Inspection·October 8, 2021

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/8/2021 at 10:18 a.m. an interview with Staff G, Certified Nursing Assistant (CNA) revealed she had Resident #150 on her assignment today and has had him once before since his admission. She revealed she was from agency staffing and floats all over the facility. She was unaware of why Resident #150 still had his FALL RISK yellow band on his wrist and indicated those usually come with the resident when they are discharged from the hospital. She revealed he has been here about a week and perhaps the band should have been cut off when admitted . On 10/8/2021 at 10:24 a.m. an interview with Staff F, Licensed Practical Nurse (LPN) confirmed that usually when returning or admitted from the hospital, if a resident has that band on, it was usually removed upon their admission. On 10/8/2021 at 1:45 p.m. an interview with the Director of Nursing (DON) revealed when a resident is admitted to the facility from the hospital and is wearing a wrist band, to include a FALL RISK band, it should be removed the day of their admission to the facility. She confirmed they have facility assessments and care plans that would identify the resident as fall risk and would not need to wear a band to identify that. She confirmed the resident's dignity should be maintained by not wearing signage like that on their person. 2. On 10/5/2021 at 10:10 a.m. Staff A, CNA was observed wearing a white plastic electronic phone ear bud device in her right ear. She was observed walking up and down the 200 hallway and going into various rooms providing care and services to residents. She was observed talking to someone on her electronic phone ear bud device. She was then observed at the nurses' station, charting and still talking to someone on this device. On 10/6/2021 at 9:45 a.m. Staff A, CNA was observed in the 200 hallway walking by herself and going in and out of resident rooms. During that time, she was observed talking with no one around her to communicate with. Further observations revealed she was again wearing an electronic phone ear bud device in her right ear and was talking and communicating with it. At 10:20 a.m. she was again observed pushing a resident (#19) while in her wheelchair and talking using the same device. Further observation revealed she was not talking to the resident, but rather talking and communicating with the device. In an interview at this time Resident #19 revealed she was not aware the staff member (A) was talking to her and she knew she was talking to someone, but there was no one around. Resident #19 also confirmed that staff talk on phones to other people all the time. On 10/6/2021 at 12:50 p.m. Staff F, LPN was observed in the 100 unit going in and out of resident rooms and assisting with care. He was further observed wearing an electronic phone device in his right ear. He was observed wearing this device throughout the entire shift. Also, he was observed speaking and communicating with this device while preparing medications. On 10/6/2021 from 7:20 a.m. through to 2:00 p.m. Staff A, CNA, and Staff D, Restorative Aide were observed on their respective halls/units, providing care and services to residents and walking up and down hallways and going in and out of resident rooms and all with wearing their electronic phone ear bud devices in their ears. Staff A, CNA and D, Restorative Aide were observed talking on their devices several times while out in the hallways and going and out of resident rooms. On 10/8/2021 Staff A, CNA at 10:40 a.m. was observed assisting a resident down the hallway, through the main dining room and to the porch area. Staff A was observed wearing the electronic phone ear bud device in her right ear. She was also observed utilizing it and communicating with someone other than the resident who she was with. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 2 of 19 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 10/08/2021 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/8/2021 at 10:00 a.m. and 12:00 p.m. random interviews with Residents #19, #94, #150, and #37, all confirmed staff have phones with them at all times and they have been observed talking on them during all times of the day and night including when they are in resident rooms assisting with care and services. The residents further confirmed that staff are sneaky and have ear plugs, ear devices that are hidden, but they can see them and have seen staff use them all the time. Residents #150 and #37 both indicated that they have recently (date unknown) told staff, to include Staff A, CNA and Staff C, Restorative Aide that it was rude to talk on the phone when assisting them while in their room. They have spoken to supervisors but there has not been any change. The following record review was obtained for Residents #19, #94, and #37. Review of Resident #19's medical record revealed she was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 7/8/2021, revealed in Section C Cognitive Patterns a BIMS score of 15 of 15, which indicated the resident was able to answer questions related to her care and services. Review of Resident #94's medical record revealed he was admitted to the facility on [DATE]. Review of the current MDS Quarterly assessment, dated 9/17/2021 revealed in Section C Cognitive Patterns a BIMS score of 13 of 15, which indicated the resident was able to answer questions related to his care and services. Review of Resident #37's medical record revealed she admitted to the facility on [DATE]. Review of the current MDS admission assessment, dated 7/27/2021, revealed in Section C Cognitive Patterns a BIMS score of 14 of 15, which indicated the resident was able to answer questions related to her care and services. On 10/8/20221 at 1:15 p.m. an interview was conducted with the Nursing Home Administrator (NHA) with regards to staff and their personal phone devices. The Nursing Home Administrator revealed they have a no use of personal phone devices policy when in the building and certainly when on the floor and providing care and services. He was not sure what type of education was