Inspection·November 15, 2019

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to have input in the operation of the facility and discussion of concerns and suggestions of improvement. The policy identified that a Resident Council Response Form would be utilized to track issues and their resolution. The facility department related to any issues would be responsible for addressing the item(s) of concern. Review of the facility policy titled Activity Programs, revised August 2006, revealed a policy statement of activity programs were designed to meet the needs of each resident and were available on a daily basis. The policy interpretation and implementation of the policy revealed: 1. Our activity programs are designed to encourage maximum individual participation and geared to the individual resident's needs. 3 .c. Weather permitting, as least one activity a month is held away from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an initial tour of the first floor unit dining room, on 11/12/19 at 10:23 a.m., an unused blue incontinence brief, cotton-batting stained with brown and red substances, and a used cup was observed on top of a bureau. In addition, the chrome pedestal of a dining room table in the first-floor dining room was observed to be rusted and the outstretched legs were uncapped. Photographic evidence was obtained. On 11/12/19 at 10:41 a.m., room [ROOM NUMBER] was observed with a co-axial cable hanging from a hole near the ceiling and resting on the floor. In addition, a hole was observed above the baseboard in the same corner of the coaxial. Photographic evidence was obtained. On 11/12/19 at 11:01 a.m., an observation was made in room [ROOM NUMBER], where two residents resided, of 4 uncovered pillows lying on top of the wardrobe closet. Photographic evidence was obtained. Based on observations, interviews with staff, and record review the facility failed to ensure that 1 of 2 residential floors was maintained in a safe and clean manner for residents related to soiled dining room vents, a patio doorway in ill repair, loose molding/baseboards, exposed strand board, sharp jagged edges on dining tables, rusted dining table with uncapped legs, miscellaneous items stored in the dining room, cable hanging from the ceiling and hole in the baseboard in room [ROOM NUMBER], and pillows with no coverings on top of a wardrobe closet in room [ROOM NUMBER]. Findings included: 1. On 11/12/19 at 11:30 a.m., on 11/13/19 at 1 p.m., and on 11/14/19 at 3:15 p.m., the following observations were made: A) 1st floor dining room vents. Three vents were observed with black bio growth specks all over them (photographic evidence obtained). Several residents were observed in the dining room during meal times. B) 1st floor doorway to patio used for Activities. A piece of loose metal in the doorframe was observed. (Photographic evidence obtained). When stepped on by staff, the metal piece lifted in another location. There was also a significant amount of dirt/debris in the door joint. This was observed to be a high traffic area with many residents observed going in and out of the patio area. C) Loose molding/baseboard by the 1st floor nursing station, and in the main hall. (Photographic evidence obtained). D) The first floor nursing station desk was observed to have a large area of exposed strand board with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some jagged surfaces facing the main dining room. This desk could easily be accessed by residents walking past the nursing station or dining room. (Photographic evidence obtained). An observation of the first-floor dining room was conducted on 11/12/19 at 9:30 a.m. Three dining tables had no dining cloth on them. One of the three tables had sharp, jagged edges. When meal times were over, Residents used this room to watch television. This table was easily accessible to any residents walking between the dining room and the patio. (Photographic evidence obtained). Review of the Facility's Maintenance Log, located at the 1st floor Nursing station, revealed that from 9/29/19 through 11/11/19, none of the above-named concerns were listed. Only one call bell was identified with a problem and had to be repaired. An interview was conducted with Staff K, the Maintenance Director, on 11/14/19 at 2 p.m. Staff K said On the floors, we have maintenance logs where the staff lets us know that something needs to be fixed, and then we repair it. Those logs are kept at the nursing station on each floor. I also have a 5-page list of things that need to be fixed, and it is truly a work in progress, and there are budget constraints. The items highlighted in yellow have been fixed. Maintenance makes rounds on the floors daily and inspects the halls and common areas for safety issues. I just had a guy come over last week to clean the vents. Some of those discolorations are rust and are hard to come off. Staff K then confirmed the presence of observations B- D on the above list. He shook his head, and stated yes, those are areas of concern. We will take care of it. When asked if he adheres to a certain schedule for fixing items on the list, he stated No, we just mark it off as we get it done, unless it's an emergency. Review of the Maintenance Report furnished by the Maintenance Director revealed that none of the observed concerns were listed on his 5-page log. There was mention of a corner guard across from the elevator and across from the Nurse's station. It was not highlighted in yellow, indicating it was not fixed yet. There were numerous items on all 5 pages which were still pending repair. A good percentage of those items that were highlighted and fixed included changing light bulbs and replacing pull strings. Review of the Facility's policy titled Maintenance Service, revised in December 2009, revealed Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1) The Maintenance Department is responsible for maintaining buildings, grounds, and equipment in safe and operable manner at all times. 2) Functions of maintenance personnel include: b) maintaining the building in good repair and free from hazards. 3) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 8) The Maintenance Director is responsible for maintaining the following records: m) Maintenance schedules. