Inspection·March 2, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #114 had walked up to this writer with another resident and stood near the end of the hallway next to an alarmed exit door. The residents were directed away by a staff member. On 2/28/23 at 10:04 a.m., Resident #114 was seen lying in bed under blankets and in the room with the resident was Staff Member U, Certified Nursing Assistant (CNA). The staff member stated the resident was on 1:1 due to exit seeking behaviors. A review of the history of a care plan item indicated that on 12/27/22, Resident #114 was identified as having a potential for elopement due to: has cognitive impairment, Brief Interview of Mental Status (BIMS) (specify), has periods of increased confusion, is exit seeking, is (I) ambulatory, wanders the unit & wanders near exit doors. The Minimum Data Set (MDS) with a target date of 12/18/22, indicated the behavior of wandering was not exhibited by Resident #114. The comprehensive assessment identified that on 12/26/22 the residents' Functional Status was independent with no physical help from staff for bed mobility, transferring, walking in room, walking in corridor, and locomotion on unit. On 3/2/23 at 3:19 p.m., Staff Member R, Social Service Assistant (SSA) reported observing Resident #114 wandering. The SSA described wandering as exit-seeking and trying the doors and windows. 3. A review of the admission Record revealed Resident #135 was admitted into the facility on [DATE] with a primary diagnosis of encounter for attention to cystostomy. A review of an order dated 01/20/23 indicated the resident may discharge home on [DATE] with home health, skilled nursing (medication management), PT (physical therapy)/OT (occupational therapy) evaluation and treatment. May discharge home with medications. No DME (durable medical equipment) needed. The Planned Discharge Summary with an effective date of 01/20/23 indicated the resident was discharging home. Section A of the Discharge (return not anticipated) Minimum Data Set (MDS) dated [DATE] revealed Resident #135 had a planned discharge on [DATE] to an acute hospital. On 03/02/23 at 3:31 p.m., Staff D, LPN, MDS, confirmed that the MDS was inaccurate. She stated it was her fault and she would modify the MDS to make the correction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 2 of 24 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 03/02/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis for four (Residents #22, #67, #64, and#126); and 2.) ensure the accuracy of a PASRR Level I for six residents (#68, #130, #74, #98, #114, and #115) admitted with mental health diagnoses of fifty-four sampled residents. Findings included: 1. A review of Resident #22's medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of dementia, schizoaffective disorder, and major depressive disorder. A diagnosis of epilepsy was added to Resident #22's medical record on 9/26/2020. A review of Resident #22's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/4/2023 revealed under Section I - Active Diagnoses, Resident #22 had diagnoses of non-Alzheimer's dementia, seizure disorder or epilepsy, depression, and schizophrenia. A review of Resident #22's PASRR assessment, dated 4/10/2020 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Schizoaffective Disorder and Depressive Disorder were checked. The assessment also revealed, under the section titled Related Condition, the checkboxes for the selection epilepsy was not checked. 2. A review of Resident #64's medical record revealed Resident #64 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. A diagnosis of depression was added to Resident #64's medical record on 10/1/2021 and diagnoses of mood disorder and bipolar disorder were added to Resident #64's medical record on 11/11/2020. A review of Resident #64's MDS assessment, with an ARD of 2/16/2023 revealed under Section I - Active Diagnoses, Resident #64 had diagnoses of anxiety disorder, depression, bipolar disorder, and mood disorder. A review of Resident #64's PASRR assessment, dated 11/11/2020 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Depressive Disorder and Other (specify) for depression and mood disorder were checked. The checkboxes for the selections Anxiety Disorder and Bipolar Disorder were not checked. 3. A review of Resident #67's medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of major depressive disorder and Alzheimer's disease. A diagnosis of schizoaffective disorder was added to Resident #67's medical record on 11/25/2022. A review of Resident #67's MDS assessment revealed under Section I - Active Diagnoses, Resident #67 had diagnoses of Alzheimer's disease, depression, and schizophrenia. A review of Resident #67's PASRR assessment, dated 11/23/2022 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selection Depressive Disorder was checked. The checkbox for the selection Schizoaffective disorder was not checked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 3 of 24 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 03/02/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4. A review of Resident #68's medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, major depressive disorder, panic disorder, and Post-Traumatic Stress Disorder (PTSD). A review of Resident #68's MDS assessment, with an ARD of 9/17/2022 revealed under Section I - Active Diagnoses, Resident #68 had diagnoses of Non-Alzheimer's dementia, anxiety disorder, depression, schizophrenia, and PTSD. A review of Resident #68's PASRR assessment, dated 6/4/2018 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Anxiety Disorder, Depressive Disorder, and Other (specify) for anxiety and depression was checked. The checkboxes for the selections Panic Disorder, and Schizoaffective disorder were not checked. The PASRR assessment also did not address under the selection Other (specify) Resident #68's diagnoses of PTSD. 5. A review of Resident #130's medical record revealed Resident #130 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. A review of Resident #130's MDS assessment, with an ARD of 2/11/2023 revealed under Section I - Active Diagnoses, Resident #130 had a diagnosis of depression. A review of Resident #130's PASRR assessment, dated 11/14/2022 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkbox for the selection Depressive Disorder was not checked. An interview was conducted 3/2/2023 at 3:29 PM with Staff R, Social Services Assistant (SSA). Staff R, SSA stated the Social Services Director (SSD) would normally be responsible for the PASRR assessments, but the former SSD left about a month ago and a new SSD just started at the facility. The SSA also stated she checked the PASRR assessments upon the resident's admission to the facility to ensure the assessment matched the resident's diagnoses and notify the SSD if anything on the PASRR needed to be changed or updated. A review of the facility policy titled admission Criteria, last revised in March 2019, revealed under the section titled Policy Interpretation and Implementation all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the PASRR process. If the level I screen indicates that the individual may meet criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the level II screening process. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. The social worker is responsible for making referrals to the appropriate state-designated authority. 