provided to Agency staff, but he believes they receive the same education as their own in house staff. The Nursing Home Administrator at 1:32 p.m. provided their personnel/employee guide, which is provided to their staff upon orientation for review. The guide was not dated, but current as per interview with the NHA. The section titled, Cell Phones revealed: The use of cellular telephone on the premises is permitted only in your parked car in the parking lot or in the event of an emergency. While on duty, cell phones may be carried on your person in the off position and used for emergency medical aid only. Employees may use cell phones or walkie-talkies on the course when necessary to perform their duties but not for personal reasons. It is expressly prohibited to use your phone or any type of electronic device to record (audio or video) at any time. 3. On 10/07/2021 at 12:27 p.m., dining was observed on the 100 unit. Resident #28 and Resident #33 were observed seated in their wheelchairs near the nurses' station facing the dining room and had a clear view of other residents eating in the dining room through a glass window. There were seven residents in the dining room at that time eating lunch. Resident #28 was overheard asking staff how long she had to wait to eat. She then asked the surveyor how long she had to wait to eat because she had been waiting for hours. Staff L, CNA stated [Resident #28] eats in the dining room and must wait until the group that are in the dining room finishes their lunch. Resident #28 asked why she could not eat in her room. She again asked the surveyor how long she had to wait to eat. Staff O, CNA at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 3 of 19 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 10/08/2021 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12:30 p.m. stated there were two seatings for dining. The residents that were not vaccinated sit by themselves. Staff L, CNA, at 12:31 p.m., stated she could take them (Residents #28 and #33) to their room to eat but did not escort them to their room at that time. Resident #28 stated to Staff l, CNA, I thought you were my friend. Where is my food? She (Resident #28) then stated, Are they finished? We are going to starve. Resident #28 asked Staff K, Activity Aide, at 12:32 p.m., if she could have lunch now. Staff K replied, Give me five minutes. Staff L, CNA then escorted both residents to their rooms. She immediately brought them back and stated maintenance was working on their room so they couldn't eat in the room. Resident #28 asked, Can I go outside to eat? She then asked if she could go to another room to eat. Staff L did not respond. There was one empty table near the entry/exit door of the dining room. Only one resident was eating at the table in the corner in the dining room at that time. Resident #28 stated she never had to wait that long to eat. She asked was there something going on that they had to make them wait. Resident #28 said the food was going to be ice cold and no good. Resident #28 asked at 12:37 p.m., Now can we go? They are making me so mad and I'm going to push the door in stated Resident #28. She then stated, I haven't gotten anything not even a drink. They keep coming out with trays and I don't have anything, stated Resident #28. By the time we get it, it is going to be cold. Then at 12:41 p.m., she stated we can't even get a drink. They are going to pay for this stated Resident #28. The resident asked a staff member walking by if they could go eat and the staff member walked by the resident and didn't say anything. The resident said they were going to make them die and they were doing that for spite. Resident #28 said when she got her food, she was going to throw it on the floor. Is it time now, asked Resident #28. at 12:44 p.m. and Staff I, CNA, stated it's coming. The resident stated she was angry, and she was going to get up and go in the dining room. Staff M, Patient Care Assistant (PCA), stated you are about to eat in two minutes my goodness. The resident kept asking was it their turn now. She stated she had a headache and really doesn't get headaches. Then at 12:47 p.m., Staff N, Registered Nurse (RN), escorted both residents into the dining room to a table and stated we can go in now. Then at 12:51 p.m., staff started bringing in the lunch trays. Resident #28, at 12:55 p.m., received her tray and at 12:56 p.m., Resident #33 received his tray. Both residents were observed eating their meal independently. A review of the list of vaccinated residents showed both Resident #33 and Resident #28 were vaccinated. A record review of the Resident Face Sheet for Resident #28 indicated she was admitted into the facility on [DATE] with an admitting diagnosis of hypothyroidism. Section C Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], indicated the resident had a BIMS score of 05 out of 15 indicating severe impairment. Section G Functional Status of the MDS indicated the resident was independent with eating and needed set up help only. The care plan related to nutritional status with a start date of 07/21/21 included but was not limited to the following interventions: assist as needed with setup, positioning, encouragement, cueing and feeding as needed and honor any food requests as available. A record review of the Resident Face Sheet for Resident #33 indicated he was admitted into the facility on [DATE] with an admitting diagnosis of unspecified dementia without behavioral disturbance. Section C Cognitive Patterns of the MDS, dated [DATE], indicated the resident had a BIMS score of 06 out of 15 indicating severe impairment. Section G Functional Status of the MDS indicated the resident was independent with eating and needed set up help only. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 4 of 19 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 10/08/2021 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 0557 Level of Harm - Minimal harm or potential for actual harm The care plan related to nutritional status with a start date of 07/21/21 included but was not limited to the following intervention: assist with setup, positioning, encouragement, cueing and feeding as needed. In an interview with the Director of Nursing on 10/8/21 at 5:32 p.m. she stated they (Staff) could have offered her (#28) a snack or redirected her. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 5 of 19 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 10/08/2021 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, record reviews, and interviews the facility failed to implement the care plan for one (#43) out of twenty-two sampled residents that resided on the secured unit related to assessing the skin condition on a weekly basis. Findings included: Resident #43 was observed on 10/6/21 at 8:51 a.m. in the facility's secured unit's dining room. The resident was sitting in a wheelchair with a dirty surgical mask hanging from its handle. Resident #43 was observed on 10/8/21 at 8:20 a.m., sitting in the secured unit's dining room. The resident's hair was bushy and the resident's general appearance was unkept. The Resident Face Sheet for Resident #43 indicated the resident was admitted on [DATE] and included diagnoses not limited to Type 2 diabetes mellitus with ketoacidosis without coma, age-related cognitive decline, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. The care plan, initiated on 9/18/19, for Resident #43 indicated the resident was at risk for skin breakdown related to impaired mobility, episode of bowel/bladder incontinence, diagnosis of Diabetes Mellitus (DM). Stage 3 pressure ulcer to left heel, arterial ulcer to right heel. The staff approaches for this problem included: weekly skin checks by licensed nurse and to notify MD (medical doctor) if indicated for new skin breakdown issues. The care plan, initiated on 10/27/18, identified that Resident #43 required extensive to total assistance with mobility, transfer, locomotion, toileting, personal hygiene/grooming r/t (related to) weakness, complex diagnosis. The approach instructed staff to offer and encourage assistance with bed mobility, transfer, locomotion, dressing, eating, toileting, personal hygiene, and bathing as needed, encourage to participate in task. A long-term goal was that Resident #43 would have no s/s (signs/symptoms) of urinary tract infection and be free of skin breakdown r/t incontinence through the NRD (next review date) as the resident had episodes of bowel and bladder incontinence and ADL (Activities of Daily Living) deficits. The Physician Order Report from 9/8/21 to 10/8/21, provided by the facility, did not include an order for weekly skin assessment. A review of the September and October 2021 Treatment Administration Records (TAR) indicated staff were to assess Resident #43's skin once a day on Monday and to document under weekly skin inspections under Observations. This treatment began on 8/10/21 and was without a stop date. The September TAR indicated a skin assessment was completed on 9/6, 9/13, 9/20, and 9/27. The October TAR identified that a skin assessment was completed on 10/4/21. A review of the most recent 8 observations for Resident #43 indicated that the last Weekly Skin Inspection was completed on 8/12/21. The Weekly Skin Inspection completed on 8/12/21 was the last observation, of any type. A review of the 20 most recent progress notes indicated Resident #43 was seen by wound MD weekly regarding bilateral arterial heel wounds. The progress notes indicated on 9/16/21 the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 6 of 19 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 10/08/2021 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 continued on an antibiotic for skin rash, on 9/3/21 Dermatology was in the facility to visit the resident, and on 8/24/21 the resident was noted to have left great toenail peeled back. The progress notes did not describe the skin rash that was being treated. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #43 had a Brief Interview of Mental Status (BIMS) score of 00 indicative of severe cognition impairment. The MDS indicated Resident #43 required extensive physical assistance from two persons for bathing, personal hygiene, toilet use, and transferring. A review of Resident #43's September Behavior Monitoring indicated the resident had rejected care on 9/11/21. A review of the resident's October Behavior Monitoring did not indicate that the resident had rejected care. The review of the resident's 20 most recent progress notes, dated 8/21/21 to 10/1/21, indicated that on 9/30/21 a Social Services note revealed the resident could be resistive with care at times, on 8/24/21 a Social Services note indicated the resident had increased verbal outbursts, and a Registered Nurse, on 8/24/21, identified the resident was seen by psych Advanced Registered Nurse Practitioner. During an interview, on 10/8/21 at 5:05 p.m., the Director of Nursing (DON) stated that all residents get a skin assessment weekly. She confirmed the last skin assessment for Resident #43 was completed on 8/12/21. She reviewed the TAR and confirmed that staff had documented that a skin assessment was completed then stated, maybe they did a progress note. She reviewed the progress notes and stated it should be documented if the resident refused. The DON stated her expectation was the refusal to be documented and for the nurse to reapproach the resident. The facility's Supporting Activities of Daily Living (ADL) policy, revised March 2018, identified that, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy identified that Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). The policy instructed, If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, of having another staff member speak with the resident may be appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 7 of 19 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 10/08/2021 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, record reviews, and interviews the facility failed to provide adequate supervision of three residents (#21, #29 and #45) with a mechanically-altered diet and who have behavioral and/or cognition issues out of 22 residents residing a secured unit. Findings included: 1. An observation