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of policy and procedures the facility failed to investigate the grievance for one (#94) of one resident reviewed for personal property in regards to a set of missing dental implants. Findings included: During an interview, on 11/13/19 at 8:43 a.m., Resident #94 and a family member reported the resident was missing a set of dental implants, and another resident had been observed in Resident #94's bed. The resident and family member stated that they had requested a velcro stop sign for the doorway. Observation of Resident #94 at the time of the interview revealed the resident was edentulous on the front bottom of oral cavity with two (2) metal poles on either side of the edentulous area. The observation indicated no stop sign banner was present in the doorway of Resident #94's room. The family member reported they had not heard anything from the facility regarding the grievance. Follow-up interview with Resident #94 on 11/14/19 at 9:29 a.m. revealed the resident did not recall who the missing implant was reported to. Review of Resident #94's clinical record revealed she was admitted near the end of October 2019. The admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status of 15, which indicated the resident was cognitively intact. A review of the grievance log revealed no grievance was filed in regards to Resident #94's missing implants. A review of the resident's progress notes revealed no mention of missing dental implants. During an interview, on 11/15/19 at 10:17 a.m., the Social Service Director (SSD)/Grievance Officer stated Resident #94's family member spoke to her, on 11/6/19, regarding the missing teeth. The SSD stated the staff informed her that the missing implant was found in a dental cup in the resident's nightstand. According to the Director, staff had notified her that the resident had informed them that the found implants were not the original missing ones. The SSD reviewed the grievance log and investigation and stated I didn't log it. The SSD was unaware the second pair were missing also. The investigation portion of the grievance did not indicate the SSD had spoken with the resident or family member regarding the grievance. The SSD stated staff had told her they had informed the sister that the dental implants were located. When informed that the family member and resident reported missing implants, the SSD questioned, so the extra ones are missing too? A continuation of the interview with the SSD on 11/15/19 revealed she had spoken with the Director of Nursing regarding the missing implant and was told the second pair did not fit the resident so they were taken home. Resident #94 continued to be missing a set of lower dental implants. At 10:40 a.m. on 11/15/19, the SSD confirmed that she should have spoken with the family prior to resolving the grievance. The policy titled Filing Grievances/Complaints, revised April 2017, identified the Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. The policy indicated the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and /or complaint. The policy revealed the Grievance Officer, Administrator and staff would take immediate action to prevent further potential violations of resident rights while the alleged violation was being investigated. The implementation of the policy indicated the resident, or person filing the grievance and/or complaint on behalf of the resident would be informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm (verbally or in writing) of the findings and the actions that would be taken to correct the problems, and a written summary of the investigation will also be provided to the resident and a copy will be filed in the business office. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one resident (#296) of two residents reviewed for Communication-Sensory Deficits. Resident #296's MDS did not accurately reflect his vision status. Residents Affected - Few Findings Included: Review of Resident #296's Minimum Data Set (MDS) dated [DATE] revealed the section for vision: ability to see in adequate light was marked 0 as adequate. Review of Resident #296's admission Record revealed diagnoses that included: Open angle Glaucoma. His physician orders included Latanoprost eye drops; 1 drop each eye in the evening. Azopt eye drops: 1 drop twice a day in both eyes. Initiate fall prevention program (started 11/4/19). Review of Resident #296's Care plan, dated 10/14/19, revealed: Falls: at risk for falls related to impaired vision, impaired cognition, and poor safety awareness. Approach: start 11/4/19: assist/guide to chair when observing resident sitting in chair. No additional interventions for impaired vision could be found in the plan of care. An observation of Resident #296 was conducted on 11/14/19 at 12:30 p.m. Resident was ambulating by himself in the hall with frequent stops. The resident had to be guided by staff. An observation was conducted on 11/14/19 at 12: 40 p.m.: Resident #296 was observed in the dining room. The Certified Nursing Assistant (CNA) set up his meal, then oriented him to the location of items on his plate. Resident was able to eat without further help. During an interview with Staff I, CNA, on 11/14/19 at 2 p.m., she said I've known this resident since he came here. I think his vision is much worse now than when he was admitted . He can see things right in front of him, but he has difficulty with his peripheral vision, his sides. That's why he fell, I think. He was trying to sit down on the chair and missed it so we make sure to orient him to his surroundings. An interview was conducted with Staff P, also a CNA, on 11/14/19 at 2:15 p.m. Staff P said Yes, he does have trouble seeing. But he knows how to feel his way down the hall, you know, he walks and runs his hands along the wall to feel his way, but we must watch when he tries to sit. He misses sometimes. He goes to Restorative for dining, and they help him with his meals by cutting it up and telling him where everything is on his plate. When asked if he is care planned for impaired vision, Staff P said No, it's not on our kiosk, our CNA tasks. It just talks about his low vision in terms of falls, but not for assistance with Activities of Daily Living (ADL's.). Let me show you my kiosk. There were no specific tasks related to impaired vision, or assistance with ADL's due to impaired vision noted in the kiosk system. An interview was conducted with two MDS Coordinators on 11/14/19 at 3 p.m., Staff Q and Staff E, confirmed that the MDS section B: Vision: was marked incorrectly as Adequate. They confirmed that the MDS assessment related to vision was not accurate. Staff Q stated we share the responsibilities of the MDS Assessment and Care plan with Social Services. We are all present at the IDT (Interdisciplinary Team) meetings, and we should have caught it then and included it in his care plan. We missed it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0641 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff R, the Director of Social Services, on 11/14/19 at 3:20 p.m. She said Yes, we did have an interdisciplinary team meeting on 10/15/19 and on 11/4/19, but we did not talk about his impaired vision or put it on the care plan. Yes, I would expect his assessment to reflect impaired vision, and it should be