Inspection visit

InspectionJanuary 25, 2024

LAKE MARIAM HEALTH AND REHABILITATION CENTERCMS #10542850 citations on this visit

50 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 50 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Chronic Obstructive Pulmonary Disease and Cognitive Communication Deficit. Her Brief Interview for Mental Status (BIMS) score from the annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/01/23 was 13, indicating the resident was cognitively intact. Review of the resident's care plan for risk for decreased ability to perform ADLS (activities of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting, which was created on 06/12/23 revealed an intervention created on 08/06/23 of assist as indicated with transfers, ambulation, WC (wheelchair) mobility, bathing/grooming, and meals. The care plan does not address any refusals that the resident might have made for personal grooming. On 01/22/24 at 10:47 AM, Resident #15 was interviewed during the initial screening process. The resident was observed as having facial hair. The resident was asked if she wanted to keep or remove the facial hair. She stated that she would like it removed but no one has done it yet. An interview was conducted with Staff K, CNA/Transporter on 01/25/24 at 1:12 PM. Staff K was asked if an offer was made to Resident #15 to remove her facial hair. Staff K stated that the resident does allow the CNAs to do it. An interview was conducted with the Medical Director on 01/25/24 at 1:55 PM, who revealed he had an in-service with the CNAs around 6 months ago regarding personal care. Based on observations, interviews, and record review, the facility failed to treat residents in a dignified manner during dining observations for 3 of 7 sampled residents reviewed for dignity, Residents #79, #40, and #25; and failed to provide timely grooming to preserve dignity, for 1 of 7 sampled residents, Resident #15, also reviewed for dignity. The findings included: Review of the facility's policy, titled Promoting/Maintaining Resident Dignity, revised on 08/02/22, revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Staff members provide care to residents to promote and maintain resident dignity during interactions with residents. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 89 Event ID: 105428 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 01/25/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses that included Dementia, Anxiety, and Dysphagia. The care plan initiated on 06/28/23 revealed that Resident #79 had impaired cognitive function and impaired thought process due to his Dementia. In an observation conducted on 01/22/24 at 12:30 PM, Resident #79's roommate received his lunch tray. Resident #79 was noted in his bed with no lunch tray. Resident #79's lunch tray was noted sitting outside on the meal cart in the hallway. At 12:55 PM, Staff S, Certified Nursing Assistant (CNA), brought Resident #79's lunch meal into the room, about 25 minutes later. Continued observation showed that Resident #79's roommate had already finished his lunch meal. 2. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included Dementia and Behavioral Disturbances. Resident #40 was admitted to hospice services on 07/05/23. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #40 has a Brief Interview of Mental Status (BIMS) score of 99, indicating the score could not be due to cognitive impairment. In an observation conducted on 01/22/24 at 12:43 PM, Resident #40 was in her room with her lunch tray. Staff P, Hospice Registered Nurse, was observed in the room standing over Resident #40 while assisting her with the lunch meal. Closer observation did not show any sitting chairs in the room. An interview was conducted with Staff J, Registered Nurse / Unit Manager, on 01/25/24 at 9:51 AM, who stated that she expects all staff to sit at eye level while assisting residents during dining. An interview was conducted on 01/25/24 at 2:30 PM, with Staff I, Certified Nursing Assistant, who stated that when assisting a resident during dining, they need to sit at eye level and not stand over the resident. 3. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included Age-Related Nuclear Cataract, Bilateral, Anxiety Disorder, and Mild Intellectual Disabilities. The Minimum Data Set (MDS) assessment for Resident #25 dated 12/16/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) assessment was not attempted, due to the resident is rarely/never understood. Section GG revealed for eating the resident's usual performance is setup or clean-up assistance. Review of the Care Plan for Resident #25 dated 06/07/23 with a focus on the resident remains at risk for nutritional decline related to clinical condition of Depression, Dysphagia, Schizophrenia, and Heart Disease. The goal was for the resident to be free from signs/symptoms (S/S) of dehydration and/or fluid overload. The interventions included: Assist as needed with proper positioning, setup, feeding and encouragement. On 01/22/24 at 12:25 PM, an observation was made of Resident #25 sitting on the side of the bed, being fed lunch by Staff W, Certified Nursing Assistant (CNA). The CNA was standing while feeding the resident. There was a chair observed on the opposite side of the room. An interview was conducted on 01/22/24 at 12:27 PM with Staff W, who stated she has worked at the facility for 2 months. When asked if she always stands to feed the resident, she replied yeah, and sometimes the resident is sitting in his wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 2 of 89 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 01/25/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 01/25/24 at 10:30 AM with Staff D, CNA, who stated she has been working at the facility for 2 months. When asked if she stands to feed a resident, she said, No, because what you are supposed to do is sit in a chair beside the resident to assist with feeding. They always have a chair available. Not every room has a chair, sometimes you have to go across the hallway to get a chair. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 3 of 89 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 01/25/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure call lights remained in reach for 2 of 100 sampled residents observed during the initial screening process (Resident #58 and Resident #155). Residents Affected - Few The findings included: The policy of the facility, titled, Call Lights: Accessibility and Timely Response implemented 11/2020 and revised 07/19/22, revealed Staff will ensure the call light is within reach of resident and secured, as needed; and The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 1. Review of the resident's Medicare A 5-day scheduled assessment with a target date of 01/06/24 documented: Section C: the resident is rarely/never understood. Section GG: the ability to safely come to a standing position from sitting in a chair or on the side of the bed is not applicable and picking up object is dependent. On 01/22/24 at 7:55 AM, Resident #58 was observed in his wheelchair. The call light was observed on the floor next to the bed. Resident #58 was not able to pick up the call light off the floor to call staff, if needed. 2. Record review revealed Resident #155 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism and Hypocalcemia. Review of the Medicare 5-day Minimum Data Set (MDS) assessment, with an assessment reference date of 11/07/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Resident #155 was observed in bed on 01/22/24 at 9:00 AM. His call light was observed on the floor next to his bed and not within reach of the resident. Photographic Evidence Obtained. At the time of observation, Resident #155 was asked if he could reach his call light, and stated that he could not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 4 of 89 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 01/25/2024 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide written notice to the resident or the resident's representative of a room change for 1 of 32 sampled residents reviewed for room changes (Resident #69). The findings included: Review of the facility's policy, titled, Change of Room or Roommate with a reviewed / revised date of 03/08/23 included: It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. The notice of change in room or roommate will be provided in writing, in a language and manner the resident and representative understand. Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] with a diagnosis that included Bipolar Disorder and Schizophrenia. The Minimum Data Set (MDS) assessment for Resident #69 dated 01/04/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 9, indicating a moderate cognitive impairment. During an interview conducted on 01/22/24 at 1:33 PM with Resident #69, she stated they (staff) moved her one day and didn't tell her why or where she was going. She said she liked her prior room better because of the staff and her roommate. Review of the Electronic Medical Record (EMR) for Resident #69 revealed no notice of her room change, as required. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. An interview was conducted on 01/22/24 at 1:35 PM with the Activities Director, who stated she has been at the facility for just over a year. When asked about Resident #69, she stated the resident was previously in another room but thinks they moved her to make the previous room a male room. An interview was conducted on 01/23/24 at 9:50 AM with the Resident Representative (Guardian) for Resident #69, who was asked if the facility had discussed a room change for the resident on 01/04/24. She stated the facility contacted her about a room change regarding trying to get all females on one side of the hall and all males on the other side of the hall, and the resident would have a similar room and be near the window. When asked if the facility provided her with any paperwork or documentation about the room change, she said she did not recall. When the Representative was advised that the resident had informed the surveyor that she wanted to go back to her old room, the Resident Representative said the resident changes her mind all of the time and she lacks capacity to make her own decisions. An interview was conducted on 01/24/24 at 9:16 AM with the Social Service Director (SSD), who stated she has worked at the facility for 4 years. When asked if there is a room change for a resident and what she does, she said they notify the resident and the resident's representative. She would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 5 of 89 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 01/25/2024 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 0559 Level of Harm - Minimal harm or potential for actual harm complete a room change form and provide it to the resident or the resident representative. When asked about Resident #69, she said they were trying to do room changes to make the memory care unit with a male side and a female side. When asked if she had notified the representative for Resident #69 about the room change, she said she did. The SSD was asked for a copy of the written notice, but none was produced. The SSD stated the notice may not have been uploaded into the resident's EMR. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 6 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and policy review, observations and interviews, the facility failed to ensure of a safe, clean, comfortable, and homelike environment for 13 of 31 rooms on the 1st floor, 2 of 2 Shower Rooms on the 1st floor, 1 laundry area, and a pillar located in the Memory Care Unit Nursing Station. The findings included: Review of the facility's policy, titled, Safe and Homelike Environment with a reviewed / revised date of 04/11/23, included: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. General considerations: Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department. Report any furniture in disrepair to Maintenance promptly. Report any unresolved environmental concerns to the Administrator. During an initial tour of the facility conducted on 01/22/24 from 7:30 AM to 11:40 AM, the following observations were made: In room [ROOM NUMBER], the door frame had a large area of missing/chipping paint. Photographic Evidence Obtained. In room [ROOM NUMBER], the ceiling paint by the window was bubbling / peeling; the ceiling paint by the entry door / privacy curtain track was discolored; the bathroom floor and toilet seat were discolored; both nightstands had broken drawers and chipped/missing/scratched veneer. Photographic Evidence Obtained. In room [ROOM NUMBER], the bed near the window had no overbed table for meals. Photographic Evidence Obtained. In room [ROOM NUMBER], the bathroom ceiling had large unpainted patches; and the floor near the bed by the door had cracked floor tiles. Photographic Evidence Obtained. In room [ROOM NUMBER], the wall by the sink had a large scuff mark and missing paint. Photographic Evidence Obtained. In room [ROOM NUMBER], the window screen had large holes. Photographic Evidence Obtained. In room [ROOM NUMBER], the light above the bed, closest to the entry door, had a large amount of rust. Photographic Evidence Obtained. In room [ROOM NUMBER], the wall by the air-conditioning (A/C) unit had a hole with a metal plate inside; the wall of the entry door was unpainted; the closet door was off-track; and blackish mold (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 7 of 89 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 01/25/2024 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 like substance was noted on the inside closet of the wall near the floor. Photographic Evidence Obtained. Level of Harm - Minimal harm or potential for actual harm In room [ROOM NUMBER], there was no window covering except the valance, to block the light; and the closet door was missing. Residents Affected - Some In room [ROOM NUMBER], the base of the bed closest to the entry door was rusty; the nightstand closest to the entry door had drawers misaligned; the closet door was bowed and had layers of the wood separated; blackish mold like substance was noted on the inside of the closet, on the wall near the floor; and the windowsill was cracked and uneven. Photographic Evidence Obtained. In room [ROOM NUMBER], the ceiling was dark / discolored. In room [ROOM NUMBER], the privacy curtain track above the bed by the door was pulling away from the ceiling; the bed by the door had 2 large gray stains at the foot of the bed; the A/C vents were dirty; there were no chairs in the room; the cold-water handle to the bathroom sink was broken and there was no hot water; and there was an overwhelming smell of urine in the bathroom. Photographic Evidence Obtained. Outside of room [ROOM NUMBER], there was no room number, and just 1 of the 2 residents' names taped to the wall. In room [ROOM NUMBER], the florescent light in the bathroom that extends over the toilet and sink, was uncovered (Photographic Evidence Obtained), and the nightstand near the room window had a broken handle. In the Bath / Shower Room across from room [ROOM NUMBER], there was no paper towel holder and no paper towels at the sink; and 2 open gallon jugs of skin/hair cleaner were on the floor in the shower stall. Photographic Evidence Obtained. In the Bath / Shower Room across from room [ROOM NUMBER], there were 2 treatment carts; and 2 open gallon jugs of skin/hair cleaner on the floor in the shower stall. Photographic Evidence Obtained. The Memory Care Unit Nursing Station had a pillar with no laminate, exposing glue and particle board. During the laundry tour conducted on 01/22/24 from 12:00 PM to 2:50, PM with the Director of Plant Operations, Director of Maintenance, and the Director of Housekeeping, the following observations were made: The washing tub located in the sorting room was dirty / stained. There were 7 (seven) 5-gallon containers of floor stripper, directly on the floor, in the sorting room. There was an empty wet / dry vacuum that was pulled apart, with dried debris on the filter exposed in the sorting area. There were 4 (four) open containers of chemicals attached to the washing machines, placed directly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 8 of 89 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 01/25/2024 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 on the floor in the washing room. Level of Harm - Minimal harm or potential for actual harm There were 5 (five) sealed containers of chemicals stored directly on the floor in the washing room. Residents Affected - Some There was an open container of laundry detergent and an open container of fabric softener stored directly on the floor in the washing room. There was a missing ceiling tile above the washing machines in the washing room. There was a portable hot water heater stored behind the dryers in the drying room. There was a box fan covered with dust / debris and a curtain rod in plastic stored in the corner between the dryers and the wall with the window. The florescent ceiling light in the dryer room had no cover. During an environmental tour conducted on 01/24/24 at 1:30 PM with the Director of Plant Operations, the Director of Maintenance (DOM), and the Maintenance Assistant (MA), they acknowledged the identified concerns. During an interview conducted on 01/24/24 at 2:50 PM with the Director of Housekeeping, she stated the Administrator walks through the laundry area periodically and he makes suggestions on things for her to do in the laundry area. The Director of Housekeeping was unable to clarify what the Administrator had suggested for her to do in the laundry area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 9 of 89 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 01/25/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement baseline care plans within 48 hours of a resident's admission for 1 of 1 sampled resident, reviewed for catheter care (Resident #153). The findings included: During an observation on 01/22/24 at 7:30 AM, Resident #153 was observed in bed. On the floor, next to his bed, a catheter bag containing urine was observed on the floor. Record review revealed Resident #153 was admitted to the facility on [DATE], in the late afternoon, with diagnoses that included Type 2 Diabetes Mellitus, Heart Failure and Urinary Retention. The resident was admitted with a suprapubic catheter. (A suprapubic catheter is a device that's inserted directly into the bladder to drain urine). Review of the Electronic Health Record (EHR) revealed no evidence of a baseline care plan for the catheter or for catheter care. Review of the comprehensive care plans revealed no care plan for a catheter or catheter care. On 01/22/24 at 11:13 AM, an interview was conducted with the Director of Nurses (DON). She was asked who completes the baseline care plans. She stated the Minimum Data Set (MDS) Coordinator would initiate the baseline care plans on Monday, if a resident was admitted after hours on a Friday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 10 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide care and services in accordance with the plan of care for two (Resident #6 and Resident #9) of three residents sampled for bedrail use and two (Resident #3 and Resident #6) of three residents sampled for unnecessary medication use. Findings included: A review of Resident #6's medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of vascular dementia, cerebral atherosclerosis, schizoaffective disorder, bipolar type, major depressive disorder, and anxiety disorder. A review of Resident #6's physician's orders revealed the following orders: - An order, dated 6/16/2023, for olanzapine 10 mg (milligrams) PO (orally) two times a day for schizoaffective disorder, bipolar type. - An order, dated 6/16/2023, for clonazepam 0.5 mg PO every 12 hours for anxiety disorder. - An order, dated 6/16/2023, for Eliquis 5 mg PO two times a day for cerebral atherosclerosis. - An order, dated 6/16/2023, for Side Effect Observation: 1-Dystonia, torticollis (stiffness of neck); 2-Anticholinergic symptoms: dry mouth/blurred vision, constipation/urinary retention; 3-Hypotension ; 4-Sedation/drowsiness; 5-Increased falls/dizziness ;6-Cardiac abnormalities; 7-Anxiety/agitation; 8-Blurred Vision; 9-Sweating/rashes; 10-Headache; 11-Urinary retention/hesitancy; 12-Weakness; 13-Hangover effect; 14-Pseudoparkinsonism; 15-Insomnia; 16-New Onset Confusion, every shift for medication side effect monitoring. - An order, dated 6/16/2023, Side Effect Observation: 17-Akathisia--restlessness/pacing/inability to sit still/anxiousness/sleep disturbances; 18-Tardive dyskinesia--lip smacking/chewing/abnormal tongue movement/spasmodic movement of arms/legs-rocking/swaying; 19-Sore throat; 20-Seizures; 21-Photosensitivity; 22-Suicidal ideations; 23-Hepatic or renal abnormalities; 24-Ataxia; 25-Nausea/Vomiting; 26-Diarrhea; 27-Abdominal Discomfort; 28-discolored urine; 29-black tarry stools; 30-bruising; 31-nose bleeds, every shift for medication side effect monitoring. - An order, dated 6/16/2023, for antianxiety medication monitoring. Observe for restlessness every shift. - An order, dated 6/16/2023, for antipsychotic medication monitoring. Observe for delusions, hallucinations, and/or paranoia every shift. - An order, dated 3/11/2024, for 1/4 side rail x (times) 1 for bed mobility. A review of Resident #6's Side Rail Evaluation dated 3/11/2024 revealed Resident #6 demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed and required assistance with toileting and a quarter rail on the left side of the bed was implemented to assist with positioning, support, and/or bed mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 11 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #6's care plan revealed a Focus area, last revised on 3/21/2024, Resident #6 required assistance to perform, improve or maintain Activities of Daily Living (ADL) activities. Interventions included to assist the resident with ADL's as needed, observe for ADL decline, and 1/4 side rail x 1 for bed mobility. Resident #6's care plan also revealed a Focus, last revised on 2/13/2024, Resident #6 uses antipsychotic and anxiolytic medications. Interventions include to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift. Resident #6's care plan revealed a Focus area, last revised on 6/8/2023, Resident #6 is on anticoagulant therapy. Interventions include to administer anticoagulant medications as ordered and monitor for side effects and effectiveness every shift. A review of Resident #6's Behavior Monitoring Log for March 2024 revealed the following related to Resident #6's order for antianxiety medication monitoring: - No documentation of monitoring for the day shift on 3/21/2024. - No documentation of monitoring for the night shift on 3/6 and 3/17/2024. A review of Resident #6's Behavior Monitoring Log for March 2024 revealed the following related to Resident #6's order for antianxiety medication monitoring: - No documentation of monitoring for the day shift on 3/21/2024. - No documentation of monitoring for the night shift on 3/6 and 3/17/2024. A review of Resident #6's Behavior Monitoring Log for March 2024 