was conducted, at 8:32 a.m. on 10/8/21, of Resident #21 sitting next to her bed with an over-the-bed table near the door, on the table was a meal tray with a covered cup of orange-colored liquid and a covered plate. Staff I, Certified Nursing Assistant (CAN) entered the room next to Resident #21's, and removed Resident #29 from the room, and placed the resident in the hallway. Resident #29 propelled himself to the doorway of Resident #21's room and moments later was observed drinking a cup of orange-colored liquid, which was not observed in his possession when the staff member removed him from the other room. The cup, previously observed on Resident #21's tray, was not on the tray and the lid was lying next to the covered plate. Staff I removed Resident #29 from the doorway, into the hallway, then began to walk away. The staff member confirmed Resident #29 probably shouldn't have the juice. As the staff member removed the cup from Resident #29's grasp it was observed to be a thin consistency. A review of Resident #21's diet orders indicated the resident was to receive a mechanically-altered diet with thin liquids in addition to liquid nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. A review of Resident #29's physician orders for September 8, 2021 to October 8, 2021 indicated the resident was to receive a mechanical soft diet with honey thick liquids, with pureed meats and pureed rice. Staff Q, CNA was observed, on 10/8/21 at 12:35 p.m., with a hydration cart in the hallway of the secured unit. She stated there were no drinks on the meal trays and it was a new process the facility was trying. She stated she was passing liquids after the meals because if the residents see the liquids on the tray, they tend to leave it and this way she can make sure they're getting their drinks. The Nursing Home Administrator stated, at 1:03 p.m. on 10/8/21, the staff member had removed the liquid from Resident #29. He stated the facility will lock all beverages in the hydration cart and residents with mechanically altered diets would now be brought upstairs to the dining room and would not have access to each other liquids. 2. On 10/8/21 at 12:40 p.m., Resident #45 was observed sitting on the edge of his bed, in a room at the far end of the secured unit, drinking a cup of liquid, no other items were observed on the over-the-bed table in front of the resident. Resident #45 was observed, at 12:48 p.m. on 10/8/21, ambulating from the opposite end of the unit to his room eating a bread roll. Resident #45 and the bread roll were brought to the attention of the Risk Manager, which she removed from the resident's possession. The Director of Nursing stated, at 5:30 p.m. on 10/8/2021, that she felt the issue regarding dining was that it was a dementia unit and the residents wander. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 8 of 19 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 10/08/2021 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 0689 Level of Harm - Minimal harm or potential for actual harm The facility assessment indicated that recruitment and retention of licensed and non-licensed nursing staff is an on-going concern and is frequently cited by staff and leadership as a major obstacle to providing consistent, top quality care, and the biggest barrier to meeting resident needs in a timely way. Examples include length of time to answer call lights, meal pass and assistance to eat, and medication pass. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 9 of 19 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 10/08/2021 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure a medication error rate of less than 5% related to four errors in twenty five opportunities for one resident (#17) out of seven residents sampled, resulting in a 16% medication error rate. Residents Affected - Few Findings included: On 10/07/21 at 10:42 a.m. during a medication administration observation with Staff Q, Registered Nurse (RN) the following medication Resident #17 was given at 10:42 a.m., but due at 8:00 a.m.: Midodrine 5 mg (milligram) In addition the following medications were given at 10:42 a.m., but due at 9:00 a.m.: Memantine 10 mg and Iron 325 mg. The following medication on the Resident #17's Medication Administration Record (MAR) for October 2021 was due at 9:00 a.m., but not given to the resident: MVI with MIN (Multivitamin with Minerals). Review of Resident #17's medical record revealed no documentation in the resident's progress notes about the medications being late. The only notation documented was found in the October 2021 MAR about the MVI with MIN not being available, and not being given. There was no order from the physician indicating that it was ok not to give the medication, or ok to give the other medications late. A review of the Resident Face Sheet revealed Resident #17 was admitted to the facility on [DATE] for a diagnosis of dementia. The resident had physician orders from September 8, 2021, to October 8, 2021, that included: *MVI with MIN 1 tab by mouth daily once a day 09:00AM *Memantine tablet 10 mg by mouth twice daily for dementia without behavioral disturbance twice a day 09:00 AM, 05:00 PM *Iron (Ferrous sulfate) tablet 325 mg (65 mg iron) once a day 09:00AM *Midodrine tablet 5 mg give 5 mg by mouth daily three times a day 08:00AM 01:00PM, 06:00PM. Review of a policy titled, Administering Medications, with a revised date of April 2019, showed under the Policy Interpretation and Implementation section, #4. Medications are administered in accordance with prescriber orders, including any required time frame . #7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). In an interview with the Director of Nursing (DON) on 10/08/21 at 6:00 p.m., she said it was her expectation that medications are to be given on time, which is one hour before and one hour after their scheduled time. If a nurse is running behind, she expects them to speak up, communicate, and ask for assistance. If a medication is given late or not at all, the physician should be notified, and it should be documented in the chart. If a medication is an over the counter (OTC) medication, then it should be available in either one of the two medication storage rooms (one on each floor of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 10 of 19 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 10/08/2021 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 0759 Level of Harm - Minimal harm or potential for actual harm facility). If it is not available in either medication storage room, staff is to look and see if central supply has them. If the medication is not available in the building, then we can go to the local pharmacy and get it, there is no reason an OTC medication shouldn't be given. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 11 of 19 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 10/08/2021 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to implement an effective Quality Assurance/Performance Improvement plan of action to correct a deficiency cited during the annual recertification survey on 10/08/2021. The facility failed to ensure a medication administration error rate below 5%. A total of 12 administration opportunities were observed with 2 errors for 2 (Resident #4 and Resident #5) of 4 residents observed for medication administration, resulting in a medications administration error rate of 16.7%. Findings included: A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program Analysis and Action, dated March 2020, revealed under the section titled Policy Interpretation and Implementation that the QAPI committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and reporting findings to the Administrator and governing board. A review of Resident #4's Medical Record revealed that Resident #4 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. A review of Resident #4's Physician's Orders revealed the following order: - Insulin Aspart solution 100 units per milliliter (ml) to be administered subcutaneously three times a day before meals per sliding scale: If Blood Sugar is 181 to 220, give 5 units. A review of Resident #4's Care Plan revealed a problem, dated 12/06/2021, that Resident #4 had a diagnosis of Type 2 Diabetes Mellitus and was at risk for complications. Interventions included to administer medications as ordered and to evaluate, record, and report for any adverse side effects and effectiveness. An observation of medication administration was conducted on 12/09/2021 at 11:27 AM with Staff A, Agency Registered Nurse (RN). Staff A, RN prepared 5 units of Insulin Aspart solution 100 units per ml to be administered subcutaneously by FlexPen based on Resident #4's blood glucose reading of 220. Staff A, RN gathered Resident #4's Insulin Aspart FlexPen, a disposable needle, and an alcohol pad from the medication cart. Staff A, RN cleaned the tip of the Insulin Aspart FlexPen with the alcohol pad before attaching the disposable needle to the tip of the FlexPen. Staff A, RN then dialed 5 units on the dosage selector of the FlexPen and brought the FlexPen and an additional alcohol pad into Resident #4's room for administration. Staff A, RN did not prime the disposable needle of the FlexPen with insulin before dialing 5 units on the dosage selector. Staff A, RN cleaned Resident #4's lower left quadrant with the alcohol pad and administered the Insulin Aspart subcutaneously without difficulty. A follow up interview was conducted with Staff A, RN following the observation. Staff A, RN stated that she was not aware that FlexPens needed to be primed with insulin before administration. Staff A, RN also stated that she did not receive education related to insulin pens and addressed that if the needle was not primed prior to administration then the resident may not receive the proper dose of insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 12 of 19 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 10/08/2021 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #5's Medical Record revealed that Resident #5 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. A review of Resident #5's Physician's Orders revealed the following order: - Insulin Aspart solution 100 units per ml to be administered subcutaneously four times a day (06:30 AM, 11:30 AM, 04:30 PM, and 09:00 PM) by sliding scale: If Blood Sugar is 201 to 250, give 4 units. An observation of medication administration was conducted on 12/09/2021 at 11:45 AM with Staff B, Agency RN. Staff B, RN prepared 4 units of Insulin Aspart solution 100 units per ml to be administered subcutaneously by FlexPen based on Resident #5's blood glucose reading of 210. Staff B, RN gathered Resident #5's Insulin Aspart FlexPen, a disposable needle, and an alcohol pad from the medication cart. Staff B, RN cleaned the tip of the Insulin Aspart FlexPen with the alcohol pad before attaching the disposable needle to the tip of the FlexPen. Staff B, RN then dialed 4 units on the dosage selector of the FlexPen and brought the FlexPen and an additional alcohol pad into Resident #5's room for administration. Staff B, RN did not prime the disposable needle of the FlexPen with insulin before dialing 4 units on the dosage selector. Staff B, RN cleaned Resident #5's right upper extremity with the alcohol pad and administered the Insulin Aspart subcutaneously without difficulty. A follow up interview was conducted with Staff B, RN following the observation. Staff B, RN stated that she was not aware that FlexPens needed to be primed with insulin before administration. Staff B, RN also stated that she did not receive education related to insulin pens and the necessity of priming the needle before administration. An telephone interview was conducted on 12/09/2021 at 03:18 PM with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that she provided documents to the facility to assist the facility in conducting medication administration audits and had worked with the facility's Director of Nursing (DON) things to watch for during the audits, such as timeliness of the administration and proper documentation. The Consultant Pharmacist also stated that she did not recall discussing use of insulin pens as part of the plan of corrections. The Consultant