on the care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a care plan for impaired vision was developed and implemented for one resident (#296) of two residents reviewed for care plan interventions applicable for Communication-Sensory Deficits. Findings Included: Review of Resident #296's admission Record revealed that he was re-admitted on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus, Open angle Glaucoma, and Cognitive Communication Deficit. His physician orders included Latanoprost eye drops; 1 drop each eye in the evening. Azopt eye drops: 1 drop twice a day in both eyes. Initiate fall prevention program (started 11/4/19). Review of Resident #296's Minimum Data Set (MDS) dated [DATE] revealed: Brief Interview for Mental Status: Score 99 unable to complete. Hearing/Speech/Vision: vision: ability to see in adequate light (marked 0 = adequate). Functional status: Limited to extensive assist most activities of daily living. (Walking/transfers: limited one person assist). Review of Resident #296's Care plan, dated 10/14/19, revealed: Falls: at risk for falls related to impaired vision, impaired cognition, and poor safety awareness. Approach: start 11/4/19: assist/guide to chair when observing resident sitting in chair. No interventions for impaired vision. Review of Progress notes revealed: 9/4/19: Resident was going to sit but there was no chair and he went back and hit his head and landed his buttocks on the floor. 10/3/19: Patient was in the dining hall when he missed his chair. Patient went to have a seat and fell to the floor. 11/5/19: Resident had a fall on 11/4/19 when he missed the chair, he attempted to sit in. Resident has low vision. Staff to guide/direct to chair. An observation was conducted on 11/13/19 at 1 p.m.: Resident #296 was sitting out in the patio area listening to music. An observation of Resident #296 was conducted on 11/14/19 at 12:30 p.m. Resident was ambulating by himself in the hall with frequent stops; had to be guided the rest of the way. An observation was conducted on 11/14/19 at 12: 40 p.m.: Resident #296 was observed in the dining room. CNA set up his meal, then oriented him to the location of items on his plate. Resident was able to eat without further help. During an interview with Staff I, Certified Nursing Assistant (CNA), on 11/14/19 at 2 p.m., she said I've known this resident since he came here. I think his vision is much worse now than when he was admitted . He can see things right in front of him, but he has difficulty with his peripheral vision, his sides. That's why he fell, I think. He was trying to sit down on the chair and missed it so we make sure to orient him to his surroundings. An interview was conducted with Staff P, also a CNA, on 11/14/19 at 2:15 p.m. Staff P said Yes, he does have trouble seeing. But he knows how to feel his way down the hall, you know, he walks and runs his hands along the wall to feel his way, but we must watch when he tries to sit. He misses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 sometimes. He goes to Restorative for dining, and they help him with his meals by cutting it up and telling him where everything is on his plate. When asked if he is care planned for impaired vision, Staff P said No, it's not on our kiosk, our CNA tasks. It just talks about his low vison in terms of falls, but not for assistance with Activities of Daily Living (ADL's.). Let me show you my kiosk. There were no specific tasks related to impaired vision, or assistance with ADL's due to impaired vision noted in the kiosk system. Residents Affected - Few An interview was conducted with two MDS Coordinators on 11/14/19 at 3 p.m., Staff Q and Staff E, confirmed that the MDS section B: Vision: was marked incorrectly as Adequate. Both Staff Q and Staff E confirmed that Impaired Vision was not listed on the care plan as a target area and therefore no interventions were developed or implemented. They confirmed that the MDS assessment related to vision was not accurate. Staff Q stated we share the responsibilities of the MDS Assessment and Care plan with Social Services. We are all present at the IDT meetings, and we should have caught it then and included it in his care plan. We missed it. An interview was conducted with Staff R, the Director of Social Services, on 11/14/19 at 3:20 p.m. She said Yes, we did have an interdisciplinary team meeting on 10/15/19 and on 11/4/19, but we did not talk about his impaired vision or put it on the care plan. Yes, I would expect his assessment to reflect impaired vision, and it should be on the care plan. Review of the facility's policy titled Care Plans, Comprehensive, revised in December 2016, revealed: Policy Statement: 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. Policy Interpretation and Implementation: 2) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8) The comprehensive person-centered care plan will b) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g) incorporate identified problem areas. 9) areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Review of the facility's policy titled Goals and Objectives, Care plans, revised in April 2009, revealed: Policy interpretation and implementation: 4) Goals and objectives are entered into the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #14 was admitted [DATE] and 5/4/19. The clinical record included medical diagnoses not limited to Type 2 diabetes mellitus without complications. At 9:26 a.m. on 11/14/19, Resident #14 was observed in a wheelchair, being propelled in the hallway towards the units' shower room. On 11/15/19 at 2:10 p.m., Resident #14 was observed lying in bed, alert and spoke in a repetitive manner. A review of Resident #14's Physician Order Report identified the following current medication order: - Novolin 70/30 (insulin nph and regular human) suspension; 100 unit/milliliter (mL) (70-30); amount: 20 unit subcutaneous. Special instructions: Inject 20 units sub-q (subcutaneous) twice daily. Diagnosis (dx): Diabetes Mellitus (DM) if accucheck below or above 400 call MD (medical doctor). Dx: Type 2 Diabetes Mellitus without complications. Twice daily: 6:30 a.m. and 5:00 p.m., start date 4/1/19 - open ended. Resident #14's clinical record included a Pharmacy Consultation Report, dated 3/31/2019, with a recommendation to please increase Novolin 70/30 insulin from 20 to 22 units twice daily with meals and consider increasing the twice daily dose by 2 units/dose every 4 days until fasting glucose targets were achieved. The comment, included with the recommendation, indicated Resident #14 had experienced episodes of morning hyperglycemia with fasting glucose levels being frequently elevated to greater than 200- 300 milligram/deciliter (mg/dL) in March. The recommendation did not identify a response from the physician or