:28 p.m. Staff O stated that Resident #30 had sensitive skin. He stated that when the resident was admitted on [DATE], he had old bruises different sizes and stages. When asked about the injury marks on the shin, Staff O (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 6 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that he was not aware of those. When asked what he would expect if a resident had acquired new injuries, Staff O, RN stated that they should be reported and assessed. An interview was conducted with the DON (Director of Nursing) on 06/09/21 at 2:30 p.m. DON was asked about Resident #30's injuries from the Geri chair. She stated that these incidents had not been reported. When asked what she would expect to see if an equipment were causing injuries, DON stated that she would expect to see on-going assessments and notification to the doctor. The DON said, there should be a therapy referral. During an interview with the DON on 06/10/21 at 10:10 a.m., she stated that Resident should have been assessed following the injuries. On 06/10/21 12:42 p.m. Staff L, RN, Unit Manager was interviewed about the scabs on the Resident #30's shin. Staff L reported that the Resident is usually active and out and about. He gets in and out of the chair constantly, that is how he hurt himself causing all the bruising. When asked if this was addressed with the DON, Physician or Therapist, Staff L stated that it was not addressed. On 06/10/21 01:58 p.m., an interview was conducted with Staff P, PT (Physical Therapist) and Staff Q, COTA (Certified Occupational Therapists.) Staff P stated that Resident #30 was on therapy when he fell, and that they had continued to work on transfers to Geri chair from 3/16/21 to 5/3/21. Staff P stated that Resident #30 was discharged from therapy because his transfers stayed on maximum assistance. When asked if Resident #30 had been assessed for the use of the Geri chair, Staff P stated, No, we could not find an order to assess. Staff P stated that Resident #30 was standing up at the time they ended therapy. When asked if Resident #30 had any assessments done on his use of the Geri chair or transfers following reported injuries, Staff P stated they had not. Staff P explained that if a resident has trouble with an equipment, the protocol is for nursing to report and therapy does the assessment. Staff P confirmed that this was not done for Resident #30. On 06/11/21 02:37 p.m., an interview was conducted with the DON who stated that she would expect the nurses to track and treat any wounds, scabs and injuries acquired in the facility or noted upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 7 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 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 observations, record reviews and interviews, the facility failed to ensure 1 (Resident #45) of 33 sampled residents had a urinary catheter and catheter tubing properly positioned for 3 of 4 observations made from 6/9/2021 to 6/11/2021. Findings included: On 6/9/2021 at 12:19 pm resident #45 was observed in his wheelchair (without footrests) between rooms [ROOM NUMBERS] approximately 3-4 inches of the catheter tubing was observed hanging down and dragging on the floor under resident #45's wheelchair. On 6/10/2021 at 7:09 am resident #45 was observed asleep in bed with his catheter bag lying on the floor on the right side of the bed, at that time staff H, Social Services Director entered the room and moved the Catheter bag from the floor on to the mattress of resident #45's bed. On 6/10/2021 at 2:48 pm resident #45 was observed in the hallway outside his room facing towards his room door. Resident #45 was seated in his wheelchair and resident #45's catheter bag was on the floor approximately 6 inches from the right front wheel of the wheelchair and the catheter tubing was approximately 2 inches from the right front wheel of the wheelchair. Resident #45 was observed moving back and forth using his feet and stepping on the catheter bag and tubing with his right foot, in addition resident #45 was observed pulling on the Catheter tubing and dragging the Catheter bag on the floor. Review of resident #45's medical record on 6/10/2021 revealed he was initially admitted on [DATE] and re-admitted on [DATE] with a diagnosis of obstruction and reflux uropathy, bladder neck obstruction, retention of urine and uses a Foley Catheter. Review of resident #45's Care Plan (4/8/2021 - 7/12/2021) on 6/10/2021 revealed that resident #45 had an indwelling (Foley/Supra-pubic) catheter due to obstructive uropathy with the following interventions: Provide catheter care and peri care every shift as needed. Maintain closed drainage system and keep drainage bag below level of the bladder. Review of the facility's Policy and Procedure for Catheter Positioning (Catheter Care, Urinary) Nursing Services Policy and Procedure Manual for Long Term Care (Revised September 2014) on 6/11/2021 revealed the following: Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 8 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0690 3. Level of Harm - Minimal harm or potential for actual harm The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and draining bag from flowing back into the urinary bladder. Residents Affected - Few Infection Control: 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. b. Be sure the catheter tubing and drainage bag are kept