Pharmacist stated that nursing staff should be priming insulin pens by applying the needle to the pen, adjusting the dosage selector to 2 units, and injecting 2 units of insulin into the needle before dialing up the dosage needed for administration. The Consultant Pharmacist also stated that a resident could potentially not receive the correct dose if the needle was not primed prior to administration. An interview was conducted on 12/09/2021 at 04:09 PM with the facility's DON and Risk Manager (RM). The RM stated that the initial issue that the facility was correcting was related to documentation and medications being administered late. Medication administration times were adjusted in order to give the nursing staff a larger window to administer them. The DON stated that education related to medication errors was provided to facility staff by a third party and that all agency staff were educated as part of their orientation. The DON and RM stated that facility Agency staff were not educated specifically on the use of insulin pens and the need to prime the insulin pen needle before administering insulin. The DON stated that insulin pens required priming of the needle with 2 units of insulin prior to administration to ensure that there was no air in the needle of the pen. The RM stated that the facility may need to conduct more education with their staff to ensure that staff knows how to properly use the insulin pens. A review of the facility policy titled Insulin Administration, last revised in September 2014, revealed under the section titled Preparation, that the nursing staff will have access to specific (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 13 of 19 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 10/08/2021 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. A review of facility pharmacy guidelines titled Guidance for Using Insulin Products, dated August 2018, revealed under the section titled Preparation of Product, to minimize air bubbles in pen-like devices prime the pen prior to each and every injection by pushing 2 units into the air until a drop of insulin is seen at the top of the needle. If this does not happen after 4 attempts, change needles. The guidelines also revealed that air bubbles themselves are not considered dangerous but could result in a decrease in the dose administered. A review of the manufacturers instructions for the Novolog (insulin aspart) FlexPen indicated the following steps under the section titled Priming your Novolog FlexTouch Pen: - Turn the dose selector to select 2 units. - Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. - Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. - A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat the steps no more than 6 times. If you still do not see a drop, change the needle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 14 of 19 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 10/08/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy reviews, and interviews the facility failed to provide a safe, sanitary, and homelike environment on one unit (first secured floor) out of two units affecting eight resident rooms (room [ROOM NUMBER], #104, #106, #101, #111, #109, #108, #113, and #121) and three common areas (hallway, dining room and activity porch) for four of four days. Findings included. 1. During tours of the facility's secured unit located on the first floor the following observations were identified: - room [ROOM NUMBER]: On 10/5/21 at 10:01 a.m., an observation indicated the top of the wardrobe leaned towards the back with a television on top of it and below the towel dispenser next to the room's sink was an unpainted area with holes. (Photographic Evidence Obtained) - Hallway between room [ROOM NUMBER] and room [ROOM NUMBER]: The observation on 10/5/21 at 10:13 a.m., revealed a missing baseboard in the hallway between rooms [ROOM NUMBERS]. The area contained unprotected paper-backed wallboard. (Photographic Evidence Obtained) - room [ROOM NUMBER]: On 10/5/21 at 10:18 a.m., an observation indicated a coaxial cable stored in between the wall and the dresser (there was no television in the area), in the corner next to the wardrobe was an unconnected coaxial cable hanging from the ceiling onto the floor, both of the air conditioning filters were filled with lint and dust, five holes were observed next to the sink in the resident room below the towel dispenser, and a hole was observed in the wall next to the bathroom door with an attached baseboard. The hole extended through the wall and into the bathroom. The observation indicated that in the bathroom shared by rooms [ROOM NUMBERS] revealed water damage in the ceiling over the toilet.(Photographic Evidence Obtained) - room [ROOM NUMBER]: On 10/5/21 at 10:10 a.m., an unpainted area with five holes was observed under the towel dispenser next to the room's sink. A continued observation of room [ROOM NUMBER], at 10:36 a.m., identified brown discoloration of white tiles around the tile in the bathroom with a urinal and graduated container, a hole in the plaster and paint next to the sink in the bathroom, and the front of the air condition (AC) unit was splattered with a brownish-black substance. An observation on 10/6/21 at 9:51 a.m., revealed the front of the AC unit continued to be splattered with a substance, and holes in the bathroom wall. - room [ROOM NUMBER]: On 10/5/21 at 10:44 a.m., during a tour revealed a hole in the bedroom wall next to the bathroom door with chipped paint and wallboard, five screw holes below the towel dispenser and next to the rooms sink, the air conditioning unit electrical cord was not plugged in and lying in front of the wardrobe, and the cleanable plastic trim of both beds was not intact and completely missing from the footboard of the bed next to the window, and partially missing from the bed next to the door. (Photographic Evidence Obtained) - Dining Room of secured unit: On 10/5/21 at 10:51 a.m., an observation revealed one of four air vent coverings was missing leaving a whole in the wall. On 10/7/21, at approximately 9:30 a.m., an observation indicated