a physician signature. A Pharmacy Consultation Report, dated 5/22/19, indicated a repeat recommendation to increase Resident #14's Novolin 70/30 insulin from 20 units to 22 units due to an increase in blood glucose levels. The report did not indicate a physician response or signature regarding the recommendation to increase the residents' insulin. The report asked for a prompt response to assure the facility compliance with Federal regulations. The Pharmacy Consultation Report, dated 7/31/19, indicated a repeat recommendation from 3/31 and 5/22/19 to increase Resident #14's Novolin 70/30 insulin to 22 units twice daily and to consider increasing the twice daily dose by 2 units every 4 days until fasting glucose targets were achieved due to elevated glucose level in March 2019 which persisted in May 2019. The recommendation did not indicate a physician response or signature. During an interview, on 11/15/19 at 11:38 a.m., the Consulting Pharmacist stated a recommendation regarding Resident #14's Novolin 70/30 was made in March, May, and July. A repeat recommendation was scheduled to occur in September but Resident #14's blood glucose levels were below 200 so it was no longer a concern and a repeat recommendation was not made at that time. On 11/15/19 at 11:38 a.m., the Regional Director of Clinical Services provided the Consulting Pharmacists' July recommendation regarding Resident #14's Novolin 70/30 and stated she could not find one that had been followed up with the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The policy titled, Medication Regimen Reviews, revised April 2007, identified the primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. The policy indicated if the physician does not provide a pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or if the Medical Director is the Physician of Record, the Administrator. Based on interviews and record review, the facility failed to ensure that pharmacy recommendations were reviewed and acted upon in a timely manner for 2 (#10, and #14) of 4 residents reviewed for unnecessary psychotropic medications. Findings Included: 1. Review of Resident #10's admission Record revealed that she was admitted to the facility on [DATE] with diagnoses that included: psychotic disorder with delusions, dementia, major depressive disorder, and anxiety disorder. Her physician's orders included: Do Not Resuscitate, Buspirone tablet 7.5 milligrams (mg); oral; one tab twice a day for anxiety. Celexa tablet 10 mg; oral, give 10 mg tab every day for depression. Review of Resident #10's care plan revealed: 5/4/2019: Psychotropic Drug Use: anti-anxiety medication related to anxiety. Approach: monitor for drug use and effectiveness and adverse consequences. Pharmacy consultant review every month. Resident receives anti-depressant medication related to depression. Approach: Monitor mood and response to medication. Pharmacy consultant review monthly. Resident receives antipsychotic medication related to aggressive behavior. Approach: pharmacist consult review monthly. Review of Pharmacy Consultation Reports revealed: 3/1/19 -3/31/19: Comment: received celexa 10 mg daily for depression since 11/12/18, when the dose was reduced from 20 mg. 4/1/19-4/30/19: Comment: prescriber accepted a pharmacy recommendation on 4/23/19 to decrease celexa to 5 mg once daily for 30 days, then discontinue, but the order has not been processed. recommendation: process the accepted pharmacy recommendation and update the medical record accordingly. Not signed, just states completed 5/23/19. 8/1/19 -9/1/19: repeated recommendation from 7/31/19, and from 5/2/19. prescriber accepted a pharmacy recommendation on 4/23/19 to decrease celexa to 5 mg daily for 30 days, then d/c, but the order has not yet been processed. Not signed. (Photographic evidence obtained). Review of Medication Administration Record for #10 for the month of 10/1/2019 through 10/31/2019 and for 11/1/2019 through 11/14/2019 revealed: Celexa 10 mg tablet was given every day for depression (start date: 5/28/2019). A phone interview was conducted with the Consultant Pharmacist, Staff L, on 11/15/2019 at 11:39 a.m. She stated: The Celexa recommendations were faxed and re-faxed to the Director of Nursing (DON). From there, the DON is expected to communicate with the physician and get his order. I am not sure of why it wasn't done, but I have not received a response on it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's policy titled Medication Regimen Reviews, revised in April 2007, revealed: Policy Statement: The Consultant Pharmacist shall review the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 1) The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility. 5) The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. 9) The consultant pharmacist will provide the Director of Nursing and Medical Director with a written, signed, and dated copy of the report, listing the irregularities found, and recommendations for their solutions. 10) Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #14 was admitted on [DATE] and readmitted on [DATE]. The clinical record included diagnoses not limited to unspecified dementia with behavioral disturbance, unspecified anxiety disorder, unspecified single episode major depressive disorder, and psychotic disorder with hallucinations due to known physiological condition. Resident #14 was observed, on 11/14/19 at 9:26 a.m., in a wheelchair being propelled by a staff member towards the shower room, the residents' eyes were closed. On 11/15/19 at 2:10 p.m., Resident #14 was observed lying in bed, the resident responded to questions inappropriately and with repetitive speech. The Physician Order Report indicated Resident #14 received the following medications: - Depakote Delayed Release 125 milligram (mg) tablet twice daily for behavioral disturbance. - Paxil 30 mg tablet, 1/2 tablet daily for depression disorder. - Ativan 0.5 mg tablet, 1/2 tablet twice daily for severe anxiety. - Quetiapine 25 mg, 1/2 tablet at bedtime for psychotic disorder. The Physician Order Report did not include an order for staff to monitor the number of times a behavior occurred, the type of behavior that Resident #14 exhibited, if any side effects of the medications were observed, or the efficiency of the received medications. The October and November 2019 Medication Administration Records (MAR) indicated staff did document as the target behavior for Ativan anxiety, mood, 0, +, and calm. The MAR's did not direct staff as to what the target behavior was, the number of times the behavior occurred, or if any non-pharmacological interventions were attempted. The effectiveness of the Ativan was documented less than daily and not for each administration. The October and November 2019 MAR's indicated nursing staff were