revealed the following related to Resident #6's order for antipsychotic medication monitoring: - No documentation of monitoring for the day shift on 3/21/2024. - No documentation of monitoring for the night shift on 3/6 and 3/17/2024. A review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and anxiety disorder. A review of Resident #9's physician's orders revealed an order, dated 3/11/2024 for 1/4 side rail x 1 for bed mobility. A review of Resident #9's Side Rail Evaluation dated 3/11/2024 revealed Resident #9 demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed and required assistance with toileting and a quarter rail on the right side of the bed was implemented to assist with positioning, support, and/or bed mobility. A review of Resident #9's care plan revealed a Focus area, last revised on 6/9/2023, Resident #9 was at risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. Interventions included to use a wheelchair for locomotion and side rail x 1 for bed mobility. A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of dementia, cerebral infarction, cognitive communication deficit, and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 12 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 A review of Resident #3's physician's orders revealed the following orders: Level of Harm - Minimal harm or potential for actual harm - An order, dated 2/14/2024, for sertraline hydrochloride (HCl) 50 milligrams (mg) by gastric tube (GT) one time a day for depression. Residents Affected - Some - An order, dated 3/28/2024 for escitalopram oxalate 10 milliliters (ml) GT one time a day for depression. - An order, dated 2/13/2024 for apixaban 5 mg GT two times a day for cerebral infarction. - An order, dated 2/13/2024 for Side Effect Observation: 1-Dystonia, torticollis (stiffness of neck); 2-Anticholinergic symptoms: dry mouth/blurred vision, constipation/urinary retention; 3-Hypotension ; 4-Sedation/drowsiness; 5-Increased falls/dizziness ;6-Cardiac abnormalities; 7-Anxiety/agitation; 8-Blurred Vision; 9-Sweating/rashes; 10-Headache; 11-Urinary retention/hesitancy; 12-Weakness; 13-Hangover effect; 14-Pseudoparkinsonism; 15-Insomnia; 16-New Onset Confusion, every shift for medication side effect monitoring. - An order, dated 2/13/2024 for Side Effect Observation: 17-Akathisia--restlessness/pacing/inability to sit still/anxiousness/sleep disturbances; 18-Tardive dyskinesia--lip smacking/chewing/abnormal tongue movement/spasmodic movement of arms/legs-rocking/swaying; 19-Sore throat; 20-Seizures; 21-Photosensitivity; 22-Suicidal ideations; 23-Hepatic or renal abnormalities; 24-Ataxia; 25-Nausea/Vomiting; 26-Diarrhea; 27-Abdominal Discomfort; 28-discolored urine; 29-black tarry stools; 30-bruising; 31-nose bleeds, every shift for medication side effect monitoring. - An order, dated 2/13/2024 for antidepressant medication monitoring. Observe for sadness, tearfulness, and/or self-isolation every shift. A review of Resident #3's Behavior Monitoring Log for March 2024 revealed the following related to Resident #3's order for side effect observation: - No documentation of monitoring for the day (7 AM to 3 PM) shift on 3/15, 3/16, and 3/25/2024. - No documentation of monitoring for the evening (3 PM to 11 PM) shift on 3/10, 3/12, 3/20, and 3/26/2024. A review of Resident #3's Behavior Monitoring Log for March 2024 revealed the following related to Resident #3's order for antidepressant medication monitoring: - No documentation of monitoring for the day (7 AM to 3 PM) shift on 3/15, 3/16, and 3/25/2024. - No documentation of monitoring for the evening (3 PM to 11 PM) shift on 3/10, 3/12, 3/20, and 3/26/2024. A review of Resident #3's care plan revealed a Focus, last revised 12/14/2023, Resident #3 used antidepressant medication. Interventions included to administer antidepressant medications as ordered and monitor/document side effects and effectiveness every shift. An observation was conducted on 4/2/2024 at 2:33 PM of Resident #6's bed. Resident #6's bed was observed to have built in side rails, which fold up and down, into the side of the resident's bed. Both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 13 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 side rails were observed zip tied in the down position to Resident #6's bed frame. Level of Harm - Minimal harm or potential for actual harm An observation was conducted on 4/2/2024 at 2:36 PM of Resident #9's bed. No side rails were observed to Resident #9's bed. Residents Affected - Some An interview was conducted on 4/2/2024 at 1:00 PM with Staff N, Licensed Practical Nurse (LPN). Staff N, LPN stated residents on psychotropic medications should have orders in place for behavioral and side effect monitoring, which is documented every shift. An interview was conducted on 4/3/2024 at 9:34 AM with Staff M, Licensed Practical Nurse (LPN) and Unit Manager (UM). Staff M, LPN UM stated the facility mainly had two types of beds. One of the beds had built in side rails and the other type of bed required the side rails to be attached by the maintenance staff. If a resident is assessed to not have a side rail, the beds with the built in side rails have the side rails zipped tied down by the maintenance staff. If a resident is ordered a side rail and they are in a bed with built in side rails, one side rail remains zip tied to the frame while the other one is released for the resident to use as indicated in the Side Rail Evaluation. If a resident is ordered a side rail and they are in a bed without built in side rails, a request to attach the appropriate side rail is put in and addressed by maintenance staff. Following the interview, observations of Resident #6 and Resident #9's bed were conducted with Staff M, LPN UM. Staff M, LPN UM address Resident #6 and Resident #9 did not have side rails in use. Staff M, LPN UM reviewed Resident #6's and Resident #9's Side Rails Evaluations and addressed the residents should have side rails to their beds. An interview was conducted on 4/3/2024 at 1:34 PM with the facility's Director of Nursing (DON). The DON stated she conducted a facility audit and performed side rail assessments for each resident in the facility. The DON also stated she put orders in each resident's medical record who required a side rail and provided the maintenance staff with a list of the resident's requiring side rails so they could be put into place. The DON was not able to state why the side rails were not put into place as ordered. An interview was conducted on 4/3/2024 at 2:20 PM with the facility's Maintenance Director (MD). The MD stated he is directed by the DON to either put side rails on the resident beds of to remove/secure the side rails not in use. The MD also stated Resident #6's bed was supposed to have a side rail in use and both of the side rails should not have been zip tied to the bed frame. An interview was conducted on 4/3/2024 at 2:58 PM with the facility's Regional Director of Operations (RDO), DON, and MD. The RDO stated the MD was informed of the residents who required side rails. The MD stated he assigned the bed rail project to his assistant with specific directions related to which resident's required side rails and which side of the resident's bed required a side rail. The MD also stated his assistant did not carry out the task as directed and they were not able to state why the task was not completed correctly. The DON stated she performed an audit to ensure the appropriate side rails were in place to resident beds, which was spot on, but now the side rails are not in place as they should be. The DON also stated medication monitoring should be conducted in accordance with the physician's order and addressed the missing documentation for Resident's #3, #6, and #7 in the monitoring logs. A review of the facility policy titled Proper Use of Bed Rails, last revised on 7/25/2022, revealed under the section titled Policy it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. If bed rails are used, the facility ensures correct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 14 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 installation, use, and maintenance of the rails. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled Comprehensive Care Plans, last revised on 7/27/2022, revealed under the section titled Policy it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines the comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Residents Affected - Some Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 15 of 89 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 01/25/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update an Advance Directive care plan for 1 of 32 sampled residents reviewed for Advance Directives (Resident #57). The findings included: Review of the facility's policy, titled, Comprehensive Care Plans with a reviewed / revised date of [DATE] that included: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Review of the facility's policy, titled, Residents' Rights Regarding Treatment and Advance Directives with a reviewed / revised date of [DATE] that included: During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease, Bipolar Disorder, Dementia, Post-Traumatic Stress Disorder, and Anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #57 dated [DATE] revealed in Section C a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #57, dated [DATE], revealed a Do Not Resuscitate (DNR) order. Review of the Care Plan for Resident #57 dated [DATE] with a focus on the resident has an established CPR (Cardiopulmonary Resuscitation) (Full Code) order in place. The goal is to make the resident's wishes for code status to be followed through the next review date. The Interventions included: Activate the resident's advanced directives as indicated. Notify the physician of resident's wishes regarding life prolonging procedures. This indicated the Advance Directive care plan regarding code status for Resident #57 was never updated to reflect the DNR status. An interview was conducted on [DATE] at 9:16 AM with the Social Service Director (SSD), who stated she has worked at the facility for 4 years. She further explained for a resident who wants a code status of DNR (Do Not Resuscitate), the resident or the family will sign the yellow DNR form. She then has the physician sign the form and the nurse will obtain the order for the DNR and put it in the resident's EMR (Electronic Medical Record). She stated once there is an order in the computer for the code status, then she would update the care plan with the code status. When asked about Resident #57, she verified the resident had a DNR order dated [DATE], and the resident has a care plan for Full Code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 16 of 89 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 01/25/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses that included Dementia, Anxiety, and Dysphagia. The care plan initiated on 06/28/23 revealed that Resident #79 had impaired cognitive function and impaired thought process due to his Dementia. Residents Affected - Few In an observation conducted on 01/22/24 at 9:10 AM, Resident #79 was noted in bed. Closer observation showed that his fingernails were unkept, with unidentified brown matter underneath. In an observation conducted on 01/24/24 at 4:50 PM, Resident #79 was noted in bed. Closer observation showed that his fingernails were unkept, with unidentified brown matter underneath. An interview was conducted on 01/25/24 at 9:51 AM with Staff J, RN/UM (Registered Nurse / Unit Manager), who stated she expects her staff to cut the residents' fingernails during shower days, and as needed. Staff should perform the task if the fingernails need to be cleaned and trimmed. She said no when asked if she has a specific day that she audits or monitors to ensure that fingernail care is provided to all residents. They do not have a section in the electronic system specifically allocated for fingernail grooming when it is done. In a tour conducted on 01/25/24 at 9:58 AM accompanied by Staff J, Resident #79 was noted in his bed. Staff J was asked if she thinks that Resident #79's fingernails needed to be cleaned and trimmed, and she said, Definitely, yes. She then stated she had asked the night shift to go around last night and check on any residents who needed their fingernails trimmed and cleaned. 4. Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses that included Dementia, Heart Failure, and Depression. The Quarterly MDS assessment dated [DATE] showed a BIMS score of 02, indicating severe cognitive impairment. Section GG of this MDS showed that Resident #76 was coded dependent for all grooming activities. In an observation conducted on 01/22/24 at 9:20 AM, Resident #76 was noted in bed with long fingernails that were unkept. Further observation showed an unidentified brown matter underneath her fingernails. In an observation conducted on 01/23/24 at 8:41 AM, Resident #76 was noted in her wheelchair near the nurse's station. Closer observation showed her with long, unkept fingernails with unidentified brown matter underneath the fingernails. An interview was conducted on 01/25/24 at 11:16 AM with Staff L, Registered Nurse (RN), who stated that fingernail grooming is usually done when they provide showers to residents by the Certified Nursing Assistants (CNAs). Review of the CNA's documentation under the Task section revealed that from 01/12/24 to 01/21/24, Resident #76 received three showers and six-bed baths. An interview was conducted on 01/25/24 at 2:26 PM with Staff J, RN/UM, who reported the trimming and cleaning of Resident #79's fingernails earlier 'today'. When asked by the surveyor if they needed to be washed and trimmed, she said yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 17 of 89 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 01/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to provide fingernail grooming for 4 of 8 sampled residents reviewed for Activities of Daily Living (ADL) care (Residents #53, #70, #79, and #76). The findings included: Residents Affected - Few Review of the facility's policy, titled, Nail Care with a reviewed / revised date of 06/07/21 included: The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule and as the need arises. Principles of nail care: Nails should be kept smooth to avoid skin injury. Only licensed nurses shall trim or file fingernails of residents with diabetes. Procedure included: gently clean underneath nails with an orange stick. Document completion of task, any complications, or if resident refuses. 1. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility, and Unspecified Hearing Loss Bilateral. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 11/19/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 1, indicating severe cognitive impact. In Section GG, it revealed for toilet hygiene the resident had a performance of partial/moderate assistance, for walking 10 feet, walking 50 feet with two turns and walking 150 feet, the resident had a performance of partial/moderate assistance. Review of the Care Plan for Resident #53 dated 08/18/23 with a focus on the resident is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The goal was for the resident to continue to participate in their ADLs as tolerated daily through the next review date. The interventions included assist as indicated with transfers, ambulation, wheelchair mobility, bathing/grooming, and meals. On 01/22/24 at 7:44 AM, an observation was made of Resident #53 sitting on the side of his bed. It was noted his fingernails had jagged edges past the end of the fingertips, with a brownish-black matter under the nails. Photographic Evidence Obtained. On 01/22/24 at 11:00 AM, an observation was made of Resident #53 lying in bed and again it was noted his fingernails were with jagged edges past the end of the fingertips, with a brownish-black matter under the nails. On 1/22/24 at 2:35 PM, an observation was made of Resident #53 lying in bed and he continued to have his fingernails with jagged edges past the end of the fingertips with a brownish-black matter under the nails. An interview was conducted on 01/22/24 at 7:48 AM with Staff E, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 1 month. When asked how often residents' fingernails are cleaned, she said every time they get showered. When asked how often a resident gets a shower, she said 2 or 3 times a week. An interview was conducted on 01/25/24 at 11:00 AM, With Staff C, Licensed Practical Nurse (LPN), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 18 of 89 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 01/25/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who stated she has worked at the facility for 2 months. She stated the CNAs clean the residents' fingernails but was not sure how often. When asked about cutting or filing the nails, she said the CNAs provide the care, and they have their own schedule. She stated she believes it is twice a week. An interview was conducted on 01/25/24 at 11:30 AM with Staff B, LPN, who stated she has worked at the facility for 1 year. She said the residents' fingernails are cleaned by the CNAs mostly, but the nurse can do it also if the nails are dirty. When asked who cuts the fingernails, she said the nurses can cut the nails, but most of the time it is the CNAs. An interview was conducted on 01/25/24 at 11:50 AM with Staff A, LPN/Unit Manager (UM), who stated he has worked at the facility since August / September last year. When asked about fingernail care, he stated the CNAs clean the fingernails of the residents. 2. Record review for Resident #70 revealed the resident was admitted to facility on 12/13/23 with diagnoses that included: Dementia, Type 2 Diabetes Mellitus, and Anxiety Disorder. Review of the MDS assessment for Resident #70 dated 12/20/23 revealed in Section C, a BIMS score of 0, indicating severe cognitive impairment. Section GG revealed for shower / bathe self, the resident had a performance of substantial assistance and for personal hygiene the resident had a performance of dependent. Review of the Care Plan for Resident #70 dated 12/14/23 had a focus on the resident is at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The goal was for the resident to have bathing, grooming, toileting, and ADL needs met with assistance from staff through the next review date. The interventions included: Set up for eating, substantial assist for showers, dependent for hygiene, dressing, grooming and toilet needs. Assist as indicated with transfers, ambulation, WC (wheelchair) mobility, bathing/grooming, and meals. Observe for changes in ADL performance and notify physician, therapy, family as indicated. Review of the Care Plan for Resident #70 dated 12/27/23 had a focus on the resident is resistive to care refuses to be changes showers r/t (related to) Anxiety, Dementia. The goal is the resident will cooperate with care through next review date. The interventions included: Allow the resident to make decisions about treatment regime, to provide sense of control. If a resident resists with ADLs, reassure the resident, leave, and return 5-10 minutes later and try again. On 01/22/24 at 7:30 AM, an observation was made of Resident #70 lying in bed with brown matter on top of and under his fingernails. The fingernails extended past the edge of his fingers and had jagged edges. On 01/23/24 8:50 AM, an observation was made of Resident #70 lying in bed with his breakfast tray untouched. Resident #70's fingernails continued to have jagged edges, past the edge of his fingers, with dried brown matter on top of the nails and under the nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 19 of 89 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 01/25/2024 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide toenail care for 1 of 32 sampled residents (Resident #53) reviewed for Foot Care. Residents Affected - Few The findings included: Review of the facility's policy, titled, Nail Care with a reviewed / revised date of 06/07/21, included: The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule and as the need arises. Principles of nail care: Nails should be kept smooth to avoid skin injury. Toenails of residents with diabetes or circulation problems shall be filed only. Procedure included: gently clean underneath nails with an orange stick. Document completion of task, any complications, or if resident refuses. Review of the facility's policy, titled, Skin Integrity - Foot Care with a reviewed / revised date of 07/25/22, included: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot. 3. Interventions for Prevention and to Promote Healing a. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and assessment of any foot ulcers. i. As needed, licensed nurses with adequate training may perform nail care to non-diabetic residents, or diabetic residents who are low risk as determined by podiatrist or physician. ii. Appropriate offloading or orthopedic devices, diabetic shoes, or pressure-relieving devices will be utilized. iii. Referrals to podiatrists, vascular or orthopedic surgeons, or wound care physicians will be made when appropriate. The facility will arrange for transportation to and from any appointments. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility, and Unspecified Hearing Loss Bilateral. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 11/19/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 1, indicating severe cognitive impairment. In (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 20 of 89 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 01/25/2024 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 0687 Level of Harm - Minimal harm or potential for actual harm Section GG, it revealed for toilet hygiene the resident had a performance of partial/moderate assistance, for walking 10 feet, walking 50 feet with two turns and walking 150 feet, the resident had a performance of partial / moderate assistance. Review of the Physician's Orders for Resident #53 revealed no order for a Podiatry consult. Residents Affected - Few Review of the Care Plan for Resident #53 dated 08/18/23 with a focus on the resident is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The goal was for the resident to continue to participate in their ADLs as tolerated daily through the next review date. The interventions included Assist as indicated with transfers, ambulation, wheelchair mobility, bathing/grooming, and meals. Review of the facility's Grievance Logs from 01/01/23 to 01/21/24 revealed no grievance filed by Resident #53 or on his behalf. On 01/22/24 at 7:55 AM, an observation was made of Resident #53's toes. On the left foot, the toenails were extremely long, past the edges of the toes, curled and yellowed. Photographic Evidence Obtained. The observation of the resident's right foot toenail was refused by the resident. An interview was conducted on 01/22/24 at 7:48 AM with Staff E, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 1 month. Staff E acknowledged that Resident #53's right foot toenails were extremely long, curled, and yellowed. When asked how often Resident #53's toenails are cut, she said we don't do that. When asked if the resident had been seen