Inspection·August 18, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bottom cupboard, to the left of the sink, was opened and the reddish grainy material on the floor of the cabinet and dead bug were still there. A staff member had placed a drink container on part of the bug. (Multiple photographs were obtained.) An interview with the housekeeper on the first floor, on 08/17/23 beginning at 10:35 a.m. revealed that the housekeepers were to sweep and mop the floor in the pantry and empty the trash daily. The floor was noted, at 10:40 a.m. on 08/17/2023, to have a spilled pink liquid in several spots. The corners and edges of the floor were noted to be stained a dark brown. At approximately 9:40 a.m. on 08/14/2023, a rattling noise was heard from inside room [ROOM NUMBER]. The door was mostly shut and after knocking, the surveyor entered the room. The rattling noise was coming from the air conditioning unit located under the window. There were no residents living in this room. A grievance had been filed, dated 8/08/23, asking for someone to look at the air conditioner. The grievance form indicated the resident would be temporarily moved from the room. Observation of the room on 08/14/2023 revealed one bed frame without a mattress, trash in the trash can and two medication cups on the floor where the second bed would be placed. The floor was soiled. To the left of the air conditioning unit, the wall was noted to be broken with a semi circle gap of approximately two inches above the baseboard. On the floor, next to this area was a dead bug. (Photographic evidence obtained.) On 08/14/2023 at 9:45 a.m. the baseboard behind the first bed in room [ROOM NUMBER] was noted not to be attached to the wall. There was a strong urine smell in the room. (Photographic evidence obtained.) In room [ROOM NUMBER], in the shared bathroom, the ceiling above the toilet was noted to be ripped open in a circular form approximately 5 across. (Photographic evidence obtained.) On 8/15/2023 beginning at 10:14 AM the following concerns were noted during an environmental tour of the first floor. In room [ROOM NUMBER], the nightstand handle was missing to the bottom drawer for bed B. The sink handle was missing. There was a strong urine smell in the bathroom. Ceiling tiles were sagging above bed A and there was no privacy curtain for bed A. In room [ROOM NUMBER] there was an unpainted drywall repair noted by bed A and in the bathroom. There was no pull cord for the overbed light for bed A. In room [ROOM NUMBER] the sink in the room was heavily patched with spackle, which was cracking and moldy in appearance as it was unpainted. The lightbulb above the sink was out. The sink in the bathroom was clogged. In room [ROOM NUMBER] the bulb was out above the sink. There had been a large repair above the toilet with the drywall compound remaining unsanded and unpainted. In room [ROOM NUMBER] the light bulb was out above the sink in the room. The trim at the air conditioning unit was peeling and the wall was broken above the baseboard, which was peeling away from the wall. In room [ROOM NUMBER] the air conditioner filter appeared dirty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 2 of 23 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 08/18/2023 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 In room [ROOM NUMBER] the sink handles were broken, the air conditioner filter was dirty and the wardrobe was missing a handle. In room [ROOM NUMBER] the air conditioner filter was dirty, the soap dispenser had been removed from the wall leaving an unpainted area where it had been attached, and there were multiple holes in the wall next to the toilet. In room [ROOM NUMBER] the lightbulb was out over the sink. In room [ROOM NUMBER] the hot water tap in the sink did not work, the wardrobe was missing a handle and the paint in the bathroom had an off color and appeared moldy. In room [ROOM NUMBER] the cold water tap did not work, the lightbulb above the sink was out and there were gnats through out the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 3 of 23 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 08/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Staff Development Coordinator, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility neglected to ensure one resident (#1), at risk for elopement, was provided with services related to the resident's known cognitive deficits and history of wandering out of 47 residents sampled. The facility nursing staff neglected to ensure the safety of Resident #1; between approximately 9:00 PM on 7/18/2023 and 4:00 AM on 7/19/2023, Resident #1 ambulated from his room on the second floor of the facility, passed the unit nurse's station, and walked approximately 40 feet to the facility elevator. Resident #1 pushed the elevator button to access the rear service hallway of the facility where no staff were present. Resident #1 walked approximately 45 feet unsupervised through the rear service hallway and pushed open a staff entrance door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), which was not locked. Resident #1 exited the facility without staff knowledge and walked appropriately 3.1 miles without shoes, through areas with no sidewalks, and along 4 lane roads, to a private residence. The facility neglected to take action to prevent the resident from accessing the rear service hallway by not providing supervision for the resident, not accounting for the resident for approximately 10 hours, and not ensuring facility doors were secured before the resident eloped. Resident #1 was discovered by police on 7/19/2023 at approximately 7:00 AM in the backyard of a community member, sitting on a trampoline. Resident #1 was returned to the facility by police at approximately 7:30 AM, disheveled with holes in his socks, and was discovered to have multiple insect bites and a blister to his left heel. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 8/17/2023. The findings of Immediate Jeopardy were determined to be removed on 8/18/2023 and the severity and scope was reduced to a D. Findings included: A review of a law enforcement report dated 7/19/2023 at 5:41 AM revealed law enforcement responded to the facility at approximately 6:11 AM for a report of a missing endangered person, who went missing around 6:00 PM on 7/18/2023. A search of the facility was conducted by law enforcement but Resident #1 was not found on the facility grounds. The report revealed Staff H, CNA, who was the last caretaker to have contact with Resident #1, provided law enforcement with a description of the resident. Law enforcement received a service call at a residence approximately 3.1 miles from the facility involving a suspicious person matching Resident #1's description. Upon arrival at the residence, law enforcement observed Resident #1 in the backyard of the residence sitting on a trampoline. Resident #1 was returned to the facility and interviewed by law enforcement. Resident #1 told law enforcement he exited the facility around 4:30 PM on 7/18/2023 to go for a walk. A review of Resident #1's progress notes dated 7/19/2023 at 11:49 AM and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following: Upon arrival to facility, [Resident #1] alert with some confusion. Head to toe assessment performed .[Resident #1] c/o [complained of ] pain to [the] left heel. Tylenol was given for mild pain .Skin assessment was complete and possible mosquito bites on back, [Resident #1] noted scratching areas [to] bilateral arm, abdomen, back of both legs as well as front of legs, left foot heel has a blister MD is aware and ordered scheduled Tylenol for pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 4 of 23 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 08/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few r/t [related to] left heel as well as skin prep [a protective wipe which forms a barrier between the patient's skin and adhesives to help preserve skin integrity] to left heel blister and Hydrocortisone cream for itching . A telephone interview was conducted on 8/16/2023 at 2:24 PM with Resident #1's Responsible Party (RP). The RP stated prior to being admitted to the facility, Resident #1 went missing in December of 2022 after getting lost and was found by law enforcement. The RP stated Resident #1 had gone missing several times and had to be located by law enforcement prior to admission to the facility and was not able to make medical decisions due to his dementia. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of encephalopathy, unspecified; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; unspecified abnormalities of gait and mobility; muscle weakness (generalized); depression, unspecified; and anxiety disorder. A review of Resident #1's physician's orders revealed the following: An order dated 8/1/2023 to record active exit seeking behaviors and record the following intervention code(s) every shift: 1: N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend, 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting. An order dated 8/1/2023 for behavioral monitoring related to exit-seeking behaviors and record the number of occurrences every shift. A review of Resident #1's baseline care plan, dated 6/23/2023, did not reveal problems or potential concerns related to elopement risk. A review of Resident #1's 5-Day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of C - BIMS: 7 which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, Resident #1 did not display behaviors of wandering but rejected care 1 to 3 days of the assessment period. Section G - Functional Status revealed Resident #1 required supervision and set up help only with locomotion on the unit and required one-person physical assistance with locomotion off the unit. Resident #1 was unsteady, but able to stabilize without staff assistance while walking and turning around. Resident #1 did not require an assistive device for mobility. Resident #1's MDS assessment revealed under Section I - Active Diagnoses Resident #1 had diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Encephalopathy, unspecified. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 5 of 23 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 08/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. Residents Affected - Few https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%2 An interview was conducted on 8/15/2023 at 12:30 PM with the facility's Social Services Director (SSD), the Staff Development Coordinator (SDC) and the Nursing Home Administrator (NHA). The SDC stated on 7/19/2023, Resident #1 was returned to the facility after Staff C, Certified Nursing Assistant (CNA) discovered Resident #1 was not in his room at approximately 4:00 AM. Staff C, CNA reported Resident #1 missing to Staff D, LPN, who reported the finding to Staff B, LPN Supervisor. A code pink was called through the facility, which alerted staff a resident was missing from the facility and a facility search was conducted. After verifying Resident #1 was not in the facility, Staff B, LPN Supervisor notified law enforcement and the NHA. The SDC stated the facility cameras did not capture Resident #1 leaving the facility due to a power surge. Law enforcement located Resident #1 in a community member's backyard on a trampoline. They said Resident #1 was returned to the facility on 7/19/2023 at 7:15 AM but they did not provide an address where Resident #1 was located. The SSD stated law enforcement did not provide an incident report and stated, they said if they had one, they would send it to us. The SDC and NHA stated they conducted an interview with Resident #1 following the elopement. Resident #1 stated he left the facility by accessing the facility elevator, walking through the rear service hallway of the facility, and pushing open a door to exit the facility. Resident #1 explained he wanted to go for a walk. Upon Resident #1's return to the facility, a head-to-toe assessment was completed by Staff A, LPN and the facility's Medical Director was notified. Staff A, LPN discovered several bites on the resident's body during the assessment. The NHA stated following the incident, the facility's former maintenance director conducted an exterior door security audit to ensure all exterior doors were secure. Modifications were made to the facility elevator so the rear service hallway could not be accessed through the elevator. The NHA stated the door Resident #1 exited the facility through was equipped with a magnetic lock, but the lock did not engage. The SDC stated the last time staff confirmed seeing Resident #1 was around 11 PM on 7/18/2023 when Staff E, Agency LPN handed the resident a snack. An interview was conducted on 8/16/2023 at 9:48 AM with Staff A, LPN. Staff A, LPN stated she was called into the facility on 7/19/2023 around 4:30 AM by Staff B, LPN Supervisor due to a resident elopement. Staff A, LPN stated she last saw Resident #1 on 7/18/2023 on the 7 AM to 3 PM shift and he did not express desires of leaving the facility. Staff A, LPN stated Resident #1 usually stayed in his room during the shift and was very pleasant. Staff A, LPN stated she arrived at the facility around 5:00 AM and joined the staff at the facility in searching for Resident #1. Staff A, LPN stated the last staff member to see Resident #1 was Staff F, LPN around 9:00 PM on 7/18/2023 when the LPN provided Resident #1 with a snack. Staff A, LPN stated Resident #1 was returned to the facility by law enforcement around 8:00 AM on 7/19/2023. Staff A, LPN spoke with Resident #1 upon his return and asked the resident what happened? Resident #1 responded to Staff A, LPN I don't know. Staff A, LPN stated Resident #1 was wearing a burgundy short sleeved shirt, blue basketball shorts, and non-skid socks with a tear in the left sock. Resident #1 was not observed wearing shoes. Once Resident #1 was back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 6 of 23 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 08/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in the facility, Staff A, LPN performed an assessment. Staff A, LPN stated she documented several possible mosquito bites described as red dots throughout Resident #1's body and a blister on Resident #1's left foot. Staff A, LPN stated after the assessment, Resident #1 laid in the fetal position in his bed and appeared very tired. Staff A, LPN stated Resident #1 was provided fluids because he was very thirsty. Staff A, LPN stated the door Resident #1 exited out of was usually kept locked with a magnetic lock but Resident #1 was able to push the door open. Staff A, LPN stated she completed Resident #1's elopement assessment upon admission to the facility and did not assess the resident as an elopement risk. Staff A, LPN stated she would expect CNA staff to round every 30 minutes to an hour at the latest to check on the resident's needs and to take account of that resident. A review of Resident #1's admission assessment dated [DATE] revealed under the section titled EL. Elopement Risk a question Is resident ambulatory and/or able to self-propel wheelchair? and a documented response No. The section revealed If no, next question will be disabled. The disabled section of the EL. Elopement Risk portion of the admission assessment related to risk factors to indicate the resident was at risk for elopement and contained no information. An interview was conducted on 8/16/2023 at 10:16 AM with Staff F, LPN. Staff F, LPN stated she worked a double shift on 7/18/2023 during the 7 AM to 3 PM and the 3 PM to 11 PM shifts. Staff F, LPN stated Resident #1 would usually stay in his room and sometimes go to the nurse's station to ask for coffee. Staff F, LPN last saw Resident #1 on 7/18/2023 at 9:00 PM when the resident walked to the nurse's station and asked for a snack. Staff F, LPN left the facility around 11:15 PM and did not see Resident #1 between 9:00 PM and 11:15 PM. Staff F, LPN received a phone call around 6:00 AM on 7/19/2023 from facility staff telling her she needed to come to the facility. When Staff F, LPN arrived at the facility around 6:45 AM, facility staff were already searching for Resident #1 throughout the facility and the facility grounds. Staff F, LPN was not able to state what time Resident #1 was returned to the facility but stated the resident looked tired. Staff F, LPN stated she was not sure how Resident #1 exited the facility but thinks he might have gone out through the back door leading out to the facility staff parking lot. Staff F, LPN stated before Resident #1's elopement, staff would enter the facility through the rear entrance and the door was usually locked using the magnetic lock and could only be opened by entering a code. Staff F, LPN stated she would expect the CNA staff to check on residents at least every 2 hours to check on the resident's needs and to take account of that resident. An interview was conducted on 8/16/2023 at 10:40 AM with Staff G, CNA. Staff G, CNA stated she was familiar with Resident #1 and had transported him to several outside appointments. Staff G, CNA stated Resident #1 was normally quiet and laid back in demeanor but would observe a lot and was very sneaky. Staff G, CNA received a phone call on 7/19/2023 at approximately 4:30 AM from Staff B, LPN because Resident #1 was missing