documenting a target behavior for Resident #14's Depakote as behavior, mood, 0, behavior disturbance ukn, and anxiety. The MAR did not direct staff as to document the type of behavior, the number of times a behavior was exhibited, or the side effects that can occur with receiving Depakote. The effectiveness of the medication was documented less than daily. The October and November 2019 MAR's for Resident #14 indicated staff did not document the targeted behavior, episodes of the behavior, or if side effects occurred with the administration of Paxil. Effectiveness (+) of the medication, Paxil, was documented less than daily. Resident #14's October and November 2019 MAR's indicated the resident received the antipsychotic medication, Quetiapine, daily. The MAR's did not identify a target behavior, the number of episodes of the behavior, or if side effects of the medication had occurred. The October MAR did not include documentation if the medication was effective and the November MAR indicated + on 11/3 and . on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0758 11/9/19. Level of Harm - Minimal harm or potential for actual harm The care plan for Resident #14 included the following problems and approaches: Residents Affected - Some - Resident received antidepressant medication r/t (related to) depression. The approaches instructed staff to administer medication as ordered and to monitor resident's mood and response to medication. - Resident resists care, refuses to leave O2 (oxygen) on at times, refuses ADL (activities of daily living) care, and flails and grabs onto things when transported in wheelchair. The approaches included to allow resident to choose options. - Resident makes verbal expressions of distress, and verbalizes frustration at times, anxiety. The approaches included to observe for signs and symptoms of depression (withdrawal, isolation, loss of appetite, and etc.). - Resident #14 received antianxiety medication r/t (related to) anxiety. The approaches instructed staff to attempt non-pharmacological interventions. - Resident #14 received antipsychotic medication r/t paranoid behavior. The approaches indicated an AIMS (Abnormal Involuntary Movement Scale) every six months. 3. Resident #84 was admitted on [DATE]. The clinical record included diagnoses not limited to other specified depressive episodes, unspecified dementia with behavioral disturbance, disorganized schizophrenia, and unspecified anxiety disorder. The Physician Order Report indicated the following medications were ordered for Resident #84: - Risperidone 0.5 milligram (mg), 1/2 tab (0.25 mg) daily for disorganized schizophrenia. - Sertraline 100 mg daily for other specified depressive episodes. - Lorazepam 1 mg twice daily for unspecified anxiety disorder. - Risperdal 0.5 mg every evening for disorganized schizophrenia. - Depakote 125 mg, twice daily for aggressive behavior. - Ativan 1 mg every 6 hours as needed for anxiety/agitation. - Aggressive/Combative Behavior: Move resident to quiet room until episode resolved, remove potentially harmful objects from immediate environment, protect other residents in immediate area from harm. As needed. The October 2019 Medication Administration Record (MAR) indicated the following: - Depakote 125 mg twice daily. The documentation did not include if behaviors or side effects occurred, or if any non-pharmacological interventions were used. The effectiveness of the medication was documented eight (8) times from 10/1 - 10/30/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Risperdal 0.5 mg every evening. The documentation did not indicate behaviors or side effects were monitored, or if any non-pharmacological interventions were used. The effectiveness of the medication was documented eight (8) times from 10/1 - 10/30/19. - Risperidone 0.25 mg daily (9:00 a.m.). The documentation did not indicate if behaviors had occurred. The nursing staff documented the target behavior as schizophrenia, mood, repetitive movement/speech, and 0. - Sertraline 100 mg daily. The MAR indicated a target behavior as depression, mood, and 0. The documentation did not indicate the number of behavioral episodes, if side effects had occurred, and effectiveness was monitored four (4) times from 10/1 - 10/30/19. - Aggressive/Combative Behavior did not indicate any behavior had occurred. The November 2019 MAR indicated the following: - Depakote 125 mg twice daily. The MAR did not indicate the number of behavioral episodes occurred, if side effects occurred, or if any non-pharmacological interventions were attempted. The effectiveness of medication was documented at 9:00 a.m. on 11/1, 11/11, and 11/13/19. Effectiveness was not documented for the 5:30 p.m. dosage. - Risperdal 0.5 mg once an evening. The MAR did not indicate a target behavior, number of times the behavior occurred (if any), the effectiveness of the medication, or if side effects were observed. - Risperidone 0.25 mg daily (scheduled at 9:00 a.m.). The MAR identified the target behavior as schizophrenia and 0. - Sertraline 100 mg daily. The MAR indicated the targeted behavior was depression and 0. The documentation did not indicate if side effects occurred or if any non-pharmacological interventions were attempted. The effectiveness was documented on 11/1, 11/11, and 11/13/19. - Aggressive/Combative Behavior as needed was not documented. The care plan for Resident #84 indicated the resident has physical behavioral symptoms toward others and staff such as striking out propels w/c (wheelchair) without avoiding personal space of others and undresses self in inappropriate areas. Resident #84 propels self in corners and in different rooms, able to lock and unlock brakes, will refuse meals, and may become agitated when tired. The approaches instructed nursing to administer medication for aggression as ordered, monitor for effectiveness, and adverse reactions. Resident #84's care plan indicated the resident received antidepressant medication r/t (related to) depression and antiquity medication r/t anxiety. The approaches indicated staff were to attempt non-pharmacological interventions. Resident #84 received antipsychotic medication r/t schizophrenia. The approaches included AIMS (Abnormal Involuntary Movement Scale) every three months. Based on interviews, observation, and record review the facility failed to ensure that the effectiveness of the medication as well as behavior and side effects monitoring which are all essential for evaluating the use of psychotropic medications, was accurately recorded for four (# 10, # 14, # 52, and # 84,) of five sampled residents who were reviewed for unnecessary medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0758 Findings included: Level of Harm - Minimal harm or potential for actual harm 1. Resident # 52 was originally admitted