6. Review of Resident #74's admission Record indicated the resident was admitted on [DATE]. The record identified that the residents' primary diagnosis was COVID-19 with a secondary diagnosis of unspecified severity (of) unspecified dementia without behavioral, psychotic, and mood disturbances and anxiety. The resident also had diagnoses at the time of admission that included unspecified schizoaffective disorder, and unspecified recurrent in remission major depressive disorder. Resident #74's diagnoses, documented in Section I: Active Diagnoses of the Quarterly Minimum Data Set (MDS), dated [DATE], identified non-Alzheimer's disease, depression (other than bipolar), and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 4 of 24 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 03/02/2023 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 0644 schizophrenia. Level of Harm - Minimal harm or potential for actual harm The PASRR, dated on 7/4/22, for Resident #74 did not identify that the resident's mental illness or suspected mental illness diagnoses of depressive disorder, schizoaffective disorder, or schizophrenia. Residents Affected - Many On 3/2/23 at 3:24 p.m., Staff R (SSA), reviewed Resident #74's PASRR and acknowledged that the PASRR did not include the resident's diagnoses and it should have been redone. 7. A review of Resident #98's admission Record indicated that the resident was admitted on [DATE] with a secondary diagnosis of unspecified Alzheimer's disease and other admission diagnoses of unspecified schizoaffective disorder, single episode (of) severe without psychotic features major depressive disorder, and unspecified anxiety disorder. Review of Resident #98's comprehensive assessment, Section I: Active Diagnoses, dated 1/1/23, identified the resident was diagnosed with Alzheimer's disease, anxiety disorder, depression (other than bipolar), and schizophrenia. On 2/28/23 at 12:42 p.m. and 3/2/23 at 9:32 a.m., a review of the electronic clinical record did not indicate a PASRR had been downloaded for Resident #98. Staff R, SSA, stated on 3/2/23 at 3:29 p.m. that Resident #98's PASRR should be uploaded into the electronic record. Staff R reviewed the miscellaneous tab and confirmed no PASRR had been uploaded and should have been by now. Staff R reported going to check with Admissions to see if they had any paperwork for the resident still to be uploaded. After the interview, on 3/2/23 at 3:29 p.m., with Staff R the facility provided a PASRR for Resident #98 dated 12/27/22 and completed by the facility. The PASRR did not identify the resident's diagnosis of schizoaffective disorder that was present upon admission. The review indicated Section II questions 1, 2, 3, and 4 of the PASRR was not completed. Section II question 5 identified the resident had a primary diagnosis of dementia, with a related neurocognitive disorder. The review of the electronic record did not identify that Resident #98 had A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness (SMI) or Intellectual disorder (ID), or both. The facility did not provide a Level II evaluation for Resident #98. 8. A review of Resident #114's admission Record indicated the resident was admitted on [DATE] with diagnoses present upon admission that included but not limited to severe dementia in other disease classified elsewhere without behavioral, psychotic, and mood disturbances and anxiety, psychotic disorder with delusions due to known physiological condition, single episode major depressive disorder severe without psychotic features, and unspecified anxiety disorder. Resident #114's admission comprehensive assessment, dated 12/18/22, identified active diagnoses of non-Alzheimer's dementia, depression (other than bipolar), and psychotic disorder. Review of Resident #114's PASRR identified it was completed at the transferring facility prior to the residents' admission. Section I of the residents' PASRR screen decision-making did not identify any Mental Illness (MI) or Suspected Mental Illness (SMI), despite the admission diagnoses of anxiety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 5 of 24 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 03/02/2023 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 0644 disorder, psychotic disorder, and depressive disorder. Level of Harm - Minimal harm or potential for actual harm During an interview, on 3/2/23 at 3:19 p.m., Staff R reviewed Resident #114's PASRR and stated it should have been redone. Staff R reported the resident PASRR's are reviewed by the Social Service Director, Unit Managers, and the Director of Nursing. Residents Affected - Many 9. The admission Record for Resident #115 identified an original admission date of 12/19/22 and readmission on [DATE]. The record indicated the residents' primary diagnosis of unspecified not intractable epilepsy with status epilepticus, and included the admission diagnosis of unspecified severity (of) unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The PASRR for Resident #115 did not identify the residents' diagnosis of Epilepsy. The comprehensive assessment, dated 12/28/22, included non-Alzheimer's disease and Epilepsy as Resident #115's Active diagnoses. On 3/2/23 at 3:26 p.m., Staff R reviewed Resident #115's PASRR and stated it should have been redone. The SSA stated that it was the responsibility of the Social Service Director and Director of Nursing to redo the PASRR's as they have access to the website. 10. A record review of Resident #126's medical record showed an admission date of 09/14/22 with admission diagnosis of Unspecified Depression, Unspecified lack of expected normal physiological development in childhood, Other specified disorders of the brain, Pedestrian on foot injured in collision with car, and fracture of skull, face and pelvis with routine healing. The History and Physical Exam (H&P) dated 9/12/2022 provided by a local area hospital stated, Doctor evaluated patient. No acute psychiatric intervention necessary. Does not appear to be a primary psychiatric disorder; rather stable chronic cognitive deficits. The PASRR dated 09/13/23 identified in Section 1B Current Diagnosis of an ID, mild, moderate, severe or profound. Further record review of Resident #126's medical record showed a facility psychiatric note dated 09/17/22 that stated, Primary Psychiatric DX: Major Depressive Disorder, Recurrent, mild. Secondary DX (diagnosis) code: Unspecified psychosis, not due to a substance or known phys. Condition. Tertiary DX code: Moderate intellectual disabilities. The care plan showed a focus for Resident #126 of a potential for alteration in thought process due to a psych diagnosis of psychosis dated 09/15/22. A physician order dated 09/15/22 stated Risperdal Tablet 0.5 MG - Give 1 tablet by mouth two times a day for Psychosis No other PASRR was available with updated diagnosis of Psychosis after admission. During an interview on 03/02/23 at 3:20 PM, Staff R stated when a Resident had a new psychiatric diagnosis after admission a new PASRR should be completed. Staff R stated Resident #126 should have had a new PASRR completed with the new Psychosis diagnosis updated and marked on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 6 of 24 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 03/02/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Care Planning problem areas to include 1. Advance Directives/Code Status, and 2. Utilization of Hospice services were reflective of the residents' current medical state and choices, for one (Resident #100) of fifty-four sampled residents. Findings included: On [DATE] at 2:02 p.m., [DATE] at 7:45 a.m., and [DATE] at 8:50 a.m., Resident #100's was visited. She was observed in her room all three times lying in bed, under the covers, and with her eyes closed. The call light was within her reach and she was not presenting with