three of four of the dining tables indicated the four tubular metal legs on each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 15 of 19 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 10/08/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some did not have end caps leaving exposed edges and black paint had been worn off leaving the gold colored metal exposed. - room [ROOM NUMBER]: On 10/5/21 at 11:14 a.m., an observation indicated that a plastic drawer system was next to the single wardrobe. The drawer system was missing the top drawer with the posts intact, the air conditioning unit was missing its control knobs and had a broken vent, the air filters of the unit were dirty with lint and ripped, the framing of the one window in the room had a hole, which showed building materials underneath, and in the bathroom shared with another room the soap dispenser was sitting on top of the towel dispenser and an area next to the sink was unpainted with holes. - On 10/5/21 at 11:55 a.m., an observation revealed that seven air vents in the hallways of the unit were white with a black biofilm growth in various degrees and a vent near the floor in the area near the elevator was rusty and dusty with a bit of plastic trash attached to it. (Photographic Evidence Obtained) - room [ROOM NUMBER]: On 10/5/21 at 12:00 p.m., an observation indicated the top of the resident's wardrobe was leaning backwards and the bottom of the wardrobe was decayed leaving wood particles on the floor. On 10/07/21 at 8:54 a.m., an observation indicated the wardrobe in room [ROOM NUMBER] continued to be leaning backwards. (Photographic Evidence Obtained) - Shower room: On 10/5/21 at 1:34 p.m., an observation of the first floor shower room indicated a shower chair in the shower area had a safety belt that was dirty-looking with a black substance near the buckles. The joints of the chair were colored with a yellow substance. The drain in an area of the shower room used to store mechanical lifts and housekeeping equipment had dried hair and litter collected on it. (Photographic Evidence Obtained) - room [ROOM NUMBER]: On 10/6/21 at 8:55 a.m., one of two wardrobes was noted to have a discolored particle board bottom and the bottom of the second wardrobe was splitting away from the bottom, leaving wood particles on the floor. In the shared bathroom of room [ROOM NUMBER] was a gouge in the wall next to the toilet revealing the paper backing of the wall. On 10/8/21 at 8:30 a.m. the wardrobe in room [ROOM NUMBER] with the decayed bottom continued to be in the resident room. (Photographic Evidence Obtained) - room [ROOM NUMBER]: On 10/6/21 at 9:02 a.m., an observation of room [ROOM NUMBER] revealed a window frame with cracks, holes, and discoloration. (Photographic Evidence Obtained) - Activity Porch: On 10/7/21 at 9:11 a.m., an observation indicated a wooden glider chair holding the door into the dining room entry door open. The chair had a ripped cream cushion with a black dried substance on the corner of the seat cushion and other stains of unknown substances on it. The observation indicated the ceiling above the entry door appeared to be cracked and bubbled and the metal door frame, behind the door if opened, had two holes which were peeled back and rusty. - Hallway: On 10/7/21 at 1:56 p.m., the corner handrail across from the shower room of the secured unit was observed to be broken with a hole. In addition the following observations were made on the secured unit: - On 10/5/21 at 11:00 a.m., an observation of the first floor unit revealed ten out of ten mesh (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 16 of 19 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 10/08/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stop sign door barriers in various stages of disrepair and dirty: room [ROOM NUMBER]'s barrier was stained and visually dirty, room [ROOM NUMBER]'s barrier was stained, with a hole, and stuffed behind the handrail, room [ROOM NUMBER]'s barrier was ripped with stains and shoved behind the handrail, room [ROOM NUMBER]'s barrier was stained and wrapped around the handrail, room [ROOM NUMBER]'s barrier was dirty and hung behind the handrail, room [ROOM NUMBER]'s barrier was ripped with holes and stained, room [ROOM NUMBER]'s was stained and visually dirty, Rooms 121's and 125's barriers were stained, and room [ROOM NUMBER]'s barrier was seen stuffed behind the handrail with the edging hanging from it. (Photographic Evidence Obtained) The Housekeeping Director was observed on 10/6/21 at 8:32 a.m., standing on a ladder across from the secured unit's elevator, cleaning the ceiling air vent. She stated that this one sweats due to a nearby entrance door, which caused the black biofilm growth. She stated the air vents get cleaned every week or eight days. The Housekeeping Director stated she did not know when the top of the vents were cleaned and did not know why the other vents were dirty (bio growth). On 10/6/21 at 9:00 a.m., the Risk Manager (RM) was observed cutting away the mesh STOP signs. She stated she thought that staff wiped them down and the reason for taking them down was that they were no longer necessary for the residents residing in the room. The RM confirmed the signs did appear dirty and the ripped one in front of room [ROOM NUMBER] had been ripped for a while. She stated the residents who wandered destroyed them as they pulled the signs from the brackets. The Housekeeping Director stated, at 9:22 a.m. on 10/6/21, that her team wiped the STOP signs down but they only got laundered if they were brought to the laundry area. On 10/7/21 at 9:18 a.m., Staff K, Activity Aide, stated maintenance cleaned the chairs (on the activity porch) but did not know how often they were cleaned. She watched as Resident #45 sat down in the glider chair on the activity porch and confirmed the chair was not cleaned. She stated she was going to have the chair removed from the porch. Staff P, Housekeeper came out to the activity porch and began cleaning the glider chair, she stated the chairs were cleaned every day and the problem was the mildew. A tour of the secured unit was