to the facility on [DATE] after a short stay at an acute care facility with the primary diagnosis of Huntington's Disease. Other pertinent diagnoses included but were not limited to chronic pain, migraine, major depressive disorder, unspecified convulsions, and anxiety disorder. Residents Affected - Some A review of the minimum data set (MDS) dated [DATE] reflected that Resident # 52 was mildly impaired with a brief interview for mental status (BIMS) of 12 and had no behaviors of delirium; mood was documented as depressed and tired/little energy at a severity of 2, the behaviors section documented rejection of care. A review of the active physician orders dated 11/14/19 for Resident # 52 included the psychotropic medications paroxetine HCl 40mg at bedtime for depression, carbamazepine 800mg twice daily for seizures, doxepin 100mg at bedtime for anxiety, risperidone 3mg twice daily for Huntington's, quetiapine 50mg twice daily with meals for Huntington's and quetiapine 100mg at bedtime for insomnia. There was no physician order for the monitoring of behaviors or for the monitoring of side effects related to psychotropic medications. The physician orders also included the medication meclizine 12.5mg twice daily as needed for dizziness with a start date of 01/27/17. A review of the plan of care dated from the last care conference on 10/10/19 for Resident # 52 included a focus on Psychotropic Drug Use, with a goal that stated: Resident will be prescribed the lowest effective dose of medication. The approach to attain this goal was Abnormal Involuntary Movement Scale (AIMS) every 3 months and Pharmacy consultant review monthly. A review of the medication administration record (MAR) for the period of 10/01/19 to 11/14/19 revealed that the psychotropic medications were administered as ordered and no documentation for the effectiveness, side effects, or behavior monitoring was provided. A review of the monthly medication review (MMR) for the month of March 2019 included the following recommendation: Please attempt a gradual dose reduction (GDR) to Doxepin 75mg at bedtime, while concurrently monitoring for the reemergence of target behaviors and/or withdrawal symptoms. An interview on 11/14/19 with the pharmacy consultant revealed that although the primary physician agreed with the recommendation, it was not implemented because the Primary Physician deferred to the Neurologist treating Resident # 52's primary diagnosis, an order was written in response on 05/14/19 it read: No GDR for Doxepin; continue with current dose. A nursing progress note dated 05/14/19 documented a GDR for Doxepin was declined by psych services .would recommend discussion with neurologist prior to med changes .follow up in July. A review of the Physician progress note reflecting the service date of 10/23/19 for a Medication check follow-up the Advanced Registered Nurse Practitioner (ARNP) wrote in the assessment of Resident # 52 Sad, disheveled, .stated feeling depressed ., and in the care plan recommendation: .continue to monitor for change in mood and behavior. An interview with the Director of Nurses (DON) revealed that her expectation was for the nurses to monitor the behaviors in the nurse progress notes. Review of the nurse progress notes dated 08/01/19 to 10/31/19 revealed conflicting documentation such as on 10/30/19 at 10:19 PM No complaint of behavior at this time despite Resident # 52 refusing care for a shower for the past two days, and suffering multiple falls related to not wanting to follow instructions to call for assistance in order to transfer to the bedside commode. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm 4. Review of Resident #10's admission Record revealed that she was admitted to the facility on [DATE] with diagnoses that included: psychotic disorder with delusions, dementia, major depressive disorder, and anxiety disorder. Her physician's orders included: Do Not Resuscitate, Buspirone tablet 7.5 milligrams (mg); oral; one tab twice a day for anxiety. Celexa tablet 10 mg; oral, give 10 mg tab every day for depression. Seroquel tablet (1/2 tablet: 12.5 mg) daily at hour of sleep for psychotic disorder. Residents Affected - Some Review of Resident #10's care plan revealed: 5/4/2019: Psychotropic Drug Use: anti-anxiety medication related to anxiety. Approach: monitor for drug use and effectiveness and adverse consequences. Pharmacy consultant review every month. Resident receives anti-depressant medication related to depression. Approach: Monitor mood and response to medication. Pharmacy consultant review monthly. Resident receives antipsychotic medication related to aggressive behavior. Approach: pharmacist consult review monthly. Review of Medication Administration Record (MAR) for #10 for the month of 10/1/2019 through 10/31/2019 and for 11/1/2019 through 11/14/2019 revealed: Celexa 10 mg tablet was given every day for depression (start date: 5/28/2019). Buspirone 7.5 tablet was given twice a day for anxiety (start date: 1/23/19). Seroquel 25 mg tablet; was given 1/2 tablet (12.5 mg) daily at hour of sleep for psychotic disorder. Review of progress notes written in the month of November 2019 revealed that the presence or absence of target behaviors and the presence or absence of adverse consequences (as listed in the care plan) were not documented. According to the Director of Nursing, documentation of behaviors would be in the progress notes if not in the MAR/TAR. Review of the Treatment Administration Record (TAR) for October and November 2019 confirmed that the presence or absence of adverse consequences and target behaviors specific to psychotropic medication use were not documented. Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised in December 2016, revealed: Policy Statement: 1) Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. Policy Interpretation and Implementation: Assessment: 3) The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a) Onset, duration, intensity, and frequency of behavioral symptoms. 