any behaviors, pain or discomfort. Room appeared generally clean and maintained. Resident #100 was not interviewable. A review of Resident #100's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE] for long term care services. A review of the diagnosis sheet revealed diagnoses to include but not limited to Seizures, Dementia, Intellectual disabilities, and Anxiety. A review of the Minimum Data Set (MDS) Significant Change assessment, dated [DATE], revealed the following: Cognition/Brief Interview Mental Score or BIMS was documented as 00 of 15, which would indicated the resident was not able to speak or communicate with relation to her daily medical care and services. The MDS also revealed the resident was not checked for Long Term/Short Term memory condition or daily decision making skills. The MDS assessment did not indicate the resident was currently receiving Hospice services. A review of the current Physician's Order Sheet for the months of 1/2023 and 2/2023 did not indicate any orders for Hospice services. Further review of the order sheet revealed Resident #100 had a Do Not Resuscitate (DNR) code status, with original order date of [DATE]. Review of the current care plans with a next review date [DATE] indicated the following areas: - Resident has expressed the following wishes regarding code status and has the following advance directives in place: is FULL CODE, Power of Attorney, Health Care Surrogate, Health Care Proxy, has incapacity in place with interventions to include but not limited to: Honor resident's wishes regarding Advance Directives/CPR status (initiated [DATE]). - Self care deficit with dressing, grooming, bathing r/t cognitive deficit related to visual limitation, resident participates with ADL with cues from staff with interventions in place - Dx with terminal condition and is at risk for wt. loss, skin breakdown, pain, depression/anxiety, loss of dignity r/t dx.(diagnosis) of Alz, dementia, seizures with interventions in place to include but not limited to: Review Advance Directives and ensure resident wishes are followed, discuss with resident and responsible party as need, Hospice name, Hospice number, collaborate with hospice to ensure resident's needs are met. - Potential for or has an alteration in comfort r/t: Generalized discomfort, resident is unable to verbally communicate pain to staff/hospice with interventions in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 7 of 24 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 03/02/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Alteration in nutrition/hydration r/t dependence on staff for dining needs, regular pureed diet, dx seizures, COVID, h/o falls, repeated falls, dementia, intellectual disability, chronic pain, steady wt. gain now and is under Hospice care, with interventions in pace - Impaired cognition function and impaired decision making skills and has long term, short term impairment, with interventions in place On [DATE] at 1:00 p.m., an interview with the 400 unit manager revealed Resident #100 had been removed from Hospice services some time ago and would follow up with the discharge Hospice order. It was later found that Resident #100 was discharged from Hospice services in 12/2022. On [DATE] at 7:45 a.m., the 400 unit manager confirmed Resident #100 should be a DNR and verified the order through a review of the Physician's Order Sheet. She was shown the current care plans with the next review date of [DATE]. She confirmed the care plan indicated Resident #100 was a Full Code. She revealed she, along with other departments, were responsible for reviewing and ensuring the care plans were accurate and reflective of the resident's current medical and service status. She revealed the Care Plan team had not updated the care plans to reflect Resident #100 no longer received Hospice services and to reflect Resident #100 was a DNR. On [DATE] at 10:00 a.m., in an interview with the Minimum Data Set (MDS)/Care Plan Coordinators Staff E, and Staff D, both revealed if there were any changes and updates with care plans, problem areas, and/or interventions between care plan meetings, usually the department with the changes would make the update in the care plan and both Staff E and Staff D would review for accuracy during the quarterly or comprehensive care plan meeting. Both Staff E and Staff D were not aware as to why the advance directives section of the care plan was not accurate to reflect Resident #100 was a DNR rather than a Full Code. They were also not aware why the current care plans reflected Resident #100 was receiving Hospice services. Both revealed the resident had not been receiving Hospice services and the care plan should have been reflective of that. They confirmed the care plan was updated to reflect the discharge from Hospice services as of 12/2022, and was just updated by someone other than care planning department as of last night, [DATE]. On [DATE] at 1:00 p.m. the Nursing Home Administrator provided the Care Plans, Comprehensive Person Centered, revised date [DATE], for review. The Policy Statement 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 revealed but not limited to: (8) The comprehensive, person-centered care plans will: (j) Reflect the resident's expressed wishes regarding care and treatment goals; (k) Reflect treatment goals, timetables and objectives in measurable outcomes; (l) Identify the professional services that are responsible for each element of care; (o) Reflect currently recognized standards of practice for problem areas and conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 8 of 24 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 03/02/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm (9) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. (13) Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Residents Affected - Few (14) The Interdisciplinary Team must review and update the care plan: (b) When desired outcome is not met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 9 of 24 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 03/02/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to monitor for possible behaviors and side effects related to the use of psychotropic medications for three (Residents #22, #23, and #67) of eight residents reviewed for psychotropic medication use. Residents Affected - Few Findings included: 1. A review of Resident #22's medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, major depressive disorder, and dementia. A review of Resident #22's physician's orders revealed an order dated 1/13/2023 for quetiapine fumarate 25 milligrams (mg) by mouth at bedtime for a diagnosis of schizoaffective disorder. Resident #22's physician's orders also revealed an order dated 6/6/2022 for target behavior monitoring for Seroquel (quetiapine fumarate) for behaviors of visual/auditory hallucinations, combativeness, and agitation every shift for need of medication monitoring. Indicate number of times behavior observed; number code for intervention used; outcome of intervention; and if adverse effects noted. A review of Resident #22's care plan revealed a focus area, last revised on 1/17/2023, of Resident #22 having a potential for adverse side effects related to the use of psychotropic medications related to antipsychotic medication use for a diagnosis of schizoaffective disorder. Interventions included to administer psychotropic medications as ordered, observe for effectiveness of psychotropic medications, and observe for adverse side effects related to psychotropic medication use. A review of Resident #22's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/4/2023, revealed under Section N: Medications, Resident #22 was administered antipsychotic medications for 7 days of the 7 day review period. A review of Resident #22's Behavior Monitoring Flow Sheet (BMFS) for February 2023 revealed the following documentation related to Resident #22's physician's order for target behavior monitoring for Seroquel (quetiapine fumarate) for behaviors of visual/auditory hallucinations, combativeness, and agitation every shift for need of medication monitoring: - No documentation of behavior or side effect monitoring for the 7 AM to 3 PM shift on 2/2/2023, 2/5/2023, 2/6/2023, 2/13/2023, 2/20/2023, and 2/22/2023. - No documentation of behavior or side effect monitoring for the 3 PM to 11 PM shift on 2/1/2023 and 2/28/2023. - No documentation of behavior or side effect monitoring for the 11 PM to 7 AM shift on 2/2/2023, 2/3/2023, 2/5/2023, and 2/10/2023. 