from the facility, and he was not sure what to do. Staff G, CNA told Staff B, LPN to contact the NHA and DON and to notify the police. Staff G, CNA called Staff A, LPN and Staff I, CNA and told them to come to the facility to assist in searching for Resident #1. Staff G, CNA arrived at the facility at approximately 4:45 AM and stated local law enforcement arrived after. After searching the facility grounds for Resident #1, Staff G, CNA stated she spoke with law enforcement around 6 or 7 AM, who told her they found Resident #1 in a lady's yard on a trampoline. Staff G, CNA stated she drove to Resident #1's location in the facility van around 7 AM and witnessed Resident #1 being escorted into a police car by law enforcement. Staff G, CNA drove back to the facility and saw Resident #1. Staff G, CNA observed Resident #1 with a lot of bites on his body and wearing socks with no shoes. Staff G, CNA stated Resident #1 told herself, Staff I, CNA, Staff A, LPN, and the SDC how he was able to exit the facility. Resident #1 told Staff G, CNA he walked through the elevator, accessed the rear (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 7 of 23 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 08/18/2023 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 0600 service hallway, and exited out of the facility through the back door leading into the facility staff parking lot. Level of Harm - Immediate jeopardy to resident health or safety A telephone interview was conducted on 8/16/2023 at 1:20 PM with the facility's Medical Director (MD), who was Resident #1's primary care provider. The MD stated Resident #1 was mildly confused but was able to follow commands and was easy to redirect during previous interactions with the resident. The MD was notified by the facility Resident #1 eloped from the facility by accessing the rear service hallway through the facility elevator and was found by law enforcement several hours later. The MD assessed Resident #1 around 10 or 11 AM after the resident was showered. The MD discovered a couple of abrasions here and there and a couple of bug bites presumed to be mosquito bites. The MD stated Resident #1's feet here mildly edematous but the resident did not sustain any injuries from the elopement. The MD stated Resident #1 was able to explain how he exited the facility and he was trying to go home. Residents Affected - Few A review of a SOAP (Subjective, Objective, Assessment, Plan) note dated 7/19/2023 and authored by the MD revealed the following: .I was call[ed] to [Resident #1]'s bedside as it was brought to my attention that [Resident #1] had an elopement incident yesterday [7/18/2023]. [Resident #1] was found by the police and [br]ought back to the facility on examination. [Resident #1] appears to be stable and at baseline. [Resident #1] does have multiple mosquito bites. In various places .On questioning, [Resident #1] does not recall the incident. States that he was going for a walk . An interview was conducted on 8/16/2023 at 1:39 PM with Staff H, CNA, Resident #1's assigned CNA for the 7 AM to 3 PM shift on 7/18/2023. Staff H, CNA stated she frequently provided care for Resident #1 and Resident #1 was cooperative with care. Staff H, CNA stated on 7/13/2023, Resident #1 pressed his call light and asked Staff H, CNA how he could transfer out of here. Staff H, CNA stated Resident #1 did not express a desire to exit the facility other than that one incident. Staff H, CNA stated she arrived at the facility on 7/19/2023 around 6:45 AM and witnessed several law enforcement vehicles and personnel upon her arrival. Staff H, CNA provided a description of the clothing Resident #1 was wearing to law enforcement because other staff members gave the wrong description. Staff H, CNA stated about an hour after her arrival at the facility, Resident #1 was returned to the facility by law enforcement. Staff H, CNA stated Resident #1 appeared to be wearing wet clothing and had holes in his socks. Staff H, CNA provided Resident #1 with clean clothing and ice water because the resident stated he was thirsty. Staff H, CNA stated Resident #1 did not state how he exited the facility, but she found out by speaking with other facility staff. An interview was conducted on 8/16/2023 at 1:54 PM with Staff I, CNA. Staff I, CNA stated she received a phone call from Staff G, CNA on 7/19/2023 at approximately 4:30 AM who stated Resident #1 was missing from the facility. Staff I, CNA then drove to the facility and assisted staff in attempting to locate Resident #1 by searching inside and outside of the facility and near local businesses. Staff I, CNA stated law enforcement arrived during the search for Resident #1 and assisted in the search. Staff I, CNA stated Resident #1 was returned to the facility sometime before breakfast and appeared tired and walked out his socks, meaning Resident #1 had holes in the bottoms of his socks. Staff I, CNA spoke with Resident #1 following the incident, who stated he accessed the rear service hallway through the facility elevator, walked down the service hallway, pushed open the rear exit door and hit it, meaning he began walking down the street. Resident #1 stated to Staff I, CNA he was just going for a walk. Staff I, CNA stated Resident #1's memory comes and goes. An interview was conducted on 8/16/2023 at 2:40 PM with Resident #1 on the facility's dementia care unit. Resident #1 was observed lying in bed in his room. Resident #1 stated be remembered going for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 8 of 23 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 08/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few a walk and was gone from the facility for a few hours. Resident #1 was not able to recall details of the elopement and only stated he left through one of the exits and came back here. An interview was conducted on 8/16/2023 at 2:53 PM with the SSD and the facility's MDS Coordinator (MDS). The SSD stated when a resident is admitted to the facility, a welcome meeting or welcome conference is held with the resident and/or family to go over the resident's history. The MDS Coordinator stated the residents medications, baseline care plan, dietary preferences, allergies, and other care conditions are discussed during the meeting. The SSD stated if the resident is not alert and oriented, the resident's family is called to participate in the meeting. The SSD stated a welcome conference was conducted with Resident #1 upon admission and the RP was contact by phone to participate in the meeting. The SSD stated Resident #1 was his own responsible party upon admission. The RP told the SSD Resident #1 had an incident in December of 2022 where he went to the airport and got lost, but not much else. Telephone interviews were attempted on 8/16/2023 with Staff C, CNA, Resident #1's assigned CNA for the 11 PM to 7 AM shift on 7/18/2023, Staff B, LPN, the assigned facility supervisor for the 11 PM to 7 AM shift on 7/18/2023, Staff D, LPN, Resident #1's assigned nurse for the 11 PM to 7 AM shift on 7/18/2023, Staff J, CNA, Resident #1's assigned CNA for the 3 PM to 11 PM shift on 7/18/2023, and Staff E, Agency LPN, Resident #1's assigned nurse for the 3 PM to 11 PM shift on 7/18/2023. The staff members could not be reached. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 6/18/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form revealed under Section E: Medical Condition, primary discharge diagnoses of altered mental status (AMS) and incompetence. A review of Resident #1's psychology evaluation notes dated 7/5/2023 revealed under the section titled Patient Consent This provider confirms that the written consent to treat was obtained from the patient Power of Attorney (POA) as patient is not capable of giving the consent. The note revealed under the section titled History of Present Illness Patient has history of depression, anxiety, and dementia. Patient stated, 'my memory is bad'. He reported he feels depressed, sad, and irritable since he was admitted to the facility . An interview and tour were conducted on 8/17/2023 at 11:15 AM with the facility's Maintenance Director and NHA near the facility elevator. The NHA stated modifications were made to the facility elevator to ensure residents of the facility could not access the rear service hallway through the elevator. The NHA stated a keypad would be installed for the elevator and anyone who used the elevator would be required to enter a code, which would not be provided to facility residents. The NHA stated the rear service hallway could be accessed through the 200 unit and required a code to access. An observation of the facility elevator revealed the buttons to access the rear service hallway were not able to be pressed due to being covered with a cap and black tape. The NHA stated the modifications were temporary until the elevator vendor could install the keypad. A tour was conducted of the rear service of the facility. The facility elevator cannot be accessed through the rear service hallway and was observed to be blocked with yellow caution tape. An observation of the rear exit door of the facility revealed signage posted on the door entrance temporarily closed use front entrance!! The rear exit door was locked and secured. A review of the facility policy titled Abuse Prohibition/Investigative Policy, revised in August (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 9 of 23 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 08/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety 2023, revealed under the section titled Policy the facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation. The policy revealed under the section titled Purpose the purpose of the policy is to ensure the facility is doing all that is within its control to prevent occurrences of abuse/neglect. The policy defines neglect as .