off the floor. (Photographic Evidence Obtained) During an interview conducted on 6/10/2021 at 7:09 am staff H, Social Services Director (SSD) confirmed that the catheter bag should not be on the floor. Staff H, SSD stated, No Absolutely not. During an interview conducted on 6/10/2021 at 7:33 am staff I, Personal Care Assistant (PCA) confirmed that the catheter bag should not be on the floor. Staff I, PCA stated, that it (Catheter bag) should be hung on the side of the bed and not touching the floor. During an interview conducted on 6/10/2021 at 2:55 pm Staff I, PCA confirmed that the Catheter bag and tubing should not be on the floor and that resident #45 should be monitored for proper positioning of his catheter bag and tubing. Staff I, PCA stated, that he (resident #45) usually does this every day, and we tell the nurse. During an interview conducted on 6/10/2021 at 2:59 pm Staff G, Unit Manager/Licensed Practical Nurse (LPN) confirmed that the catheter bag and tubing should not be on the floor and that resident #45 should be monitored for proper positioning of his catheter bag and tubing. Staff G, Unit Manager/LPN stated, I agree that we need to watch him with his catheter bag. During an interview conducted on 6/11/2021 at 1:58 pm the Director of Nursing (DON) Registered Nurse (RN) confirmed that the catheter bag and tubing should not be lying or dragging on the floor. The DON/RN stated, The catheter bag and tubing should be below the level of the bladder and placed on the bed frame when the resident is in bed and not on the mattress. The catheter bag and tubing should not be dragging on the floor and staff should be checking to make sure the catheter bag and tubing are not dragging on the floor and in proper placement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 9 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, record reviews, and interviews the facility failed to store medications properly in three (400-1, 300 hall, 100-3) out of seven medication carts and one (400 Hall) out of five medication storage rooms regarding unlocked medication carts, lack of refrigeration when needed, food items stored in the medication refrigerator, items not labeled with an open date and expired medications. Findings included: On 6/10/21 at 12:23 p.m., an observation was conducted with Staff Member E, Licensed Practical Nurse (LPN), of the 400-1 medication cart. The cart contained an unopened bottle of Latanoprost in a clear bag labeled from the pharmacy. The pharmacy label identified that staff were to store the unopened bottle of Latanoprost in the refrigerator. Staff E stated that the Latanoprost was delivered today and had been kept out because the other bottle for the same resident was empty. She reviewed the opened bottle of Latanoprost and determined that it still had 2-3 doses left in it. Photographic evidence obtained. On 6/10/21 at 12:40 p.m., Staff Member E reviewed the 400-hall medication room. Inside the medication refrigerator a personal cooler, tan with black polka dots, was located in an area where a vegetable bin should have been, inside the cooler were two small cans of Mountain Dew. The staff member stated the cooler should not be in the medication refrigerator. On 6/10/21 at 5:02 p.m., Staff Member D, LPN, was observed at the 300-hall nursing station on the telephone. The 300-hall medication cart was parked approximately half way down the hallway, out of sight from the nurse and unlocked. The staff member confirmed that the cart was left unlocked while unattended. The cart contained an open 30 fluid ounce bottle of Pro-Stat Max Liquid Protein. The bottle did not identify when it was opened. The LPN stated she had opened it yesterday and dated it 6/9. According to the manufacturer, Nutricia, Pro-Stat Max should be discarded 3 months after opening. (https://www.nutricialearningcenter.com/globalassets/pdfs/specialized-adult-nutrition/policyandprocedure_pro-stat-max.pdf) On 6/10/21 at 5:32 p.m., an observation was conducted on the 100 hall-3 medication cart with Staff Member F, LPN. A bottle of Novolog 100units/milliliter (u/mL) was dated that it had been opened on 5/11/21. The sticker attached to the medicine bottle containing the vial read Discard after 28 days. A review of the May and June calendar indicated that June 7 was 28 days after the vial was opened. The Unit Manager reviewed the Novolog vial. Review of the facility policy, Storage of Medications, revised November 2020, indicated that the facility stored all drugs and biologicals in a safe, secure, and orderly manner. The Interpretation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 10 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0761 Level of Harm - Minimal harm or potential for actual harm and Implementation section of the policy identified that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended and Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 11 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 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, facility file review and staff interviews, the facility failed to ensure their pest control company was effective in keeping two of thirty resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) in hallway 400 free from live ants. Residents Affected - Few Findings include: During a facility tour on 06/09/21 02:15 p.m., live ants were observed crawling on resident #30's bed, approximately 10 