2. A review of Resident #23's medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of schizophrenia, major depressive disorder, schizoaffective disorder, mood disorder, anxiety disorder, post-traumatic stress disorder (PTSD), and extrapyramidal and movement disorder. A review of Resident #23's physician's orders revealed the following orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 10 of 24 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 03/02/2023 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 0757 - An order dated 2/16/2023 for fluoxetine hydrochloride (HCl) 40 mg by mouth one time a day for depression. Level of Harm - Minimal harm or potential for actual harm - An order dated 10/9/2022 for lithium carbonate 300 mg by mouth at bedtime for bipolar disorder. Residents Affected - Few - An order dated 8/3/2022 for lithium carbonate 150 mg by mouth one time a day for bipolar disorder. - An order dated 8/3/2022 for risperidone 4 mg by mouth two times a day for schizoaffective disorder. - An order dated 8/22/2022 for target behavior monitoring for fluoxetine for behaviors of sadness, withdrawal, and crying for prolonged periods every shift for need of medication monitoring. Indicate number of times behavior observed; number code for intervention used; outcome of intervention; and if adverse effects noted. - An order dated 8/3/2022 for target behavior monitoring for lithium for behaviors of yelling every shift for need of medication monitoring. Indicate number of times behavior observed; number code for intervention used; outcome of intervention; and if adverse effects noted. - An order dated 8/3/2022 for target behavior monitoring for risperidone for behaviors of yelling every shift for need of medication monitoring. Indicate number of times behavior observed; number code for intervention used; outcome of intervention; and if adverse effects noted. A review of Resident #23's care plan revealed a focus area, last revised on 1/17/2023, of Resident #23 having a potential for adverse side effects related to the use of psychotropic medications related to antipsychotic medication use for a diagnosis of schizophrenia and antidepressant use for depression. Interventions included to administer psychotropic medications as ordered, observe for effectiveness of psychotropic medications, and observe for adverse side effects related to psychotropic medication use. An interview was conducted on 2/28/2023 at 10:00 AM with Resident #23. Resident #23 was observed resting in bed. Resident #23 stated she was tired due to her medications. Resident #23 spoke with slurred speech during the interview and fell asleep several times. Resident #23 was not able to answer any further questions. A review of Resident #23's MDS assessment, with an ARD of 11/17/2022, revealed under Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #23 was cognitively intact. Resident #23's MDS assessment also revealed, under Section N: Medications, Resident #23 was administered antipsychotic medications and antidepressant medications for 7 days of the 7 day review period. A review of Resident #23's BMFS for February 2023 revealed the following documentation related to Resident #23's physician's order for target behavior monitoring for fluoxetine for behaviors of sadness, withdrawal, and crying for prolonged periods every shift for need of medication monitoring: - No documentation of behavior or side effect monitoring for the 7 AM to 3 PM shift on 2/13/2023 and 2/20/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 11 of 24 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 03/02/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm - No documentation of behavior or side effect monitoring for the 3 PM to 11 PM shift on 2/1/2023, 2/9/2023, 2/15/2023, 2/17/2023, 2/19/2023, and 2/28/2023. - No documentation of behavior or side effect monitoring for the 11 PM to 7 AM shift on 2/3/2023, 2/9/2023, 2/10/2023, 2/15/2023, and 2/22/2023. Residents Affected - Few A review of Resident #23's BMFS for February 2023 revealed the following documentation related to Resident #23's physician's order for target behavior monitoring for lithium for behaviors of yelling every shift for need of medication monitoring: - No documentation of behavior or side effect monitoring for the 7 AM to 3 PM shift on 2/13/2023 and 2/20/2023. - No documentation of behavior or side effect monitoring for the 3 PM to 11 PM shift on 2/1/2023, 2/9/2023, 2/15/2023, 2/17/2023, 2/19/2023, and 2/28/2023. - No documentation of behavior or side effect monitoring for the 11 PM to 7 AM shift on 2/3/2023, 2/9/2023, 2/10/2023, 2/15/2023, and 2/22/2023. A review of Resident #23's BMFS for February 2023 revealed the following documentation related to Resident #23's physician's order for target behavior monitoring for risperidone for behaviors of yelling every shift for need of medication monitoring: - No documentation of behavior or side effect monitoring for the 7 AM to 3 PM shift on 2/13/2023 and 2/20/2023. - No documentation of behavior or side effect monitoring for the 3 PM to 11 PM shift on 2/1/2023, 2/9/2023, 2/15/2023, 2/17/2023, 2/19/2023, and 2/28/2023. - No documentation of behavior or side effect monitoring for the 11 PM to 7 AM shift on 2/3/2023, 2/9/2023, 2/10/2023, 2/15/2023, and 2/22/2023. 3. A review of Resident #67's medical record revealed Resident #67 was admitted to the facility 9/3/2020 with diagnoses of major depressive disorder, schizoaffective disorder, and Alzheimer's disease. A review of Resident #67's physician's orders revealed the following orders: - An order, dated 1/17/2023 for nortrptyline HCl 25 mg by mouth a bedtime for depression. - An order, dated 1/17/2023 for risperidone 1 mg by mouth two times a day for schizoaffective disorder. - An order, dated 11/28/2022 for target behavior monitoring for risperidone for behaviors of yelling every shift for need of medication monitoring. Indicate number of times behavior observed; number code for intervention used; outcome of intervention; and if adverse effects noted. - An order, dated 11/28/2022 for target behavior monitoring for nortrptyline for behaviors of sadness, withdrawal, and crying for prolonged periods every shift for need of medication monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 12 of 24 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 03/02/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Indicate number of times behavior observed; number code for intervention used; outcome of intervention; and if adverse effects noted. A review of Resident #67's care plan revealed a focus area, last revised on 10/1/2020, of Resident #67 having a potential for adverse side effects related to the use of psychotropic medications related to antidepressant