by a podiatrist, she said she did not know. An interview was conducted on 01/22/24 at 9:30 AM with Resident #53's son who stated when he visited his father around November 2023 and at that time his father's toes were very long and looked like they had fungus. When asked if he reported this to staff, he said he spoke to the Administrator. An interview was conducted on 01/25/24 at 11:00 AM with Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. When asked about toenail care for residents, the LPN stated if a resident's toenails are long, the CNAs cut the toenails, maybe twice a week. If toenails are yellowed and crumbly, the CNA will notify the nurse and the nurse will assess the nails and will call the primary physician who would give an order for podiatry consult. Once there is an order for podiatry consultation, the nurse would call the podiatrist to inform him. The podiatrist is in the facility once or twice a week. An interview was conducted on 01/25/24 at 11:30 AM with Staff B, LPN, who stated she has worked at the facility for 1 year. Residents are scheduled to have their toenails cut by the nurse or the podiatrist. When asked if the resident needs an order to have their toenails cut by the podiatrist, she said she was not sure. She further stated she was not sure if each resident is seen by the podiatrist. The nurse can cut the toenails for the residents but if the shape is too hard or the toenails are too thick, they must be seen by the podiatrist, and she would put them on the list to be seen by the podiatrist. The list of residents to be seen by the podiatrist is usually placed behind the nursing station. However, she was unable to locate the list at the time of the interview. An interview was conducted on 01/25/24 at 11:50 AM with Staff A, LPN/Unit Manager (LPN/UM), who stated he has worked at the facility since August / September of 2023. When asked about toenail care for residents, the LPN/UM stated the podiatrist comes to cut the toenails. If a resident has long or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 21 of 89 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 01/25/2024 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 0687 Level of Harm - Minimal harm or potential for actual harm yellow, brittle toenails, the staff would call the Social Service Director (SSD) to put them on the list to be seen by podiatry. For a resident to be seen by the podiatrist, they only have the residents name added to the list by the SSD. When asked if they need an order for a podiatry consult, the LPN/UM stated he has never seen an order put in the chart for a resident to be seen by podiatrist. When asked if Resident #53 has ever been seen by a podiatrist, he was unable to verify the resident had been seen by a podiatrist. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 22 of 89 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 01/25/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to identify and treat the resident with hand contractors for 1 of 1 sampled resident reviewed for range of motion (Resident #79). The findings included: A review of the facility's policy, titled, Use of Assistive Devices, revised on 2/2023, revealed the following: the purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and dignity. The facility will provide assistive devices for residents who need them. The nursing, dietary, social services, and therapy departments will work together to ensure the availability of devices, such as for ordering and replacement. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses that included Dementia, Anxiety, and Dysphagia. The care plan initiated on 06/28/23 revealed Resident #79 had impaired cognitive function and impaired thought process due to his Dementia. In an observation conducted on 01/22/24 at 9:10 AM, Resident #79 was noted in bed. Closer observation showed that his hands were contracted tightly close to his chest. In an observation conducted on 01/24/24 at 4:50 PM, Resident #79 was noted in bed. Closer observation showed that his hands were contracted tightly close to his chest. In an interview with the Rehab Director on 01/24/24 at 5:30 PM, she stated that Resident #79 came into the facility as a hospital contract resident. They were told that Resident #79 was only supposed to be seen by Speech Therapy. Resident #79 was first seen on 06/08/23, and the Occupational Therapist Assessment revealed that he was with maximum assistance for transfer and dependent for all care. The Rehab Director said that the assessment done on 06/08/23 did not mention any hand contractors. In an interview conducted on 01/25/24 at 9:36 AM, with the Rehab Director, she stated that she assessed Resident #79 last night and noticed that his hands clamped tight into a fist. She did not remember seeing him like this in the past. She wanted to see how much movement he had and whether he was able to open both hands into a functional position. According to the Rehab Director, when she opened Resident #79's right hand, he brought his left hand over in a functional position and was trying to push her fingers away from his hands. This showed that Resident #79 does have some active movement. She will further assess to see if he will benefit from splinting and a range of motion program. Review of the Occupational Therapist (OT) Evaluation and Plan of Treatment dated 01/25/24 revealed the following: Resident #79 will be trialed on resting hand splints for tone control, prevent further flexion, and encourage extension of digits in hands and wrists. In preparation for splint use, the therapist will introduce palm guards to begin to accustom the patient to having items in his hands to aid in his transition to tolerate splints. An interview was conducted on 01/25/24 at 1:40 PM with the facility's Medical Director, who stated that he was aware that Resident #79's hands had contractors, and he told staff months ago when he noticed his hands. He was unaware that the facility did not take care of the issue and was under the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 23 of 89 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 01/25/2024 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 0688 impression that the resident was on a restorative program. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 01/25/24 at 2:30 PM with Staff I, Certified Nursing Assistant, who stated that she worked with Resident #79 once in the past. She stated that she remembered noticing that his hands were contracted into fists but did not report it to her supervisor or the rehab department. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 24 of 89 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 01/25/2024 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the residents' environment remained free of accident hazards for 2 of 2 sampled residents reviewed for accident hazards (Residents #25 and #53). The findings included: Review of the facility's policy, titled, Safe and Homelike Environment with a reviewed/revised date of 04/11/23, included: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of the facility's policy, titled, Administration of Injections with a reviewed/revised date of September 2023, included Practices to prevent injuries: Dispose of sharps in puncture-resistant containers near the point of use. 1. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included: Age-Related Nuclear Cataract, Bilateral, Anxiety Disorder, and Mild Intellectual Disabilities. The Minimum Data Set (MDS) assessment for Resident #25 dated 12/16/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) assessment was not attempted due to resident is rarely / never understood. Section GG revealed for personal hygiene the resident is dependent on staff. Review of the Care Plan for Resident #25 dated 06/01/23 with a focus on the resident having an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) confusion and impaired mobility. The goal was to maintain the current level of function through the review date. The interventions included: Set up for eating. Dependent for hygiene, dressing and shower. Review of the Care Plan for Resident #25 dated 06/01/23 with a focus on the resident is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness. Resident wanders aimlessly, significantly intrudes on the privacy or activities (of others). The goal was for the resident's safety to be maintained through the review date. The interventions included: Redirect resident from other resident's room. Review of the Care Plan for Resident #25 dated 06/12/23 with a focus on the resident has the following behavior problem(s) combative and aggressiveness. The goal was to have fewer episodes of disruptive behavior through the next review date. The interventions included: Intervene as necessary to protect the rights and safety of others. Redirect resident as necessary. Review of the Care Plan for Resident #25 dated 12/06/23 with a focus on the resident is/has potential to be physically aggressive r/t dementia, poor impulse control. Resident has physical behavioral symptoms toward others and staff such as striking out, propels w/c (wheelchair) without avoiding personal spaces of others, and undresses self in inappropriate areas. Resident does propel self in corners and in different room he is able to lock and unlock his own brakes, will sometimes refuse meals, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 25 of 89 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 01/25/2024 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 [NAME] aggressively when agitated, resident showing increased behaviors restlessness, grabbing others, grabbing others food, medications adjusted, 9 swats at nurse while attempting to give him medication, throws food, drinks, grabs food from others or tray carts. The goal was for the resident to not harm self or others through the review date. The interventions included: When resident becomes agitated: intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Residents Affected - Some On 01/22/24 at 8:18 AM, an observation was made in the bathroom for Resident #25 of 3 safety razors in the bathroom cabinet. Photographic Evidence Obtained. On 1/22/24 at 3:00 PM, an observation was made in the bathroom for Resident #25 of 3 safety razors in the bathroom cabinet. On 01/23/24 at 9:00 AM, an observation was made in the bathroom for Resident #25 of 3 safety razors in the bathroom cabinet. During an environmental tour conducted on 01/24/24 at 1:30 PM with the Director of Plant Operations, the Director of Maintenance (DOM), and the Maintenance Assistant (MA), they acknowledged the 3 safety razors in the unlocked bathroom cabinet for Resident #25. An interview was conducted on 01/25/24 at 10:30 PM with Staff D, Certified Nursing Assistant (CNA), who stated she has been working at the facility for 2 months. When asked about razors, the CNA stated if a resident needs a razor the nurse will have to get the razor to give to the CNA, so the CNA can shave the resident. The razors are never left with the resident or in the resident's room. Once the razor is used it is disposed of in one of the sharp containers, which are in the shower rooms. There are 2 shower rooms on the first floor that are utilized for residents. Shower rooms are locked at all times and residents are never left in the shower rooms unattended. An interview was conducted on 01/25/24 at 11:00 AM with Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. When asked about razors, the LPN stated the nurses get the razors and only give them to a CNA to shave the resident. The LPN said the CNA is responsible for disposing of the razor after use. An interview was conducted on 01/25/24 at 11:30 AM with Staff B, LPN, who stated she has worked at the facility for 1 year. When asked about razors, the LPN stated she will get the razor for a CNA to shave the resident and the CNA disposes of the razor after use. An interview was conducted on 01/25/24 at 11:50 AM with Staff A, LPN/Unit Manager (LPN/UM), who stated he has worked at the facility since August/September of 2023. When asked about razors, the LPN/UM stated residents cannot have razors in their rooms. We [staff] shave the residents. Razors are disposed of after 1 use. This is a memory unit, and the residents are cognitively impaired. The LPN/UM stated he does rounds each day of each of the residents' rooms to make sure each resident is okay, and the residents' rooms are safe. Staff A had no response about the razors being found in Resident #25's bathroom cabinet. 2. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility, and Unspecified Hearing Loss Bilateral. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 26 of 89 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 01/25/2024 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 - Some Review of the MDS for Resident #53 dated 11/19/23 revealed in Section C, a BIMS score of 1, indicating severe cognitive impairment. In Section GG, it revealed for toilet hygiene the resident had a performance of partial / moderate assistance, for walking 10 feet, walking 50 feet with two turns and walking 150 feet, and the resident had a performance of partial/moderate assistance. Review of the Care Plan for Resident #53 dated 06/06/23 with a focus on the resident is at risk for elopement as evidenced by resident currently on memory unit has verbalizations of wanting to go home. Resident can usually be redirected. Can resist care at times showers and wander. The goals were for the resident's safety will be maintained through the next review date and the resident will not leave facility unattended through the next review date. The interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers music, talking about fishing and hunting. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something: Does it indicate the need for more exercise? Intervene as appropriate. Review of the Care Plan for Resident #53 dated 06/06/23 with a focus on the resident has behavioral symptoms not directed to others per spouse has history of sitting himself on floor and even laying on floor at times. Per spouse resident has had episodes of aggressive behavior. Resident has been noted laying himself on the floor in his room beside his bed. The goal was to not harm self and/or others secondary to socially inappropriate and/or disruptive behavior. The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Explain all procedures to the resident before starting and allow the resident to adjust to changes. Review of the Care Plan for Resident #53 dated 06/06/23 with a focus on the resident has impaired decision-making r/t diagnosis of Dementia, speaks in low voice memory impaired long and short resident is able to answer simple questions and can make simple needs known. The goal was to maintain current level of cognitive function through the review date. The interventions included: Ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Review of the Care Plan for Resident #53 dated 08/18/23 with a focus on the resident is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The goal was to continue to participate in their ADLs as tolerated daily through the next review date. The interventions included: Independent for eating, supervision/touch assist for dressing, partial/moderate assist for hygiene, showers. Transfers independently. On 01/22/24 at 7:45 AM, an observation was made of Resident # 53 in his room and upon opening Resident #53's bathroom there was an overwhelming urine smell, the toilet was closed with plastic over it. On 01/22/24 at 7:55 AM, an observation was made in Resident #53's room of a white uncovered bin with magazines, unused briefs, loose disposable gloves, items of clothing and a spray bottle of fabric spray. Photographic Evidence Obtained. During an interview conducted on 01/22/24 at 7:48 AM with Staff E, Certified Nursing Assistant (CNA), she stated she has worked at the facility for 1 month. When asked about the bottle fabric spray in the uncovered bin, she said she was not sure about that, but acknowledged that the bottle of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 27 of 89 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 01/25/2024 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 fabric spray was in Resident #53's room. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 28 of 89 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 01/25/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to identify significant weight loss in a timely manner; and failed to provide nutritional intervention to prevent weight loss for 3 of 5 sampled residents reviewed for weight loss (Resident #55, Resident #57, and Resident #86). Residents Affected - Few The findings included: Review of the facility's policy, titled, Weight Monitoring, revised on 11/30/23, revealed the following: It is the policy of the facility to minimize the risk of a resident's significant weight loss and for residents to maintain acceptable parameters of nutritional status. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes identifying and assessing each resident's nutritional status and risk factors and evaluating/ analyzing the assessment information. Developing and consistently implementing pertinent approaches, monitoring the effectiveness of interventions, and revising them as necessary. The newly recorded resident weight should be compared to the previously registered weight. A significant change in weight is defined as a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) C. 10% change in weight in 6 months (180 days). 1. Record review revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses to include Dysphagia, Type 2 Diabetes, and Depression. The Order Summary Report showed the following orders: low concentrated sweets, regular texture with large protein at meals (dated 08/16/23), and Glucerna (nutritional supplement) once a day for weight loss, dated 11/21/23. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #55 had a Brief Interview of Mental Status (BIMS) score of 03, indicating severely cognitively impaired. Further review of physicians' orders revealed an order for Med Pass (high nutritional supplement) two times a day for those at risk for malnutrition for 45 days, which started on 08/16/23 and stopped on 09/30/23. In an observation conducted on 01/24/24 at 8:44 AM, Resident #55 ate his breakfast meal independently. The meal ticket revealed the following: low concentrated sweet, large protein, one serving of omelet, and 1 ounce of sausage patty. Observation of the breakfast plate showed one piece of sausage patty (regular serving) and one serving of a baked omelet (standard serving). In this observation, Resident #55 first ate one serving of omelet and then the sausage patty. In an observation conducted on 01/24/24 at 12:24 PM, Resident #55 was eating his lunch meal. Closer observation showed that he received 8 ounces of shepherd's pie (regular serving) and 4 ounces of corn. Resident #55 was observed enjoying the food on his lunch tray and consumed 100% of his meal. The Weights and Vitals Summary revealed the following weights recorded: 183.8 pounds on 04/06/23, 179.6 pounds on 05/16/23, 175.4 pounds on 06/04/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 29 of 89 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 01/25/2024 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 0692 171.6 pounds on 07/04/23, Level of Harm - Minimal harm or potential for actual harm 168.2 pounds on 08/03/23, 165.2 pounds on 09/05/23, Residents Affected - Few 166.3 pounds on 10/01/23, 159.3 pounds on 11/04/23, 158.6 pounds on 11/08/23, 154.2 pounds on 12/03/23, 152.6 pounds on 01/04/24. The above weights revealed 10.1 percent (%) severe weight loss in 6 months from 04/06/23 to 09/05/23 and 8.2% severe weight loss in 3 months from 10/01/23 to 01/04/24. A nutritional progress note dated 10/18/23 showed that Resident #55 was on a regular large protein diet and receiving nutritional supplements as ordered. This note did not address the severe 10.1% severe weight loss in 6 months from 04/06/23 to 09/05/23. It was further noted that Resident #55 was receiving nutritional supplements, which were discontinued on 09/30/23. One month later, a weight change note dated 11/20/23 revealed that Resident #55 continued to trigger significant weight loss with a current weight of 158.6 pounds. Resident #55 was provided with a large amount of protein for each meal. In this note, Staff O, Registered Dietitian, recommended providing one can of Glucerna once a day to promote weight stability. A follow-up nutrition note dated 12/11/23 revealed a recent weight of 154.2 pounds (4.4 pounds of further weight loss). Resident #55's intake of meals fluctuated, but no other nutritional interventions were made at this time. In an interview conducted on 01/24/24 at 11:25 AM, Staff O stated that the follow-up nutrition note on 10/18/23 was completed by the Certified Dietary Manager (CDM), who only comes to the facility once time a week, and the CDM will follow up on all residents when needed. Staff O confirmed that the 10.1% severe weight loss was not addressed by the CDM in her note on 10/18/23. When asked by the surveyor as to why she ordered only one can of Glucerna a day, she said that this is what Resident #55 agreed to take. Staff O reported that weekly weights are done for residents with significant weight loss. Staff O further stated that all nutritional supplements have a duration period and stop dates when entered into the electronic system. Once the order is completed, the system will not trigger reminders to reorder the supplements again. 