small black ants. An immediate follow up was conducted with Staff K, LPN. Staff K made the observation and stated, that is not good we have to get resident #30 out of that bed right away. An immediate room inspection was conducted in room [ROOM NUMBER]. Ants were noted crawling on bed (mattress and sheet), window seal, bedside table, and privacy curtain. Food remnants (green peas) were noted on the floor by the corner of the air conditioning unit. A jar of fish was observed on the table, noted to have bio growth inside the bottle. Rooms 420 to 430 were inspected to rule out infestation. room [ROOM NUMBER], located next to room [ROOM NUMBER] was noted to have ants crawling on the window seal, walls and inside bags of snacks stored on a table in the corner of the room. 06/09/21 02:26 p.m., Staff L, Unit Manager was notified of the observation. Staff L stated that she dropped the ball. Staff L stated that she should have been more vigilant about ensuring proper food storage and cleaning in resident rooms. Staff L stated that she would contact the families to let them know she would be throwing out some food items. When asked what her expectation was, Staff L stated that she will ensure food was stored in appropriate sealed containers. When asked if they have had an infestation, Staff L stated that in her 30 years she had seen ants here and there and especially this time of the year. Staff L stated maintenance will spray the area. An interview was conducted with the Director or NUrses (DON) on 06/09/21 at 2:37 p.m. She stated that the maintenance and housekeeping departments would be in the rooms cleaning right away. She stated that she was not aware there was an issue with ants. The DON stated that it was their expectation that residents would be living in clean, comfortable environment, free of ants and pests. On 06/10/21 8:45 a.m., an interview was conducted with Staff M, Maintenance. He reported that (Company Name) was contracted for pest control and that they are here today. Staff M stated that they come every 30 days and address any concerns reported and then go wing to wing spraying for pests. When asked if they had received any complaints related to ants in the resident's rooms, he stated that it is not unusual due to weather in the rainy months. When asked if there were concerns reported in hall 400 recently, he stated, yes, in room [ROOM NUMBER]. Staff M stated that any reported cases should be noted in the log in the nurse's unit. Staff M confirmed that room [ROOM NUMBER] was now the problem. Staff M stated that he was notified that ants were found in rooms [ROOM NUMBERS] and that they sprayed the rooms the night before. An interview was conducted with Staff N, Housekeeping on 06/10/21 09:36 a.m. When asked if he had encountered any ants during his cleaning routine, Staff N stated that it was not any unusual amounts. When asked if he had seen any ants in room [ROOM NUMBER], he stated that he was informed there were ants and that is why he was super cleaning the room. Staff N stated that if there are ants or pests the expectation is to notify maintenance right away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 12 of 13 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 105354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Lakeland 1919 Lakeland Hills Blvd 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/11/21 09:40 a.m. an interview was conducted with the Assistant Director (AD) of Housekeeping. When asked if he was aware of any pests in the resident rooms, AD stated that he was not aware. He stated that it was reported to him the night before and that rooms [ROOM NUMBERS] had live ants and that they were about to deep clean the rooms. When asked how often they deep clean rooms, AD stated every 3 months. When asked why there were ants in rooms [ROOM NUMBERS], he stated that some residents have a lot of food brought from outside and Housekeeping staff cannot touch it. When asked what he would do if he found items improperly stored or that were expired, he stated he would notify the unit manager. On 06/11/21 10:00 a.m. an interview was conducted with the Nursing Home Administrator (NHA). He was notified that there were problems with ants in two rooms in Hallway 400, (room [ROOM NUMBER] and 424). He stated that it was brought to his attention and that the current pest care provider was not doing a good job. He stated that they have terminated that contract and they have a new provider starting soon. The NHA stated that it was their expectation to provide a pest free environment. Review of the facility's pest control logbook documentation titled Facility inspection: Preventative maintenance daily log due by June 12,2021 revealed visits to include ants rounds conducted on 6/10, 6/7/21, 6/8/21 and 6/9/21. The documentation did not specify areas that were serviced. The facility's pest control policy, revised May 2008 states that the facility shall maintain an effective pest control program. Policy interpretation and implementation (1.) This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Residents in rooms [ROOM NUMBERS] were not able to be interviewed related to ants in their rooms. It was determined through observations, staff interviews and facility/pest control contract review, the pest control company was and is ineffective at this time related to small ants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 13 of 13