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Residents Affected - Few Facility's immediate actions to remove the Immediate Jeopardy included: o Facility egress doors checked for alarming/functioning with no other issues identified. The door that resident exited from noted to not automatically close has been taken out of services. An outside vendor was contacted on 7/19/2023 by the NHA to replace the door. The rear elevator door was taken out of service on 7/19/2023 by blocking the buttons to open them. An outside vendor was contacted on 7/19/2023 by the NHA to service the elevator and put a code box on to prevent it from opening without putting in the code. o Elopement drills initiated on 7/19/2023 starting on 7:00 AM to 3:00 PM shift then conducted every shift for 3 days then weekly for 4 weeks then monthly. o Staff education was initiated 7/19/2023 on Abuse, Neglect and Exploitation Policy w/ emphasis on neglect to include reporting requirements, elopement standard and guidelines, shift to shift rounds and mid night census by the staff development coordinator, this education included actual visualization of each resident during these rounds this education was completed on 7/20/2023. Newly hired staff and agency staff will be educated during the orientation process. Staff will be educated on every 2-hour rounding on residents to include physical visualization of residents. Licensed nurses will validate that this rounding is being done and document attestation of rounding in the medication administration record. Education will be completed by the SDC, or designee. Residents that are evaluated to be at risk for elopement and not placed on the secured unit will have rounding with physical visualization every 1 hour or as indicated in their plan of care. The licensed nurse will validate that this rounding is being done and document attestation of rounding the medication administration record. o Residents currently residing in the facility were re-evaluated for elopement risk by the DON or Designee on 7/19/2023 to 7/25/2023. No new residents identified at risk for elopement. o An ad-hoc QAPI meeting was held on 7/19/2023 at 3:00 PM. o Elopement risk alert binders reviewed for accuracy and confirmed to have demographics present for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 10 of 23 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 08/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety all residents at risk for elopement based on Elopement Risk Evaluations on 7/19/2023. The binders were again reviewed on 7/25/2023, no new updates were needed. New admissions or residents with a change in behavior that increases risk for elopement will be reviewed during morning clinical meeting and placed in the elopement risk binders located at each nurses station and at the receptionist desk. o Residents Affected - Few Care plans for residents at risk for elopement confirmed to be present on 7/20/2023. Updates were completed as needed. o Rounds are conducted throughout each shift, at shift change, during AM, PM care, during meal services and during care provision. Mid-night census sheet will be signed by the unit nurse and turned into the Director of Nurses each day. Verification of the facility's removal plan was conducted by the survey team on 8/18/2023. An attestation provided by the facility revealed on 7/19/2023, the former maintenance director ensured the rear service elevator door, and the rear exit door of the facility were taken out of service and outside vendors were contacted to service the elevator door and to replace the rear door of the facility. A sample of five residents at risk for elopement, including Resident #1, were reviewed for verification of new orders related to rounding, care plan including elopement risk, elopement risk evaluation, and presence in the facility elopement book. Review of the five residents revealed all residents had new orders related to rounding, care plan including elopement risk, updated elopement risk evaluation, and presence in the facility elopement book. A review of education conducted by the DON and the SDC revealed education related to resident rounding was conducted on 8/17/2023 for facility nursing staff. Education related to abuse/neglect and elopement procedures was conducted on 7/19/2023 and completed on 7/20/2023 with all staff educated. Post-test and competencies included as part of the facility training. A review of facility elopement drills revealed elopement drills were conducted from 7/19/2023 to 7/22/2023. Elopement drills completed on all shifts with documentation of participating staff. Interviews were conducted with 48 staff members, including 2 Registered Nurses, 7 LPNs, 13 CNAs, 7 dietary staff, 3 therapy staff, 6 housekeeping staff, and 10 other staff members. The staff members were able to state that they had been trained and were knowledgeable about the policies and procedures. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 8/18/2023 and the non-compliance was reduced to a scope and severity of D. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 11 of 23 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 08/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Staff Development Coordinator, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 47 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility nursing staff failed to ensure the safety of Resident #1; between approximately 9:00 PM on 7/18/2023 and 4:00 AM on 7/19/2023, Resident #1 ambulated from his room on the second floor of the facility, passed the unit nurse's station, and walked approximately 40 feet to the facility elevator. Resident #1 pushed the elevator button to access the rear service hallway of the facility where no staff were present. Resident #1 walked approximately 45 feet unsupervised through the rear service hallway and pushed open a staff entrance door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), which was not locked. Resident #1 exited the facility unsupervised and without staff knowledge and walked appropriately 3.1 miles without shoes, through areas with no sidewalks, and along 4 lane roads, to a private residence. The facility failed to take action to prevent the resident from accessing the rear service hallway by not providing supervision for the resident, not accounting for the resident for approximately 10 hours, and not ensuring facility doors were secured before the resident eloped. Resident #1 was discovered by police on 7/19/2023 at approximately 7:00 AM in the backyard of a community member, sitting on a trampoline. Resident #1 was returned to the facility by police at approximately 7:30 AM disheveled and with holes in his socks and was discovered to have multiple insect bites and a blister to his left heel. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 8/17/2023. The findings of Immediate Jeopardy were determined to be removed on 8/18/2023 and the severity and scope was reduced to a D. Findings included: A review of Resident #1's progress notes dated 7/19/2023 at 11:49 AM and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following: Upon arrival to facility, [Resident #1] alert with some confusion. Head to toe assessment performed .