2. Record review revealed Resident #57 was readmitted to the facility on [DATE] with diagnoses of Dysphagia, Alzheimer's Disease, and Muscle Weakness. Review of the physician's orders showed the following: On 07/31/23, a mechanical soft diet, pureed meats, pureed vegetables, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 30 of 89 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 01/25/2024 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 0692 On 11/14/23, fortified foods, Level of Harm - Minimal harm or potential for actual harm On 01/09/24, house shake (nutritional supplement) 3 times a day. Residents Affected - Few In an observation conducted on 01/24/24 at 8:33 AM, Resident #57 was observed in the main dining room on the 1st floor. In this observation, Staff T, Certified Dietary Assistant, was sitting near Resident #57, and assisted her with her breakfast meal. An interview was conducted with Staff T on 01/24/24 at 8:37 AM who stated that Resident #57 eats between 80% and 100% of her meals and she needed extensive assistance with all her meals. In an observation conducted on 01/24/24 at 12:19 PM, Resident #57 was noted eating her lunch in the 1st-floor dining room. Closer observation showed Staff U, Activity Aide, sitting near Resident #57, assisting her with the lunch meal. In this observation, Staff U said Resident #57 eats between 80% and 100% of all meals. The Weights and Vitals Summary revealed the following: 118.2 pounds dated 10/23/23, 115.3 pounds on 10/29/23, 110.7 pounds on 11/04/23, 109.4 pounds on 11/08/23, 110.9 pounds on 12/03/23, 103.7 pounds on 01/14/24, 101.6 pounds on 01/21/24. A weight change nutrition follow-up note dated 11/13/23 revealed the following: Resident #57 was triggered for significant weight loss of 6% in 30 days. It was recommended to provide fortified foods with all meals to promote weight gain and monitor weekly weights (which was not done). A weight change progress note dated 01/09/24 revealed that Resident #57 triggered significant weight loss of 7.2% in 1 month and 12.2% in 3 months. Resident #57's Ideal Body Weight (IBW) was noted at 115 pounds. In this note, Staff O recommended providing a house shake three times a day and that the weight loss was unplanned and unfavorable. The care plan dated 12/09/23 revealed that Resident #57 was experiencing a nutritional decline related to clinical conditions. Resident #57 will be free of all unavoidable significant weight changes. In an interview conducted on 01/24/24 at 11:08 AM, Staff O stated that Resident #57 had a severe weight loss of 6.5% from 10/23/23 to 11/08/23. Fortified foods were ordered on 11/14/23, which was six days later. When asked why she only provided fortified foods and not nutritional supplements, she said that Resident #57 was on dietary supplements in the past, which she had refused. She offered a house shake three times a day, only on 01/09/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 31 of 89 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 01/25/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm 3. Record review revealed Resident #86 was admitted to the facility on [DATE] with diagnoses that included Parkinsons, Dementia, and Depression. The Quarterly MDS dated [DATE] revealed a BIMS score of 04, indicating severe cognitive impairment. Review of the Physician's orders showed the following: Residents Affected - Few 12/04/23, regular texture diet with fortified foods with meals, 12/05/23, Med Pass at bedtime for weight loss once a day. This was ordered a month after 9.9% significant weight loss was identified on 11/08/23. In an observation conducted on 01/23/24 at 5:13 PM, Resident #86 was in her room with the dinner tray. In this observation, Resident #86 stated that her appetite is picking up. In an observation conducted on 01/24/24 at 8:40 AM, Resident #86 was noted eating her breakfast tray in her room. Closer observation showed a meal plate consisted of one serving of omelet, sausage patty, one slice of toast, 8 ounces of milk, and 6 ounces of hot cereal. Resident #86 ate all of her eggs, toast, and sausage but did not eat any hot cereal or drink any milk. In this observation, Resident #86 was asked why she did not eat any hot cereal or drink any milk. She responded, I am done eating, and I do not like the milk. Resident #86 was shaking and constantly having body movements during this entire observation. No fortified food was noted on the meal ticket or the meal plate. In an observation conducted on 01/24/24 at 12:27 PM, Resident #86 was in the room eating her lunch meal. Closer observation showed 8 ounces of Sheperd's pie, 4 ounces of corn, one serving of dinner roll, and 4 ounces of Sherbert. No fortified food item was noted on the lunch tray or the meal ticket. The Weights and Vitals Summary revealed the following weights for Resident #86: 131.6 pounds on 07/04/23, 118.4 pounds on 11/04/23, 112.4 pounds on 12/03/23, 112.6 pounds on 12/26/23 115.4 pounds on 01/03/23. This showed that Resident #86 lost 14.6% in less than six months from 07/04/23 to 12/3/23 and 9.9% weight loss in 4 months from 07/04/23 to 11/08/23. Review of a weight change note dated 12/04/23 revealed that Resident #86 consumes less than 50% of her meals. Underweight for age range with goal of gradual weight gain. It further showed recommendations for fortified foods (which were not provided) and house supplements three times a day. In an interview conducted on 01/24/24 at 10:08 AM, Staff O stated that fortified foods are foods with added calories provided on meal trays. It is grits / oatmeal; for lunch and dinner, it is mashed potatoes or pudding. If a resident's intake of meals is documented, she cannot tell if the intake of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 32 of 89 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 01/25/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the food items was from the regular food items or the fortified food items on the tray. Staff O said that some nutritional supplements (house shakes, magic cups, mighty shakes) are placed on the meal tray and are entered in the diet order under general directions. This is why she cannot tell the percent intake that is consumed for these nutritional supplements. When asked how often nutrition progress notes are completed, she said as needed or for any significant changes. Staff O further stated that she runs a report on weekly weights to identify any substantial changes in weights. Event ID: Facility ID: 105428 If continuation sheet Page 33 of 89 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 01/25/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow physician orders for tube feedings, for 2 of 2 sampled residents reviewed for tube feedings (Resident #58 and Resident #34). The findings included: Review of the facility policy, titled, Care and Treatment of Feeding Tubes, revised on 11/27/23, revealed in part the following: 'Direction for staff regarding nutritional products and meeting the residents' nutritional needs will be provided, how to determine whether the tube feedings meet the resident's needs, and when to adjust them accordingly-ensuring that the selection and use of enteral nutrition is consistent with manufacturer's recommendations-ensuring that the administration of enteral nutrition is compatible with and follows the practitioner's orders. Feeding tubes will be utilized according to physician orders, which typically include the kind of feeding and its caloric value, volume, duration, mechanism of administration, and flush frequency. The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs.' Review of the facility's policy, titled, Weight Monitoring, revised on 11/30/23, revealed, in part, that 'newly admitted residents monitor weight weekly for four weeks, residents with significant weight loss, the Registered Dietitian determines the frequency of obtaining weights, and all others, monitor weight monthly'. 1. Record review documented Resident #58 was readmitted on [DATE] with diagnoses to include Gastrostomy, Dementia and Sepsis. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #58's cognitive status was impaired. Review of the Physician's orders revealed the following: one time a day for nutritional support, Jevity 1.5 (tube feeding formulary) to be administered at 55 ml an hour for 20 hours with a start time at 2:00 PM and stop time at 10:00 AM, which was discontinued on 01/24/24. In an observation conducted on 01/23/24 at 3:10 PM, Resident #58 was not in the room. Closer observation showed a tube feeding bag, which was dated 01/23/24 and had a start time of 1:45 AM. The tube feeding was noted with Jevity 1.5 (tube feeding formulary) at 55 milliliters (ml) an hour. The tube feeding bag was at the 400 ml mark out of a 1000 ml capacity bottle. An interview was conducted on 01/23/24 at 3:15 PM, with Staff R, Registered Nurse (RN), who stated she arrived at the facility at 6:45 AM this morning and did not touch the tube feeding bag or replace it. Staff R stated the tube feeding was started by the night nurse. Staff R stated she had stopped the tube feeding at 8:30 AM this morning because Resident #58 was walking around the facility with the tube feeding connected. An interview was conducted on 01/23/24 at 3:19 PM with Staff J, Unit Manager, who stated that for tube feeding orders, the nurses would take the tube feeding bottles from the supply room and the set-up kit, which consists of the tube feeding kit and the water kit. The tube feeding formula is then poured into the bag and added to the top level around the 1000 ml level. Some residents' tube feedings may be held for 4 hours for social time and activities. Staff J said that once the tube feeding bag is started, it is only touched or refilled once it is completed and a new tube feeding bag is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 34 of 89 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 01/25/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few replaced. When the tube feeding bag is started, they will write the start time, date, name of the resident, name of formulary, and the rate. When asked about the time that is written on the tube feeding bag, she said that it is the actual time that the tube feeding was hung and started. In an observation conducted on 01/24/24 at 8:57 AM, Resident #58's tube feeding was observed to be set with Jevity 1.5 at 55 ml an hour. The tube feeding showed that it started this morning at 6:25 AM by the 11 PM to 7 AM nurse. The tube feeding bag was noted at the 350 ml mark out of the 1000 ml capacity bottle. In this observation, Staff R was asked if she was the one who started the new bag of tube feeding this morning, and she said no. Staff R further said that it was the night nurse who started the tube feeding bag. The surveyor questioned the tube feeding bag observed at the 350 ml mark when the new bag was only started at 6:25 AM. Staff R stated that maybe the night nurse did not fill the bag to capacity level but could not say for sure. In an observation conducted on 01/24/24 at 2:47 PM, Resident #58 was noted in bed. Closer observation showed the same tube feeding bag that was observed earlier was still noted at the 350 ml mark. The Weights and Vitals Summary revealed the following weights for Resident #58 as follows: 153.6 pounds on 01/04/24, 149.4 pounds on 01/18/24, 145.4 pounds on 01/21/24. This showed a significant weight loss of 5.3% in less than one month. There were no weights obtained or documented weekly for the first three weeks from the readmission on Resident #58. Review of a 'weight change note', dated 01/08/24, revealed Resident #58 had 'a significant weight loss for the last two months. The weight loss's etiology was unknown, and the current tube feeding was meeting nutritional needs.' Review of the nutrition progress note dated 01/22/24 revealed that Resident #58 had 8.2 pounds weight loss in 3 weeks. A goal should be in place for gradual weight gain to Ideal Body Weight (IBW). In this note, Resident #58 tube feeding was increased to Jevity 1.5 at 60 ml an hour running at 20 hours. An interview was conducted on 01/24/24 at 4:18 PM with Staff O, Registered Dietitian, who stated that when she identified the significant weight loss on 01/22/24, she increased the tube feeding order from 55 ml an hour to 60 ml an hour. When the surveyor asked why the new tube feeding rate of 60 ml only started today, she said that nursing thought the order was a mistake and changed it back to 55 ml an hour. Staff O said that she spoke to nursing staff and that the tube feeding order was changed back to 60 ml an hour to meet the resident's nutritional needs better. 