4) New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Management: 10) When medications are prescribed for behavioral symptoms, documentation will include: a) rationale for use, e) specific target behaviors and outcomes, h) monitoring for efficacy and adverse consequences. Monitoring: 4) the nursing staff will monitor for side effects and complications related to psychoactive medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 observation, interviews, and record review, the facility failed to maintain drugs and biologicals in accordance with accepted professional standards in 1 of 2 medication storage rooms. Findings included: On 11/14/19 at 12:42 p.m., an observation of the medication room located on the 1st floor was conducted. On the far-left corner of the room, against the wall, was a blue toolbox. Staff M, a Licensed Practical Nurse, identified the toolbox as an EDK (Emergency Drug Kit). There were no red or green tags on the outside of the box. A label on the top of the box provided the following information: item description, units of measure, quantity, product identification, expiration date, and tray description. The item description indicated that antibiotics were stored inside. Staff M was able to freely open the box, and inside, several drawers of antibiotics were observed. There was no pharmacy reconciliation slip inside to indicate if any medications had been removed. On the far-right corner of the room, on an open shelf, was a plastic see-through drawer, containing antibiotic medications. Again, there were no red or green tags on the outside to indicate if the drawer had been opened and contents removed. Several rows in the drawer were empty. There was no pharmacy reconciliation slip in the drawer. During an interview with Staff M on 11/14/19 at 1 p.m., Staff M stated Since there are no red or green tags on either of these kits, and there is no pharmacy slip, there is no way to know if any of the medications were removed from either box. It looks like they are all antibiotics. But I don't know when these boxes were put in here, they weren't here earlier. During an interview with the Director of Nursing (DON)on 11/14/19 at 1:15 p.m., the DON confirmed that neither of the boxes had green or red tags, nor did they have pharmacy reconciliation slips. The DON said I don't know why these kits are not tagged. Pharmacy usually brings it with labels and tags. I don't know how these got here. I have no idea if anyone took any medications from either box. I will have to recount them all. An interview was conducted with the Consultant pharmacist, Staff L, on 11/15/19 at 11 a.m. She said Pharmacy packs the medication into the EDK toolbox, puts a label on the top, and places a green tag on it; meaning that medications have not been removed from it yet. The clear drawer belongs inside the blue EDK kit, and it should not be outside by itself on a shelf. Review of the facility's policy titled Pharmacy Services, Role of the Provider Pharmacy, revised in April 2010, revealed: Policy Statement: The facility shall have a written agreement with a provider pharmacy to provide regular and reliable pharmacy services to residents, including medications and supplies. Policy Interpretation and Implementation: 3) The provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, laws and regulations, including the following: b) Help the facility identify needed supplies and services related to medications. I) Provide and maintain the facility's emergency medication supply. J) Deliver medications to the facility and help the facility ensure that all deliveries are correct and proper documentation related to delivery is provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 Review of the facility's policy titled Storage of Medications, revised in April of 2007, revealed: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1) Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. 2) The nursing staff shall be responsible for maintaining medication storage. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2. An observation was made on 11/12/19 at 11:58 a.m., of one of two metal tray carts on the secured unit of the facility. The tray cart contained meal trays for the residents eating in their rooms. The meal trays contained a covered plate and an uncovered tart-sized cheesecake. Photographic evidence obtained. At 12:07 p.m. on 11/12/19, Staff Member J, CNA, confirmed the cheesecakes were not covered and stated the kitchen sent them to the unit uncovered. On 11/14/19 at 12:44 p.m., the Dietary Manager stated dessert on the meal trays are to be covered. He stated even though the carts are covered, the food should also be covered and felt the kitchen staff was trying to preserve the presentation. Based on dining observations, interviews and record review the facility failed to serve food in a safe and sanitary manner related to 1) food being prepared in close proximity to a hand hygiene sink/soap; 2) uncovered desserts transported to unit and 3) lack of hand hygiene between residents in one of four dining observations. Findings included: 1. On 11/12/19 at 11:47 a.m., an observation of the afternoon meal service was conducted in the main dining room on the second floor of the facility. Residents were seated at sixteen different tables around the dining area. Six staff members where present in the dining room to assist with the afternoon meal. Soup, salad and beverage service had begun in the dining room for the residents. A counter top area with cabinetry was observed along the back area of the dining room which included a sink with a soap dispenser attached to the wall behind the sink. A large black electric soup kettle was observed on the counter, set up on the right side of the sink, and a large metal bowl of salad was observed on the counter, set up on the left side of the sink. A staff member was observed dispensing salad from the large metal bowl into small individual bowls for the residents. A staff member was observed dispensing soup from the electric kettle into small individual bowls for the residents. During the preparation of soup and salad, multiple staff members were observed accessing the sink area and using soap and water to wash their hands. Water and soap were observed splashing around the sink area as staff members performed hand hygiene in close proximity to the soup and salad that was being served to the residents. Staff C, Certified Dietary Manager (CDM), was brought into the dining room to observe the service of salad and soup to the residents at the request of the surveyor. Staff C, CDM stated that the food should not have been set up on the counter area near the hand hygiene sink. Staff C, stated the soup and salad was sent out to the dining room on a metal serving table and should have been served from there. Staff C, CDM instructed the staff to move the soup and salad off of the counter and away from the hand washing sink for service to the residents. A review of the facility policy entitled Food Preparation and Service (revised October 2017) indicated the following: Policy Statement: Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Food preparation area Level of Harm - Minimal harm or potential for actual harm 2 Equipment will be arranged to facilitate food preparation, based on input from appropriate individuals including food and nutrition services staff. Residents Affected - Few A review of the facility policy entitled Food Receiving and Storage (revised October 2017) indicated the following: Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1 Food services, or other designated staff, will maintain clean food storage areas at all times. 