[Resident #1] c/o [complained of ] pain to [the] left heel. Tylenol was given for mild pain .Skin assessment was complete and possible mosquito bites on back, [Resident #1] noted scratching areas [to] bilateral arm, abdomen, back of both legs as well as front of legs, left foot heel has a [has a] blister MD is aware and ordered scheduled Tylenol for pain r/t [related to] left heel as well as skin prep [a protective wipe which forms a barrier between the patient's skin and adhesives to help preserve skin integrity] to left heel blister and Hydrocortisone cream for itching . A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of encephalopathy, unspecified; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; unspecified abnormalities of gait and mobility; muscle weakness (generalized); depression, unspecified; and anxiety disorder. A review of Resident #1's physician's orders revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 12 of 23 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 08/18/2023 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 - Immediate jeopardy to resident health or safety An order dated 8/1/2023 to record active exit seeking behaviors and record the following intervention code(s) every shift: 1: N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend, 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting. Residents Affected - Few An order dated 8/1/2023 for behavioral monitoring related to exit-seeking behaviors and record the number of occurrences every shift. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%2 A review of Resident #1's baseline care plan, dated 6/23/2023, did not reveal problems or potential concerns related to elopement risk. A review of Resident #1's 5-Day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of C - BIMS: 7 which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, Resident #1 did not display behaviors of wandering but rejected care 1 to 3 days of the assessment period. Section G - Functional Status revealed Resident #1 required supervision and set up help only with locomotion on the unit and required one person physical assistance with locomotion off the unit. Resident #1 was unsteady, but able to stabilize without staff assistance while walking and turning around. Resident #1 did not require an assistive device for mobility. Resident #1's MDS assessment revealed under Section I - Active Diagnoses Resident #1 had diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Encephalopathy, unspecified. An interview was conducted on 8/15/2023 at 12:30 PM with the facility's Social Services Director (SSD), the Staff Development Coordinator (SDC) and the Nursing Home Administrator (NHA). The SDC stated on 7/19/2023, Resident #1 was returned to the facility after Staff C, Certified Nursing Assistant (CNA) discovered Resident #1 was not in his room at approximately 4:00 AM. Staff C, CNA reported Resident #1 missing to Staff D, LPN, who reported the finding to Staff B, LPN Supervisor. A code pink was called through the facility, which alerted staff a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 13 of 23 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 08/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few resident was missing from the facility and a facility search was conducted. After verifying Resident #1 was not in the facility, Staff B, LPN Supervisor notified law enforcement and the NHA. The SDC stated the facility cameras did not capture Resident #1 leaving the facility due to a power surge. Law enforcement located Resident #1 in a community member's backyard on a trampoline. They said Resident #1 was returned to the facility on 7/19/2023 at 7:15 AM but they did not provide an address where Resident #1 was located. The SSD stated law enforcement did not provide an incident report and stated, they said if they had one they would send it to us. The SDC and NHA stated they conducted an interview with Resident #1 following the elopement. Resident #1 stated he left the facility by accessing the facility elevator, walking through the rear service hallway of the facility, and pushing open a door to exit the facility. Resident #1 explained he wanted to go for a walk. Upon Resident #1's return to the facility, a head to toe assessment was completed by Staff A, LPN and the facility's Medical Director was notified. Staff A, LPN discovered several bites on the resident's body during the assessment. The NHA stated following the incident, the facility's former maintenance director conducted an exterior door security audit to ensure all exterior doors were secure. Modifications were made to the facility elevator so the rear service hallway could not be accessed through the elevator. The NHA stated the door Resident #1 exited the facility through was equipped with a magnetic lock, but the lock did not engage. The SDC stated the last time staff confirmed seeing Resident #1 was around 11 PM on 7/18/2023 when Staff E, Agency LPN handed the resident a snack. A review of the facility policy titled Safety and Supervision of Residents, revised in July of 2017, revealed under the section titled Policy Statement the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy revealed under the section titled Individualized, Resident-Centered Approach to Safety the individualized, resident centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. An interview was conducted on 8/16/2023 at 9:48 AM with Staff A, LPN. Staff A, LPN stated she was called into the facility on 7/19/2023 around 4:30 AM by Staff B, LPN Supervisor due to a resident elopement. Staff A, LPN stated she last saw Resident #1 on 7/18/2023 on the 7 AM to 3 PM shift and he did not express desires of leaving the facility. Staff A, LPN stated Resident #1 usually stayed in his room during the shift and was very pleasant. Staff A, LPN stated she arrived at the facility around 5:00 AM and joined the staff at the facility in searching for Resident #1. Staff A, LPN stated the last staff member to see Resident #1 was Staff F, LPN around 9:00 PM on 7/18/2023 when the LPN provided Resident #1 with a snack. Staff A, LPN stated Resident #1 was returned to the facility by law enforcement around 8:00 AM on 7/19/2023. Staff A, LPN spoke with Resident #1 upon his return and asked the resident what happened? Resident #1 responded to Staff A, LPN I don't know. Staff A, LPN stated Resident #1 was wearing a burgundy short sleeved shirt, blue basketball shorts, and non-skid socks with a tear in the left sock. Resident #1 was not observed wearing shoes. Once Resident #1 was back in the facility, Staff A, LPN performed an assessment. Staff A, LPN stated she documented several possible mosquito bites described as red dots throughout Resident #1's body and a blister on Resident #1's left foot. Staff A, LPN stated after the assessment, Resident #1 laid in the fetal position in his bed and appeared very tired. Staff A, LPN stated Resident #1 was provided fluids because he was very thirsty. Staff A, LPN stated the door Resident #1 exited out of was usually kept locked with a magnetic lock but Resident #1 was able to push the door open. Staff A, LPN stated she completed Resident #1's elopement assessment upon admission to the facility and did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 14 of 23 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 08/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few assess the resident as an elopement risk. Staff A, LPN stated she would expect CNA staff to round every 30 minutes to an hour at the latest to check on the resident's needs and to take account of that resident. A review of Resident #1's admission assessment dated [DATE] revealed under the section titled EL. Elopement Risk a question Is resident ambulatory and/or able to self-propel wheelchair? and a documented response No. The section revealed If no, next question will be disabled. The disabled section of the EL. Elopement Risk portion of the admission assessment related to risk factors to indicate the resident was at risk for elopement and contained no information. An interview was conducted on 8/16/2023 at 10:16 AM with Staff F, LPN. Staff F, LPN stated she worked a double shift on 7/18/2023 during the 7 AM to 3 PM and the 3 PM to 11 PM shifts. Staff F, LPN stated Resident #1 would usually stay in his room and sometimes go to the nurse's station to ask for coffee. Staff F, LPN last saw Resident #1 on 7/18/2023 at 9:00 PM when the resident walked to the nurse's station and asked for a snack. Staff F, LPN left the facility around 11:15 PM and did not see Resident #1 between 9:00 PM and 11:15 PM. Staff F, LPN received a phone call around 6:00 AM on 7/19/2023 from facility staff telling her she needed to come to the facility. When Staff F, LPN arrived at the facility around 6:45 AM, facility staff were already searching for Resident #1 throughout the facility and the