use for depression. Interventions included to administer psychotropic medications as ordered, observe for effectiveness of psychotropic medications, and observe for adverse side effects related to psychotropic medication use. A review of Resident #67's MDS assessment revealed under Section N: Medications, Resident #67 was administered antipsychotic medications and antidepressant medications for 6 days of the 7 day review period. A review of Resident #67's BMFS for February 2023 revealed the following documentation related to Resident #67's physician's order for target behavior monitoring for risperidone for behaviors of yelling every shift for need of medication monitoring: - No documentation of behavior or side effect monitoring for the 7 AM to 3 PM shift on 2/2/2023, 2/6/2023, 2/13/2023, 2/20/2023, and 2/22/2023. - No documentation of behavior or side effect monitoring for the 3 PM to 11 PM shift on 2/1/2023 and 2/28/2023. - No documentation of behavior or side effect monitoring for the 11 PM to 7 AM shift on 2/2/2023, 2/3/2023, 2/5/2023, and 2/10/2023. A review of Resident #67's BMFS for February 2023 revealed the following documentation related to Resident #67's physician's order for target behavior monitoring for nortrptyline HCl for behaviors of sadness, withdrawal, and crying for prolonged periods every shift for need of medication monitoring: - No documentation of behavior or side effect monitoring for the 7 AM to 3 PM shift on 2/2/2023, 2/6/2023, 2/13/2023, 2/20/2023, and 2/22/2023. - No documentation of behavior or side effect monitoring for the 3 PM to 11 PM shift on 2/1/2023 and 2/28/2023. - No documentation of behavior or side effect monitoring for the 11 PM to 7 AM shift on 2/2/2023, 2/3/2023, 2/5/2023, and 2/10/2023. An interview was conducted on 3/2/2023 at 12:47 PM with Staff S, Licensed Practical Nurse (LPN). Staff S, LPN stated residents receiving psychotropic medications should have an order in place for behaviors and side effects related to the use of that medication, which was completed by the nurse every shift. Staff S, LPN also stated documentation in the BMFS should not be missing and the documentation should be completed every shift as ordered. An interview was conducted 3/2/2023 at 12:55 PM with Staff W, LPN Unit Manager (UM). Staff W, LPN, UM stated residents receiving psychotropic medications should have orders in place to monitor target behaviors and side effects related to use of the medication, which should be completed by the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 13 of 24 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 03/02/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm every shift. Staff W, LPN, UM also stated she was able to view documentation that had not been completed on the dashboard of the electronic medical record and she verified at the end of the nurse's shift all documentation was completed as ordered. Staff W, LPN UM viewed the BMFS for Residents #22, #23, and #67 and verified the documentation was not completed every shift as ordered. Staff W, LPN UM stated the BMFS should not have any missing documentation. Residents Affected - Few An interview was conducted on 3/2/2023 at 2:41 PM with the facility's Director of Nursing (DON) and Regional Nurse Consultant (RNC). The DON stated residents who received psychotropic medications should have orders in place for monitoring of behaviors and side effects related to the medication. The RNC stated the monitoring should be completed every shift. Both the DON and RNC stated they would expect the nursing staff to document in the BMFS every shift and the management team should be verifying the documentation was completed as ordered. A telephone interview was conducted on 3/3/2023 at 11:32 AM with the facility's Consultant Pharmacist (CP). The CP stated they ensure behavioral and side effect monitoring was conducted for residents prescribed psychotropic medications during the monthly review of the resident's chart. The CP also stated the purpose of the monitoring was to ensure the medication was working and if the proper dose of the medication was being used. The CP stated the nursing staff and UMs were able to verify if there was any missing documentation in the residents BMFS. A review of the facility policy titled Antipsychotic Medication Use, last revised in December 2018, revealed under the section titled Policy Interpretation and Implementation the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. A request was made on 3/2/2023 at 11:30 AM and 3/2/2023 at 2:22 PM to the RNC for a policy related to the monitoring of psychotropic medications. A policy was not provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 14 of 24 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 03/02/2023 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 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, record reviews, and review of facility policy, the facility failed to ensure a medication administration error rate of less than five percent. A total of twenty-six medication administration opportunities were observed with six errors for two (Residents #120 and #19) of four residents sampled for medication administration, which resulted in a medication administration error rate of 23.08%. Residents Affected - Few Findings included: A review of Resident #120's physician's order revealed the following orders: - An order, dated 4/7/2022 for Cetirizine Hydrochloride (HCl) 10 milligrams (mg) by mouth one time a day with an administration time of 8:00 AM. - An order, dated 4/7/2022 for Lisinopril 5 mg by mouth one time a day with an administration time of 8:00 AM. - An order, dated 8/22/2022 for oxybutynin chloride 10 mg by mouth two times a day with administration times of 8:00 AM and 4:00 PM. - An order, dated 10/18/2022 for Depakote 125 mg by mouth two times a day with administration times of 9:00 AM and 9:00 PM. An observation of medication administration was conducted on 3/1/2023 at 9:55 AM on the 400 unit of the facility with Staff T, Licensed Practical Nurse (LPN). Staff T, LPN prepared the following medications to administer to Resident #120: - Cetirizine HCl 10 mg. - Lisinopril 5 mg. - Oxybutynin chloride 10 mg. - Depakote 125 mg. After preparing the medications, Staff T, LPN administered the four medications to Resident #120 at 9:58 AM. An interview was conducted with Staff T, LPN following the observation. Staff T, LPN stated they could administer medications within the timeframe of an hour before to an hour after the scheduled medication administration time. Staff T, LPN verified that Resident #120's Cetirizine, Lisinopril, and oxybutynin were administered late but was not able to state if late administration of medications was a medication error. Staff T, LPN stated if a medication was administered late, she would continue with the medication administration without notifying anyone. A review of Resident #19's physician's order revealed the following orders: - An order, dated 8/29/2022 for Colace 100 mg by mouth one time a day with an administration time of 9:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 15 of 24 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 03/02/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm - An order, dated 2/20/2019 for ditiazem HCl 120 mg by mouth one time a day with an administration time of 9:00 AM. - An order, dated 8/29/2022 for metoprolol succinate 25 mg by mouth one time a day with an administration time of 9:00 AM. Residents Affected - Few An observation of medication administration was conducted on 3/1/2023 at 10:11 AM on the 300 unit of the facility with Staff S, LPN. Staff S, LPN