16 Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage area from food storage and labeled clearly. 3. On 11/12/19 at 11:56 a.m., during the initial dining observation in the first-floor dining room, the following was observed: Three residents were seated at a table. Staff O, a Certified Nursing Assistant (CNA), opened the utensil package and used a knife to cut up food for one of the residents. She then removed one of the other resident's used food tray from the table, walked over to the center table, emptied the food waste on the plates into the garbage can, and stacked the soiled tray/plates on the center table. She did not have gloves on. She then walked over to the food cart, pulled out a new tray, and delivered it to the resident. Hand hygiene was not observed. At 11:59 a.m., Staff N, also a CNA, was observed emptying food waste into the garbage can and storing the used tray. She did not perform hand hygiene. She then went over to a resident and proceeded to cut up her food. At 12: 11 p.m., Staff O emptied food waste into the garbage can, and stacked the trays. Without performing hand hygiene, Staff O obtained a new tray from the food cart and served it to a resident. Review of the facility's policy titled Handwashing/Hand Hygiene, revised in August 2015, revealed: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2) All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7) Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: O) Before and after eating or handling food. P) before and after assisting a resident with meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation, on 11/12/19 at 11:10 a.m., revealed the emergency call light in the bathroom between rooms [ROOM NUMBERS] was not operational. The call light was tested and no light or sound was observed or audible from the hallway. Residents Affected - Some On 11/13/19 at 3:19 p.m., Staff Member G, Licensed Practical Nurse (LPN) and another nurse, confirmed the light in the hallway for the shared bathroom, of rooms 113-115, flickered when the string was pulled then stopped, even though the light was not shut off in the bathroom. On 11/12/19 at 11:21 p.m., the emergency light in the bathroom shared by rooms [ROOM NUMBERS] was tested and found to be not working. During the testing of the light, neither the light in the hallway turned on or was audible. At 3:24 p.m. on 11/13/19, the Director of Nursing (DON) tested the emergency light in the bathroom of rooms [ROOM NUMBERS], it was found if the string was pulled and wiggled the light would work but if it was just pulled it did not. The DON confirmed the bathroom lights for rooms 113 - 115 and 105 - 107 were not operational. She confirmed that during the facility-wide testing of the call lights, on 11/13/19, she had checked the lights on the unit and found that they had worked. The DON notified the Maintenance Director of the issues with the emergency lights. On 11/13/19 at 3:47 p.m., the Nursing Home Administrator stated the lights were not operational if residents and/or staff had to shake it to work. She stated she was going to review the handwritten list, done by staff, to see who said the lights in the bathrooms between rooms 105 -107 and 113 - 115 worked. Based on observations, interviews and review of maintenance records, the facility did not ensure that a preventative maintenance schedule was in place to maintain the call light system for 1 of 2 floors in the building. Seven resident rooms and/or bathrooms (105, 107, 111, 113, 115, 124 and 125) out of 31 total resident rooms on the first floor of the building had call lights that were not functional and needed repair. Findings Included: Direct observation of call light function on 11/12/19 at 11 a.m. and 11/13/19 at 1 p.m. confirmed that the call lights for room [ROOM NUMBER] were not functioning. An observation was conducted on 11/12/19 at 1:30 p.m. The resident was observed sitting in her wheelchair in the hall, and she was observed going into room [ROOM NUMBER]. She pressed the call bell laying on the bed near the door. The call light did not light up (activate). The resident left the room and went down the hall. She called out to one of the nursing assistants at the end of the hall and expressed her need for assistance to the bathroom. The nursing assistant asked the resident why she didn't use her call bell, and the resident responded, I did, it didn't work. The nursing assistant escorted the resident to her room and assisted her with toileting. Afterward, they exited the room. After 2 hours, the surveyor tested the call light for the resident residing in room [ROOM NUMBER], and it remained non-functional. During an interview with the Director of Nursing on 11/13/19 at 11:40 a.m., she confirmed that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 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 105428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 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 0919 call lights were not working for room [ROOM NUMBER] and 125. Level of Harm - Minimal harm or potential for actual harm Results of a call light audit done by the facility on 11/13/19 at 12:15 p.m., revealed that there were 7 rooms on the first floor with identified nonfunctional call lights and/or nonfunctional bathroom call lights. (Rooms: 105-107 plus bathroom, 111, 113 bathroom, 124, and 125) Residents Affected - Some During an interview with the Maintenance Director on 11/14/19 at 2 p.m., he said that he had a very long list of repairs that were pending and referred to the repair work as a work in progress. He said, Maintenance makes rounds on the floors daily and inspects the halls and common areas for safety issues. When asked if he adhered to a certain schedule for fixing items on the list, he stated No, we just mark it off as we get it done, unless it's an emergency. Review of invoice statements from 8/14/19, 10/17/19, and 10/22/19 revealed that the facility had the call lights tested and repaired on those dates. However, the facility was not able to produce documents of regular inspections and maintenance of the call light system. Review of the facility policy titled Maintenance Service, revised in December 2009, revealed Policy Statement: Maintenance service shall be provided in all areas of the buildings, grounds and equipment. Policy Interpretation and Implementation: 1) The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2) Functions of maintenance personnel include: g) maintaining the paging system in good working order. I) providing routinely scheduled maintenance service to all areas, including the call light system for resident rooms, shower rooms and bathrooms. 3) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 24 of 24