facility grounds. Staff F, LPN was not able to state what time Resident #1 was returned to the facility but stated the resident looked tired. Staff F, LPN stated she was not sure how Resident #1 exited the facility but thinks he might have gone out through the back door leading out to the facility staff parking lot. Staff F, LPN stated before Resident #1's elopement, staff would enter the facility through the rear entrance and the door was usually locked using the magnetic lock and could only be opened by entering a code. Staff F, LPN stated she would expect the CNA staff to check on residents at least every 2 hours to check on the resident's needs and to take account of that resident. An interview was conducted on 8/16/2023 at 10:40 AM with Staff G, CNA. Staff G, CNA stated she was familiar with Resident #1 and had transported him to several outside appointments. Staff G, CNA stated Resident #1 was normally quiet and laid back in demeanor but would observe a lot and was very sneaky. Staff G, CNA received a phone call on 7/19/2023 at approximately 4:30 AM from Staff B, LPN because Resident #1 was missing from the facility, and he was not sure what to do. Staff G, CNA told Staff B, LPN to contact the NHA and DON and to notify the police. Staff G, CNA called Staff A, LPN and Staff I, CNA and told them to come to the facility to assist in searching for Resident #1. Staff G, CNA arrived at the facility at approximately 4:45 AM and stated local law enforcement arrived after. After searching the facility grounds for Resident #1, Staff G, CNA stated she spoke with law enforcement around 6 or 7 AM, who told her they found Resident #1 in a lady's yard on a trampoline. Staff G, CNA stated she drove to Resident #1's location in the facility van around 7 AM and witnessed Resident #1 being escorted into a police car by law enforcement. Staff G, CNA drove back to the facility and saw Resident #1. Staff G, CNA observed Resident #1 with a lot of bites on his body and wearing socks with no shoes. Staff G, CNA stated Resident #1 told herself, Staff I, CNA, Staff A, LPN, and the SDC how he was able to exit the facility. Resident #1 told Staff G, CNA he walked through the elevator, accessed the rear service hallway, and exited out of the facility through the back door leading into the facility staff parking lot. A telephone interview was conducted on 8/16/2023 at 1:20 PM with the facility's Medical Director (MD), who was Resident #1's primary care provider. The MD stated Resident #1 was mildly confused but was able to follow commands and was easy to redirect during previous interactions with the resident. The MD was notified by the facility Resident #1 eloped from the facility by accessing the rear (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 15 of 23 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 08/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few service hallway through the facility elevator and was found by law enforcement several hours later. The MD assessed Resident #1 around 10 or 11 AM after the resident was showered. The MD discovered a couple of abrasions here and there and a couple of bug bites presumed to be mosquito bites. The MD stated Resident #1's feet here mildly edematous but the resident did not sustain any injuries from the elopement. The MD stated Resident #1 was able to explain how he exited the facility and he was trying to go home. A review of a SOAP (Subjective, Objective, Assessment, Plan) note dated 7/19/2023 and authored by the MD revealed the following: .I was call[ed] to [Resident #1]'s bedside as it was brought to my attention that [Resident #1] had an elopement incident yesterday [7/18/2023]. [Resident #1] was found by the police and [r]ought back to the facility on examination. [Resident #1] appears to be stable and at baseline. [Resident #1] does have multiple mosquito bites. In various places .On questioning, [Resident #1] does not recall the incident. States that he was going for a walk . An interview was conducted on 8/16/2023 at 1:39 PM with Staff H, CNA, Resident #1's assigned CNA for the 7 AM to 3 PM shift on 7/18/2023. Staff H, CNA stated she frequently provided care for Resident #1 and Resident #1 was cooperative with care. Staff H, CNA stated on 7/13/2023, Resident #1 pressed his call light and asked Staff H, CNA how he could transfer out of here. Staff H, CNA stated Resident #1 did not express a desire to exit the facility other than that one incident. Staff H, CNA stated she arrived at the facility on 7/19/2023 around 6:45 AM and witnessed several law enforcement vehicles and personnel upon her arrival. Staff H, CNA provided a description of the clothing Resident #1 was wearing to law enforcement because other staff members gave the wrong description. Staff H, CNA stated about an hour after her arrival at the facility, Resident #1 was returned to the facility by law enforcement. Staff H, CNA stated Resident #1 appeared to be wearing wet clothing and had holes in his socks. Staff H, CNA provided Resident #1 with clean clothing and ice water because the resident stated he was thirsty. Staff H, CNA stated Resident #1 did not state how he exited the facility, but she found out by speaking with other facility staff. An interview was conducted on 8/16/2023 at 1:54 PM with Staff I, CNA. Staff I, CNA stated she received a phone call from Staff G, CNA on 7/19/2023 at approximately 4:30 AM who stated Resident #1 was missing from the facility. Staff I, CNA then drove to the facility and assisted staff in attempting to locate Resident #1 by searching inside and outside of the facility and near local businesses. Staff I, CNA stated law enforcement arrived during the search for Resident #1 and assisted in the search. Staff I, CNA stated Resident #1 was returned to the facility sometime before breakfast and appeared tired and walked out his socks, meaning Resident #1 had holes in the bottoms of his socks. Staff I, CNA spoke with Resident #1 following the incident, who stated he accessed the rear service hallway through the facility elevator, walked down the service hallway, pushed open the rear exit door and hit it, meaning he began walking down the street. Resident #1 stated to Staff I, CNA he was just going for a walk. Staff I, CNA stated Resident #1's memory comes and goes. A review of the facility policy titled Emergency Procedure - Missing Resident, revised in August of 2016, revealed under the section titled Policy Statement a resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed under the section titled Policy Interpretation and Implementation residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. A review of a law enforcement report dated 7/19/2023 at 5:41 AM revealed law enforcement responded to the facility at approximately 6:11 AM for a report of a missing endangered person, who went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 16 of 23 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 08/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few missing around 6:00 PM on 7/18/2023. A search of the facility was conducted by law enforcement but Resident #1 was confirmed not on the facility grounds. The report revealed Staff H, CNA, who was the last caretaker to contact Resident #1, provided law enforcement with a description of the resident. Law enforcement received a service call at a residence approximately 3.1 miles from the facility involving a suspicious person matching Resident #1's description. Upon arrival at the residence, law enforcement observed Resident #1 in the backyard of the residence sitting on a trampoline. Resident #1 was returned to the facility and interviewed by law enforcement. Resident #1 told law enforcement he exited the facility around 4:30 PM on 7/18/2023 to go for a walk. A telephone interview was conducted on 8/16/2023 at 2:24 PM with Resident #1's responsible party (RP). The RP stated prior to being admitted to the facility, Resident #1 went missing in December of 2022 after getting lost and was found by law enforcement. The RP stated Resident #1 had gone missing several times and had to be located by law enforcement prior to admission to the facility and was not able to make medical decisions due to his dementia. A review of the facility policy titled Wandering and Elopements, revised in March of 2019, revealed under the section titled Policy Statement the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy revealed under the section titled Policy Interpretation and Implementation if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An interview was conducted on 8/16/2023 at 2:40 PM with Resident #1 on the facility's dementia care unit. Resident #1 was