prepared the following medications to administer to Resident #19: - Colace 100 mg. - Ditiazem HCl 120 mg. - Metoprolol succinate 25 mg. After preparing the medications, Staff S, LPN administered the three medications to Resident #19 at 10:15 AM. An interview was conducted with Staff S, LPN following the observation. Staff S, LPN stated they could administer medications within the timeframe of an hour before to an hour after the scheduled medication administration time. Staff S, LPN addressed the three medication administered to Resident #19 were administered late. Staff S, LPN stated if medications were administered late, she keeps plugging along with the medication administration until it is completed. Staff S, LPN also stated she could ask the Unit Manager on the unit for assistance if medications were being administered late. During the interview, Staff W, LPN Unit Manager (UM) was observed directly across the hall and looking in the direction of Staff S, LPN. Staff W, LPN UM joined Staff S, LPN at the medication cart and stated she could assist the nurse with medication administration if the medications were being administered late. Staff W, LPN UM was not able to state why she was not assisting Staff S, LPN with the medication pass prior to the observation of Resident #19's medication administration. Staff W, LPN UM stated if a residents medications were administered late, the resident's physician should be notified because a late administration would be considered a medication error. An interview was conducted on 3/2/2023 at 2:41 PM with the facility's Director of Nursing (DON) and Regional Nurse Consultant (RNC). The DON stated she would expect facility nurses to follow the five rights of medication administration when administering medications to residents, which include the right resident, right route, right dose, right medication, and the right time. The DON also stated the purpose of the five rights of medication administration was to prevent medication errors. The DON stated facility nurses had a time frame of an hour before to an hour after the scheduled medication administration time and the resident's physician should be notified if the medication was administered before or after that time frame. The RNC stated if a medication was only 15 or 30 minutes late, she would not expect the nurse to call the physician because the physician would cuss them out if they were notified of a medication being administered late. After hearing the RNC's expectation, the DON agreed with the RNC and stated it would be her expectation as well. The RNC addressed the facility policy for medication administration was for medications to be administered within the timeframe of an hour before to an hour after the scheduled medication administration time, but it would screw the nurses to follow the policy. The RNC stated we can change it if that's what you want. No request was made to change a facility policy during the interview. A telephone interview was conducted on 3/3/2023 at 11:32 AM with the facility's Consultant Pharmacist (CP). The CP stated some medications are more important than others, but ideally, they should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 16 of 24 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 03/02/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete administered within the parameters ordered by the physician. The CP also stated the DON and UMs would be able to view if medications were being administered late by viewing the electronic medical record. A review of the facility policy titled Administering Medications, last revised in April 2019, revealed under the section titled Policy Statement medications are administered in a safe and timely manner, and as prescribed. The policy also revealed under the section titled Policy Interpretation and Implementation medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Event ID: Facility ID: 105354 If continuation sheet Page 17 of 24 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 03/02/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure residents were provided with dietary meals and food items of their choices for two (Residents, #102, and #29) of fifty-four sampled residents . Findings included: On 2/27/2023 at 9:40 a.m., Resident #102 was visited while in her room. She was observed in a private room and was lying in bed with the HOB (head of bed) at approximately 45 degrees. Resident#102 agreed to an interview and revealed she had been having problems with her meals to include: 1. Food does not taste good, 2. Vegetables are overcooked to mush, 3. Meal service is always late and does not like to eat so late for each meal service., and 4. Meal service is always late and not at times she and other prefers. The resident still had her breakfast tray on her over the bed table. She revealed she had spoken to various staff as well as other residents have done the same. She revealed the staff would not listen to them and would not serve them any earlier. An observation of the resident's meal ticket on her breakfast tray revealed she was to receive a banana and boiled eggs. She did not receive either and had told the staff when they brought her tray she was missing those items. She revealed the aides just tell her, Ok, we will tell the kitchen. The resident said it was never corrected. Photographic evidence was taken of her tray and meal ticket. On 2/28/2023 at 8:50 a.m., Resident #102 was served her breakfast meal tray. After the aide left the room, the resident invited this surveyor to come in the room to look at her meal. She first stated, It is out of line to get our meals this late. I didn't get my hard boiled eggs, I didn't get my banana this morning and I hardly ever get those items. A review of her meal ticket indicated she should have received hard boiled eggs and a banana. She received what appeared to be an egg omelet and did not receive any type of fruit. Resident #102 said she was not happy with her meal served this morning and did not order cornbread for breakfast. On 3/1/2023 at 9:02 a.m., Resident #102 was interviewed while in her room. She had received her breakfast tray just a few moments before. She said, See, again we get served so late in the morning. She said she got her boiled eggs today. Her tray was observed along with her meal ticket. She was supposed to get a banana and apple juice. She did not receive either. Photographic evidence was taken. On 3/2/2023 at 8:28 a.m. Resident #102 received her breakfast tray. She received what appeared to be scrambled eggs and a very small pastry. She did not receive any boiled eggs as per her ticket request. The resident provided meal tickets from the day before for lunch and dinner that read: a. Lunch 3/1/2023 (double portions). The meal served to her was baked pork chops, pork gravy, parsley, buttered egg noodles, green peas, yellow cake, and ginger ale. The resident said she marked on her lunch menu that she wanted the following: Turkey sandwich, fruit bowl, and one ginger ale. She revealed she did not receive what she had on her meal ticket and this happens all the time. She also was told the kitchen was and had been out of ginger ale. b. Dinner 3/1/2023 (double potions). The meal the resident requested was a Chef salad, 3 French dressings, 2 ginger [NAME]. She revealed she did not receive the dressing and ginger ale. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 18 of 24 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 03/02/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm A review of Resident #102's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed the resident was her own decision maker. Review of the Minimum Data Set (MDS) assessment (Quarterly), and dated 2/19/2023 revealed: Cognition/Brief Interview Mental Status or BIMS score - 15 of 15, which indicated the resident was able to speak in relation to her daily care, choices and services. Residents Affected - Few On 3/1/2023 at 12:30 p.m., an interview was conducted with Resident #29's in her room. The resident revealed she finally received her lunch tray and there were things that she requested and did not receive. The over the bed table was observed with her meal tray and the meal ticket was placed near her plate. The resident was served the following items: 1. Beef with gravy, 2. Mashed potatoes with brown gravy, 3. Peas, 4. A carton of whole milk, and 5. A bowl with what appeared to be a piece of cake, and 6. A bowl that appeared to be soup. The meal ticket was as follows: 1. Apple juice x two, 2. Saltine crackers, 3. Beef stroganoff, 4. Chopped parsley, 5. Buttered egg noodles, 6. Buttered green peas, and 7. Yellow cake. The meal ticket had writing on it, which was written prior to the resident receiving her meal tray. The ticket had been updated to include: No stewed tomatoes; Add green beans; Add chips if available. The resident did not receive the following items as requested: 1. Apple juice x two; 2. Chips; 3. [NAME] beans. Photographic evidence was taken. On 3/1/2023 at 12:45 p.m., in an interview with Staff F, Dietary Aide and Staff H, Dietary Manager, both verified they had a mixed vegetables with green beans, chips, and cups of apple juice available for the noon meal. On 3/2/2023 at 11:00 a.m. the Nursing Home Administrator provided the past six months of resident council meeting minutes. A review of the following minutes revealed: 1. 9/6/2022 indicated under Dietary Concerns; Residents does not get alternate or sandwich when they ask. 2. 10/10/2022 indicated under Dietary Concerns; Residents are getting the same meal over and over. 3. 11/7/2022 indicated under Dietary Concerns; Not getting what is on the menu. 4. 12/5/2022 indicated under Dietary Concerns; Staff not paying attention to meal ticket, not getting soup on trays. The following month old business did not indicate how the above mentioned concerns were followed up on and corrected or attempted correction. On 3/2/2023 at 11:20, in an interview with Staff H, Dietary Manager and Staff J, Regional Dietary Manager, both revealed they were aware of residents voicing concerns, from time to time, related to not receiving what they ordered or food item likes/dislikes not followed. The Grievance log was reviewed for the past seven months and revealed the following: 1. Grievance dated 8/2/2022 by resident #138. The grievance indicated: Social Service Department (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 19 of 24 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 03/02/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm was made aware that the resident had not received his breakfast and it was almost 10:00 a.m. A tray was then provided to the resident. 2. Grievance dated 8/5/2022 by resident #139. The grievance indicated: Informed staff that he had not received breakfast. Informed dietary. Residents Affected - Few 3. Grievance dated 8/30/2022 by resident #140. The grievance indicated: Resident stated she is a diabetic receiving a regular diet, she also stated that food service is bad and slow and she is not receiving drinks with her meals. 4. Grievance dated 1/13/2023 for resident #91. The grievance by the resident's daughter, indicated: Gets food she does not like, constantly sends food back, Dietary does not correct these issues when asked to do so. On 3/2/2023 at 10:25 a.m., Staff H was interviewed related to monitoring and honoring resident meal tickets for all three meal services. Staff H said upon the resident's admission, she or he was interviewed and assessed for dietary needs by the dietary staff as well as the Registered Dietitian. Staff H indicated she and/or her assistant dietary manager, Staff G were responsible for going over food allergies, food likes/ dislikes, and the Registered Dietitian would follow up with the resident or representative within 7-10 days of admission. Staff H revealed the assessment of food likes/dislikes and food allergies would then be noted in the electronic medical record. The meal tickets were printed off to include the resident's food choices and food allergies. Staff H revealed she was responsible for creating and maintaining the actual meal tickets and audits the tray line each meal service to ensure the tickets were being followed. Staff H also indicated nursing staff on the floor should be auditing the meal tickets when they pass meals from the tray cart. Staff H did not have any documented evidence to show how she audited the meal tickets or the meal service for accuracy during the last three months, 12/2022, 1/2023, 2/2023. On 3/2/2023 at 1:00 p.m. the Nursing Home Administrator provided the following policy and procedure for review. The policy was not dated: Resident Rights, not dated, and under the Basic Human section, revealed: Every resident, regardless of race, color, creed, national origin, age, sex, religion, handicap, or payment source, should be treated with respect and consideration. When a person becomes sick and requires institutional care, adjustments in lifestyle must be mad. As a healthcare employee, you should be aware that every human being has: 1. The right to be treated fairly; 2. The right to be treated with dignity. Under the Individual Rights section of this policy, it revealed: In addition to basic human rights, the long-term care resident has individual rights that are specific to institutional care. They include, but are not limited to: (25) The right to reside and receive services with reasonable accommodations of individual needs and preferences, except where the health or safety of the individual or other residents would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 20 of 24 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 03/02/2023 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 0806 endangered. 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: 105354 If continuation sheet Page 21 of 24 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 03/02/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to ensure timely meal service in one (400 unit) of four units for eleven (Residents #91, #102, #127, #116, #48, #37, #113, #33, #94, #29, and #14) of fifty four sampled residents. Findings included: On 2/27/2023 at 12:00 p.m., a tour of the 400 unit, consisting of two halls, (rooms 401 - 413, and 414 - 430) was conducted. The wall across from the nurses station, and next to the nursing assignment board was a framed sheet of paper that indicated all three meal service times. The sheet of paper indicated the following: Meal Service times 400 hall (Breakfast 7:30 a.m. until 8:15 a.m.; Lunch 11:30 a.m. until 12:15 p.m., Dining room open at 11:30 a.m., Dinner 4:30 p.m. until 5:15 p.m. Dining room open at 4:30 p.m. Photographic evidence was obtained On 2/27/2023 at 12:42 p.m. the first lunch tray cart arrived on the floor for rooms 414 - 430. All but two residents who resided on this unit ate in their rooms. Two staff members took the trays from the cart and passed and set up meals to residents while in their rooms. The last tray was set up in a resident room on the 414 - 430 hall at 12:56 p.m. Per the dining service schedule, staff were late with receiving and passing meal trays by thirty-three minutes. On 2/28/2023 at 8:02 a.m. the first cart for the 400 unit arrived and staff began to pass trays immediately. The