conducted, on 10/7/21 at 9:41 a.m., with the Director of Nursing (DON). She stated the shower room needed to be cleaned by the aides after each use and during Angel Rounds she looked into each resident room on the unit. The Risk Manager (RM) joined, at 9:44 a.m., during the tour of the unit. The RM observed the wardrobe in room [ROOM NUMBER] and stated the wardrobe bottom was not cleanable. The DON and RM agreed the unused coaxial cable hanging from the resident room walls could be hazards. The DON viewed all resident rooms with concerns and stated the Maintenance Director was only one person and he was working on replacing the baseboards. She admitted to a sour smell in rooms [ROOM NUMBERS]. The RM explained the holes under the towel dispensers were made as the dispensers were moved to their current spaces. The DON stated she had informed housekeeping to wipe down the stop signs when they were cleaning high touch areas and confirmed the signs were torn prior to be taken down. The DON confirmed the exposed particle board on the residents' beds was not cleanable and could be an issue with residents going in and out of other rooms. She confirmed the legs of three out of four tables in the dining room were opened and uncapped and the residents fragile skin could be torn by the table legs. During a tour of the activity porch with the DON, she made note of the water damage above the door and confirmed the door frame was rusty metal. The DON stated the Maintenance Director was the only one at the facility and was trying to do what he could. She stated that some of the issues had been identified during the last Quality Assurance meeting and admitted that the decayed wardrobes were a hazard and should have been replaced when they were identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 17 of 19 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 10/08/2021 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/7/21 at 4:14 p.m., the Nursing Home Administrator (who had viewed the leaning wardrobe in room [ROOM NUMBER] during the tour with the DON) confirmed the facility had issues with the wardrobes. On 10/8/21 at 12:24 p.m., a sour and musty smell was noted in the hallway of the secured unit. The facility provided copies of a calendar that indicated when air vents were cleaned but it did not indicate if all vents were cleaned. The September 2021 calendar was not provided and the August 2021 calendar indicated the last cleaning of the air vents was done on August 31st. The DON provided the Guardian Angel Visit tool. The tool identified that staff were to make environmental observations that included if the closets were clean and orderly, equipment was clean and labeled, if furniture was in good repair, and if handrails were in good repair. 2. On 10/05/21 at 9:45 a.m., the baseboard was observed missing throughout the room in room [ROOM NUMBER] (Photographic Evidence Obtained). On 10/07/21 at 10:18 a.m., the baseboard was observed missing in room [ROOM NUMBER] near the hand washing sink (Photographic Evidence Obtained). The policy titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, indicated that Environmental surfaces will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. The policy identified furniture as non-critical items and would be disinfected with an EPA [Environmental Protection Agency]-registered intermediate or low-level hospital disinfectant. Housekeeping surfaces would be cleaned on a regular basis, when spills occur, and when these surfaces were visibly soiled. The policy indicated environmental surfaces would be disinfected (or cleaned) on a regular basis and when the surfaces were visibly soiled and walls, blinds, and window curtains in resident areas would be cleaned when those surfaces were visibly contaminated or soiled. The Maintenance Service policy, revised December 2009, identified Maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy indicated the Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The functions of the maintenance personnel included maintaining the building in good repair and free from hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 18 of 19 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 10/08/2021 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to maintain and effective pest control program control pests for one unit (secured) of two units where vulnerable residents resided. Residents Affected - Few Findings included: A tour of the secured unit of the facility was conducted, on 10/5/21 at 11:14 a.m., a small legged insect was observed scurrying along the baseboard in room [ROOM NUMBER]. The insect was able to disappear in a space between the baseboard and the tiled floor. (Photographic Evidence was Obtained) On 10/5/21 at 12:30 p.m., a flying insect was observed crawling on a sock of a resident in room [ROOM NUMBER]. During a tour of the facility's secured unit with the Director of Nursing (DON) and Risk Manager (RM), which began at 9:41 a.m. on 10/7/21, a large legged insect lying on its back with legs waving in the air was observed next to a decayed wardrobe in room [ROOM NUMBER]. Resident #84 stated, while lying in the bed closest to the wardrobe, Oh we have roaches in here. The management staff acknowledged the insect and the DON removed it. Multiple requests were made to the Maintenance Director and the DON for the maintenance work orders, these orders were not received by the exit date (10/8/21) of the survey team. The Maintenance Director did provide Pest Control Vendor statements. The vendor statements included the following findings: - 9/28/21: Treated rooms 204, 208, 213, 115, and 113 and Activity - Live, American roaches. The statement read, If you experience pest issues between scheduled visits, we will come back and address the problem at no additional charge. - 8/30/21: Activity seen on second floor. The policy titled, Pest Control, with a revised date of 5/2008, identified the Facility shall maintain an effective pest control program, and the pest control program was to ensure the building was kept free of insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 19 of 19