observed lying in bed in his room. Resident #1 stated be remembered going for a walk and was gone from the facility for a few hours. Resident #1 was not able to recall details of the elopement and only stated he left through one of the exits and came back here. An interview was conducted on 8/16/2023 at 2:53 PM with the SSD and the facility's MDS Coordinator (MDS). The SSD stated when a resident is admitted to the facility, a welcome meeting or welcome conference is held with the resident and/or family to go over the resident's history. The MDS Coordinator stated the residents medications, baseline care plan, dietary preferences, allergies, and other care conditions are discussed during the meeting. The SSD stated if the resident is not alert and oriented, the resident's family is called to participate in the meeting. The SSD stated a welcome conference was conducted with Resident #1 upon admission and the RP was contact by phone to participate in the meeting. The SSD stated Resident #1 was his own responsible party upon admission. The RP told the SSD Resident #1 had an incident in December of 2022 where he went to the airport and got lost, but not much else. Telephone interviews were attempted on 8/16/2023 with Staff C, CNA, Resident #1's assigned CNA for the 11 PM to 7 AM shift on 7/18/2023, Staff B, LPN, the assigned facility supervisor for the 11 PM to 7 AM shift on 7/18/2023, Staff D, LPN, Resident #1's assigned nurse for the 11 PM to 7 AM shift on 7/18/2023, Staff J, CNA, Resident #1's assigned CNA for the 3 PM to 11 PM shift on 7/18/2023, and Staff E, Agency LPN, Resident #1's assigned nurse for the 3 PM to 11 PM shift on 7/18/2023. The staff members could not be reached. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 6/18/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form revealed under Section E: Medical Condition, primary discharge diagnoses of altered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 17 of 23 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 08/18/2023 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 mental status (AMS) and incompetence. Level of Harm - Immediate jeopardy to resident health or safety A review of Resident #1's psychology evaluation notes dated 7/5/2023 revealed under the section titled Patient Consent This provider confirms that the written consent to treat was obtained from the patient Power of Attorney (POA) as patient is not capable of giving the consent. The note revealed under the section titled History of Present Illness Patient has history of depression, anxiety, and dementia. Patient stated, 'my memory is bad'. He reported he feels depressed, sad, and irritable since he was admitted to the facility . Residents Affected - Few A review of Resident #1's care plan meeting minutes, dated 6/23/2023 revealed a Welcome Meeting was conducted with Resident #1 and Resident #1's RP via telephone. The care plan meeting minutes did not reveal documentation under the sections titled Behavioral Health/Activities or Resident/Family Concerns. Resident #1's diagnosis of dementia was not documented on the care plan meeting minutes. An interview and tour was conducted on 8/17/2023 at 11:15 AM with the facility's Maintenance Director and NHA near the facility elevator. The NHA stated modifications were made to the facility elevator to ensure residents of the facility could not access the rear service hallway through the elevator. The NHA stated a keypad would be installed for the elevator and anyone who used the elevator would be required to enter a code, which would not be provided to facility residents. The NHA stated the rear service hallway could be accessed through the 200 unit and required a code to access. An observation of the facility elevator revealed the buttons to access the rear service hallway were not able to be pressed due to being covered with a cap and black tape. The NHA stated the modifications were temporary until the elevator vendor could install the keypad. A tour was conducted of the rear service of the facility. The facility elevator cannot be accessed through the rear service hallway and was observed to be blocked with yellow caution tape. An observation of the rear exit door of the facility revealed signage posted on the door entrance temporarily closed use front entrance!! The rear exit door was locked and secured. Facility's immediate actions to remove the Immediate Jeopardy included: o Facility egress doors checked for alarming/functioning with no other issues identified. The door that resident exited from noted to not automatically close has been taken out of services. An outside vendor was contacted on 7/19/2023 by the NHA to replace the door. The rear elevator door was taken out of service on 7/19/2023 by blocking the buttons to open them. An outside vendor was contacted on 7/19/2023 by the NHA to service the elevator and put a code box on to prevent it from opening without putting in the code. o Elopement drills initiated on 7/19/2023 starting on 7:00 AM to 3:00 PM shift then conducted every shift for 3 days then weekly for 4 weeks then monthly. o Staff education was initiated 7/19/2023 on Abuse, Neglect and Exploitation Policy w/ emphasis on neglect to include reporting requirements, elopement standard and guidelines, shift to shift rounds and mid night census by the staff development coordinator, this education included actual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 18 of 23 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 08/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few visualization of each resident during these rounds this education was completed on 7/20/2023. Newly hired staff and agency staff will be educated during the orientation process. Staff will be educated on every 2-hour rounding on residents to include physical visualization of residents. Licensed nurses will validate that this rounding is being done and document attestation of rounding in the medication administration record. Education will be completed by the SDC, or designee. Residents that are evaluated to be at risk for elopement and not placed on the secured unit will have rounding with physical visualization every 1 hour or as indicated in their plan of care. The licensed nurse will validate that this rounding is being done and document attestation of rounding the medication administration record. o Residents currently residing in the facility were re-evaluated for elopement risk by the DON or Designee on 7/19/2023 to 7/25/2023. No new residents identified at risk for elopement. o An ad-hoc QAPI meeting was held on 7/19/2023 at 3:00 PM. o Elopement risk alert binders reviewed for accuracy and confirmed to have demographics present for all residents at risk for elopement based on Elopement Risk Evaluations on 7/19/2023. The binders were again reviewed on 7/25/2023, no new updates were needed. New admissions or residents with a change in behavior that increases risk for elopement will be reviewed during morning clinical meeting and placed in the elopement risk binders located at each nurses station and at the receptionist desk. o Care plans for residents at risk for elopement confirmed to be present on 7/20/2023. Updates were completed as needed. o Rounds are conducted throughout each shift, at shift change, during AM, PM care, during meal services and during care provision. Mid-night census sheet will be signed by the unit nurse and turned into the Director of Nurses each day. Verification of the facility's removal plan was conducted by the survey team on 8/18/2023. An attestation provided by the facility revealed on 7/19/2023, the former maintenance director ensured the rear service elevator door, and the rear exit door of the facility were taken out of service and outside vendors were contacted to service the elevator door and to replace the rear door of the facility. A sample of five residents at risk for elopement, including Resident #1, were reviewed for verification of new orders related to rounding, care plan including elopement risk, elopement risk evaluation, and presence in the facility elopement book. Review of the five residents revealed all residents had new orders related to rounding, care plan including elopement risk, updated elopement risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 19 of 23 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 08/18/2023 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 evaluation, and presence in the facility elopement book. Level of Harm - Immediate jeopardy to resident health or safety A review of education conducted by the DON and the SDC revealed education related to resident rounding was conducted on 8/17/2023 for facility nursing staff. Education related to abuse/neglect and elopement procedures was conducted on 7/19/2023 and completed on 7/20/2023 with all staff educated. Post-test and competencies included as part of the facility training. Residents Affected - Few A review of facility elopement drills revealed elopement drills were conducted from 7/19/2023 to 7/22/2023. Elopement drills completed on all shifts with documentation of participating staff. Interviews were conducted with 48 staff members, including 2 Registered Nurses, 7 LPNs, 13 CNAs, 7 dietary staff, 3 therapy staff, 6 housekeeping staff, and 10 other staff members. The staff members were able to state that they had been trained and were knowledgeable about the policies and procedures. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 8/18/2023 and the non-compliance was reduced to a scope and severity of D. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 20 of 23 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 08/18/2023 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 resident, family member and staff interviews, review of logs, pest service reports, grievance logs, and observations of two dead and two live pests on the first floor of the facility, in resident rooms and in the nourishment pantry, the facility failed to ensure an effective pest control program. Residents Affected - Some Findings included: During a tour of the first-floor resident rooms, common areas, and nourishment pantry, beginning at 9:30 a.m. on 08/14/2023, two dead bugs and one live bug were observed. (Photographic evidence obtained) Interviews with residents and one family member on 08/14/2023 from 9:30 a.m. until 12:30 p.m. confirmed they see bugs in their rooms and in the dining room. Resident # 10 was observed lying in bed with the television on. When asked about bug sightings she said yes, but mostly at night when you turn the lights on. She reported that she thought the bugs were why she felt so itchy. On 08/16/2023 at 11:00 a.m., Resident #11 was observed lying in her bed, on her left side facing the hall. As the resident was answering questions about herself, the surveyor asked about the missing baseboards in the room. When asked if she ever saw bugs, the resident answered yes, because there are no baseboards. An interview was conducted with a family member on 08/14/23 beginning at 12:30 p.m. who reported she visits her spouse three days a week. When asked if she ever sees bugs in the room, she pulled out a can of bug spray from her tote bag and said yes, and she brings her own spray. Resident # 12 was observed sitting up in bed on 08/15/2023 at 10:20 a.m. He confirmed that yes, he has seen bugs in his room. He reported that a guy came in to spray for bugs and told him that he might notice that the bugs start to move slower, which meant they had been exposed to his spray, and they were dying. Resident # 13, was questioned on 08/18/23 at 11:00 a.m. He confirmed he had submitted grievances about bugs in his room and yes, he still saw them. He denied noticing a guy spraying in his room for bugs. A review of the Grievance log revealed on 6/13/2023 Resident #13 reported Concern re: showers, pests, bed not working, w/c (wheelchair) broken. The Record of the resident grievance included the desired outcome as shower room sprayed - bed to work. Staff noted on the grievance form that pest control scheduled with the follow up dated 6/19/23. A review of the Pest Service log revealed on 6/14/23 the concern of roaches in the resident's room had been logged. A review of the Pest Prevention Service Report dated 6/14/2023 revealed a roach gel bait had been applied in another residents' room to get rid of roaches. Also, a dust was applied to reach areas to eliminate pest activity. A Pest Prevention Service Report dated 06/23/2023 was reviewed and noted to not include the repeat occurrence and sighting of pests in Resident #13's room. A review of a grievance filed for the resident in room [ROOM NUMBER] on 6/18/2023 revealed: I have been asking for 3 weeks for someone to spray his room for roaches and as I see nothing has been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 21 of 23 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 08/18/2023 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 Level of Harm - Minimal harm or potential for actual harm done. A note on the grievance form indicated the pest service had been contacted. The pest service log included an entry dated 6/24/23 for roaches - entire room. A review of the pest company's service log for the first-floor revealed roaches had been observed in room [ROOM NUMBER] on 6/11/23 and 6/24/23. Residents Affected - Some On 06/23/2023 the Pest Prevention Service Report indicated the specific resident room had been treated with a roach gel bait and dust to eliminate any pest activity found within. The log also included a sighting of roaches in Resident # 13's room on 7/23/2023. There were no Pest Prevention Service Reports indicating a visit by the pest company had been provided after 06/23/2023. A review of the Service Logs provided by the Pest Control Company revealed a column to document whether the service had been completed. The log for the second floor included entries from 5/1/23 to 08/03/2023. Initials marked three entries as having service completed dated 5/1/23 for roaches in the nourishment room and in resident dressers in resident rooms [ROOM NUMBERS]. A fourth entry was marked as having service completed on 6/14/23 indicated roaches were found in room [ROOM NUMBER]. Entries were not initialed as service completed on 7/23/2023 for rooms [ROOM NUMBERS] for roaches, 7/27/23 for black ants in the medical records office, 7/31/23 for ants in the bathroom of room [ROOM NUMBER], for 8/2/23 for roaches in the elevator and on 8/3/23 for roaches in the nourishment room. The service log for the first floor included twelve entries dated 03/07/23 to 06/24/23. None of the entries were initialed as having had service completed. All twelve entries were for roaches and specific locations included the nurses' station, the shower room, the soiled utility room, and room [ROOM NUMBER]. A review of the visit reports revealed the Pest Company made three visits in January, two visits in February, March, April, and June and one visit in May and July. The report for 03/21/23 indicated logbooks were provided for both floors, but visit reports did not reflect that the logbooks were reviewed with service completed for those specific locations where bugs were sighted. At 10:00 a.m. on 08/14/23, an observation of the first-floor nourishment pantry was conducted. The cabinet in the pantry was noted to be constructed of particle board with many sides exposed, due to missing laminate covering. Inside of the bottom left cabinet, on the floor of the cabinet was the residual of a grainy, reddish substance noted next to a squashed bug. A second visit was made to the first-floor nourishment pantry on 08/15/23 beginning at 10:00 a.m. with the Unit Manager. The door to the bottom cupboard, to the left of the sink, was opened and the reddish grainy spill and dead bug were still there. A staff member had placed a drink container on part of the bug. The pest company's service log had no entries for pest sightings in the nourishment pantry on the first floor. At approximately 9:40 a.m. on 08/14/2023, room [ROOM NUMBER] was noted to have a dead bug next to the air conditioning unit. Next to the dead bug and wheels of the over bed table was a live bug scuttling around, disappearing under the loose baseboard and out again. During a tour of the first floor with the Administrator and Maintenance Staff on 08/17/23 beginning at 12:00 p.m. a small bug was noted to be crawling around near the baseboard of the hallway leading (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 22 of 23 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 08/18/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete away from the elevator. The Administrator confirmed he was aware that the pest control was ineffective but reported the problem had gotten much better. In an interview with the Administrator on 08/15/2023 beginning at 1:20 p.m., he reported that the pest control company made visits monthly with visits more often if sightings were reported. He reported that the company began service in January with a full building sweep of both resident floors and the kitchen. When asked if the company was supposed to check the pest sighting logs and address the entered concerns, he reported he wasn't sure of their process. Event ID: Facility ID: 105428 If continuation sheet Page 23 of 23