second tray cart on the floor arrived at 8:25 a.m. These carts were for rooms 401 - 413. Staff began to pass trays from this cart at 8:27 a.m. The last tray was served in the 401 - 413 hall at 8:34 a.m. Per the dining service schedule, staff were late with receiving and passing meal trays. The dining room was locked and not open for residents to dine in. Rooms 414 - 430 meal trays still had not arrived yet. A third tray cart arrived on the floor at 8:40 a.m. There were two staff to pass trays on this hall. The last tray was served on the 414 - 430 hall at 8:58 a.m. The meals were served and set up past the posted scheduled meal times for rooms 414 - 430. On 2/28/2023 at 9:19 a.m., Staff J, Certified Nursing Assistant (CNA) was observed carrying two trays from the kitchen and revealed Resident #33 was just now receiving her tray. Staff J revealed it was not due to a change of order, or from a request for a different meal. She revealed that it just did not get out from the kitchen. Resident #33 received her meal one hour and four minutes late. On 3/1/2023 an observation of the 400 hall/unit revealed at 7:52 a.m. the first breakfast tray cart arrived on the low 400 - 413 hall. Staff began to pass trays at 7:55 a.m. Staff finished passing trays from this cart at 8:02 a.m. There was no other cart on this hall or unit. On 3/1/2023 at 8:15 a.m., a second breakfast tray cart arrived on the low 400 - 413 hall. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 22 of 24 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 03/02/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some began to pass trays from this cart at 8:18 a.m. Staff finished passing trays from this hall at 8:20 a.m. The meals were served and set up in the 401 - 413 hall five minutes past the end of the posted meal service time. The second tray cart was brought from the 400 - 413 hall, to the 414 - 430 hall. Staff began to pass trays from this second cart at 8:20 a.m. The rest of the trays in this second cart only supported the first six rooms on this hall. The last tray from this cart was served at 8:30 a.m. The third meal cart arrived at 8:44 a.m. and staff began to serve from it immediately. A fourth tray cart arrived at 8:53 a.m. and staff began to serve from it immediately. Staff finished with both carts at 9:02 a.m. At least four rooms in the 401 - 413 hall and ten rooms in the hall 414 - 430 were not served and set up with their meals per the scheduled meal service times, until forty-seven minutes after the breakfast meal service times ended. On 3/1/2023 at 8:38 a.m., an interview with Resident #91, who positioned herself in the hallway just outside her room door said, See, we have no breakfast, its late again I'm tired of this and do not like to eat so late and staff know it. On 3/1/2023 at 8:40 a.m., an interview with Resident #102 verified the meal was late again and this was not the time she liked to eat her breakfast. She said, now lunch will be late. Resident #102 was observed to receive her tray at 8:50 a.m. On 3/1/2023 at 9:03 a.m., an interview with Staff L, CNA revealed when they [staff] take out the meal trays from the carts, she along with other staff were to review the meal ticket and make sure the plate had what the ticket read. She revealed that included food allergies and food likes/dislikes. She confirmed there were times residents received things they did not want, and sometimes trays came out of the kitchen late. She did not explain what late meant and did not know exactly what the meal service times were. She only explained that multiple residents keep complaining about late breakfast and late lunch meal service. 3/2/2023 at 7:10 a.m., a breakfast meal service observation was made in the 400 unit. Both halls were observed with most residents awake and seated or lying in their bed. At 7:50 a.m. dietary staff brought the first breakfast meal tray cart on the 400 unit, which was for the 400 - 413 hall. Staff began to pass trays at 7:50 a.m. The last tray from the first cart was served and set up at 8:03 a.m. The rest of the low 400 - 413 hall to include over four rooms had not been served yet. At 8:14 a.m. the second meal tray cart arrived on the 400 unit. Staff began to serve and set up the meal trays at 8:17 a.m. to include hall rooms 414 - 430. The last tray from this second cart was placed and set up at 8:30 a.m. The third tray cart was brought to the 400 hall for all the other rooms left, at 8:44 a.m. The last tray was served at 9:04 a.m. On 3/2/2023 at 8:07 a.m., an interview with Staff M, CNA revealed the breakfast trays did come out past the times that were listed and that was a normal routine. She revealed they passed the trays immediately when the carts arrive. Staff M said residents had complained in the past about meals being served so late in the morning, but she did not know if the kitchen management was aware. At 8:35 a.m. interviews with aides Staff N,CNA and Staff O, CNA both confirmed the 400 hall had three and sometimes four meal carts for breakfast and lunch. Both confirmed the residents did complain about the tray carts coming out late every day and not following the meal schedules. On 3/2/2023 beginning at 9:10 a.m., interviews were conducted with Residents #127, #116, #48, #37, #113, #33, #94, #29, and #14. All revealed they continually received their meals for breakfast, lunch and dinner late. They said they had continually mentioned their concerns to floor staff, kitchen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 23 of 24 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 03/02/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff, the social worker, and some also indicated late trays brought to the attention at resident group meetings. The residents revealed there was no use in complaining to staff here at the facility as there was resolution. All those interviewed said they would like to eat earlier for all three meals. On 3/2/2023 at 10:00 a.m., an interview with the 400 unit manager confirmed the posted meal service times, located across from the nurse station. She confirmed the trays did not come out as posted. She said, the kitchen staff delivered the carts to the unit and as soon as they arrived, her floor staff began to pass trays. She was not sure why the tray carts were brought out later than the posted meal service times. On 3/2/2023 at 11:30 a.m., an interview with the Staff H, Dietary Manager and Staff P, Regional Dietary Manager both confirmed the posted scheduled meal service times located in the 400 unit. They revealed they were not even aware of the posted meal service times and had a different schedule. The Dietary Manager provided their general meal service times, which was posted in the kitchen on a wall near the steam table. The sheet of paper with meal service times revealed the following; Meal Cart Delivery Times Breakfast: 7:30 a.m.; Lunch: 11:30 a.m.; and Dinner: 4:30 p.m. Staff H and Staff P revealed the meal service sheet was very general and could not show any more specific times for the 100, 200, 300, and 400 halls. Both Staff H and Staff P confirmed they could see how residents believed meals were late, by way of review of the posted meal times out on the unit. Staff H had heard of some residents complaining of late meal service times but had not developed an action plan as of yet to remedy their concerns. An interview on 3/2/2023 with Staff H, Staff P, and the Nursing Home Administrator all confirmed the facility did not have a specific policy and procedure related to timeliness of meal service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105354 If continuation sheet Page 24 of 24