2. Resident #34 was readmitted to the facility on [DATE] with diagnoses that included Gastrostomy, Psychotic disturbances, and Dementia. In an observation conducted on 01/22/24 at 9:30 AM, Resident #34 was noted in the room with the tube feeding Jevity 1.2 (tube feeding formulary) running at 60 milliliters (ml) an hour. Closer observation showed that the tube feeding bag was started on 01/22/24 at 2:45 AM. The tube feeding bag was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 35 of 89 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 01/25/2024 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 0693 noted at the 1000 ml mark out of the 1000 ml capacity bottle. Level of Harm - Minimal harm or potential for actual harm An observation conducted on 01/22/24 at 4:14 PM showed that Resident #34 was in her bed with the tube feeding running at 60 ml an hour. Closer observation showed the same tube feeding bag that was observed earlier in the day was at the 800 ml mark out of the 1000 ml capacity bottle. This showed that only 200 ml of tube feeding was administered from 9:30 AM to 4:14 PM. Residents Affected - Few In an observation conducted on 01/23/24 at 8:28 AM, Resident #34 was noted in the room with the tube feeding Jevity 1.2 running at 60 ml an hour. The tube feeding bottle was started on 01/23/24 at 12:30 AM today. Closer observation showed that the tube feeding bottle was still at the 1000 ml mark out of the 1000 ml capacity bottle. An interview was conducted on 01/23/24 at 9:42 AM with Staff L, Licenses Practical Nurse, who stated that Resident #34 tolerates her tube feeding very well. Staff L reported that the tube feeding bag was replaced last night by the 11 PM to 7 AM shift, and she did not touch the tube feeding bag or replace it when she came this morning. According to Staff L, once the tube feeding bag is filled to the top and started, it is not touched or changed until the entire tube feeding bag is completed. In an observation conducted on 01/23/24 at 3:12 PM, Resident #34 was noted in her room. The tube feeding was noted with Jevity 1.2 tube feeding formulary running at 60 ml an hour. The tube feeding bag showed that it was started on 01/23/24 at 2:00 PM and was filled all the way to the top, passing the 1000 ml level. In an observation conducted on 01/24/24 at 9:00 AM, Resident #34 was noted in the room with the tube feeding running at 60 ml an hour. The tube feeding showed a start date of 01/24/24 at 4:45 AM. Closer observation showed that the tube feeding bag was at the 300 ml mark of the 1000 ml capacity bag. Review of the Physicians' orders showed the following orders: On 12/31/23, an order for enteral feeding with Jevity 1.2 continuous at 60 ml an hour for 24 hours. On 01/05/24, Start tube feeding at 2:00 PM for 20 hours in the afternoon. A On 01/05/24, to stop feeding for 4 hours. On 12/31/23, an order documented Nothing by Mouth (NPO), with the exception of Speech Therapist, introduced Food/Fluids consistency for enteral feeding which, and was discontinued on 01/23/24. Record review of Resident #34's recorded weights showed the following: 134.0 pounds on 01/05/24, 128.6 pounds on 01/14/24, 129.6 pounds on 01/21/24. Review of the Speech Therapist's note dated 01/16/24 showed the following: communication with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 36 of 89 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 01/25/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nutritionist for a plan of beginning one meal a day and the best time to do that according to peg feeding times. To follow up tomorrow with her since her computer was being repaired today. Trials of whole pureed meal and thin water. The Resident consumed 50% of the meal with partial feeding by the clinician. A nutrition note completed by Staff O, dated 01/24/24, revealed the following: to change tube feeding to Jevity 1.5 (tube feeding formulary) at 60 ml an hour for 20 hours. This note should have mentioned communication between Staff O and Staff X, the Speech Therapist, regarding Resident #34 starting on a regular pureed diet consistently one time a day for lunch. In an interview conducted on 01/24/24 at 1:42 PM, Staff L stated that Resident #34's tube feeding orders are to start at 2:00 PM and to stop at 10:00 AM the following day. The tube-feeding bottles are poured into a new tube-feeding bag and filled all the way to the top around the 1000 ml capacity line. The tube feeding bags are then labeled with the name, room number, formulary, rate, time it started, and the date it started. She will speak to the unit manager if she sees any discrepancy in the tube feeding orders. In an observation conducted on 01/24/24 at 2:21 PM, Resident #34 was observed at the nurse's station. A tube feeding bag was hanging in the room pretimed at 2:00 PM, but not running. In this observation, Staff L said that she hung the bag, timed it, and labeled it 5 minutes before her interview earlier, which was at 1:42 PM. In an interview conducted on 01/24/24 at 4:36 PM, Staff O said she remembered having a verbal conversation with the Speech Therapist regarding starting Resident #34 with trials of diet by mouth. She tried contacting the Speech Therapist the next day (after the note was written on 01/16/24) but did not reach her. The surveyor addressed concerns regarding the communication between the dietary department and the Speech Therapist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 37 of 89 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 01/25/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record and policy review, the facility failed to maintain respiratory equipment in a sanitary manner for 1 of 1 sampled resident reviewed for respiratory care (Resident #58). Residents Affected - Few The findings included: The facility's policy, titled, Nebulizer Therapy revised 05/04/22, revealed, in part, Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag or plastic bag, change nebulizer tubing weekly or as needed. Review of the record revealed Resident #58's most recent readmission to the facility was on 01/16/24, with diagnoses that included Respiratory Failure, Obstructive Uropathy and Non-Alzheimer's Dementia. Record review revealed the resident receives Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (milligrams per milliliter) via nebulizer every 4 hours. A nebulizer is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. On 01/22/24 at 8:00 AM, an observation was made of a nebulizer device on a chair in Resident #58's room. Further observation revealed the nebulizer device that was placed on the chair was not covered, and the tubing was not labeled. Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 38 of 89 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 01/25/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Side Rail Evaluation for Resident #58, with an effective date of 01/17/24 revealed Side rails not indicated. Review of the resident's Medicare A 5-day scheduled assessment with a target date of 01/06/24 revealed: Section C, the resident is rarely/never understood; and Section P: Bed rail not used. On 01/24/24 at 2:20 PM, an observation was made of Resident #58 in bed with both siderails up. 3. Resident #153 was admitted to the facility on [DATE] post hospitalization. Review of Resident #153's current active physician orders as of 01/25/24 revealed no order for siderails. On 01/25/24 at 9:41 AM, an observation was made of Resident #153 in bed with the siderail on the resident's right side in the up position. An interview was conducted with the Social Worker on 01/25/24 at 1:30 PM regarding siderail use in the facility. The Social Worker stated in June 2023 when the new company took over, they wanted to be siderail free, but this has not been finalized yet. An observation was made by this surveyor throughout the survey process of different types of beds on the second floor. Some beds had controls on the siderails, and some did not. Based on observations, interviews, and record review, the facility failed to assess residents for bedrail use for 1 of 32 sampled residents (Resident #11) reviewed for bedrail use; and failed to follow recommendations of bedrail assessments for 2 of 32 sampled residents (Residents #58 and #153) reviewed for bedrail use. The findings included: Review of the facility's policy, titled, Proper Use of Bed Rails with a reviewed / revised date of 07/25/22, included: If bed rails are used, the facility ensures correct installation, use and maintenance of the rails. Under the Section: Ongoing Monitoring and Supervision included: As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 39 of 89 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 01/25/2024 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 0700 c. Level of Harm - Minimal harm or potential for actual harm Sleep habits d. Residents Affected - Few Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility (in and out of bed) l. Risk of falling The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including but not limited to, the following information: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 40 of 89 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 01/25/2024 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 0700 a. Level of Harm - Minimal harm or potential for actual harm The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring. Residents Affected - Few b. The identification of how needs will be met during use of the bed rails, such as for re-positioning, hydration, meals, use of the bathroom and hygiene. c. Ongoing assessment to assure that the bed rail is used to meet the resident's needs: d. Ongoing evaluation of risks. e. The identification of who may determine when the bed rail will be discontinued f. The identification and interventions to address any residual effects of the bed rail (e.g. generalized weakness, skin breakdown). 1. Record review for Resident #11 revealed the resident was admitted to the facility on [DATE] with a diagnoses that included Dementia, Abnormalities of Gait and Mobility, Anxiety Disorder, Muscle Weakness (Generalized), and Other Lack of Coordination. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 11/09/23 revealed in Section C, a Brief Interview of Mental Status score of 2, indicating severe cognitive impairment. Section GG revealed for all areas for mobility the resident had a performance of independent except for lying to sitting on side of bed the resident had a performance of needing setup of clean-up assistance. Review of the Care Plan for Resident #11 dated 08/13/23 with a focus on the resident is at risk for decreased ability to perform ADLs (Activities of Daily Living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to impaired cognition. The goal was to continue to participate in their ADLs as tolerated daily through the next review date. The interventions included: 1/4 side rail x1 for bed mobility. Assist with transfers as needed. Review of Resident #11's Electronic Medical Record (EMR) revealed no assessment for bedrails. On 01/22/24 at 10:21 AM, an observation was made of Resident #11 lying in bed with the left side bedrail in the up position. The mattress was askew with the widest point between the mattress and the side rail of approximately 4 inches. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 41 of 89 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 01/25/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 01/25/24 at 11:00 AM with Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. The LPN stated most of the resident beds have at least 1 siderail. The nurse assesses the resident for siderail safety, there is an assessment in the computer, but she has not had to complete the assessment form because those were done for the resident before she started working at the facility. If there is an incident that happens such as a fall, then she would have to reassess for the side rails but that has not happened. An interview was conducted on 01/25/24 at 11:30 AM with Staff B, LPN, who stated she has worked at the facility for 1 year. When asked about bedrails, she stated this floor does not use siderails (bedrails). She said all of the beds on this floor that have siderails (bedrails) are all down (in the down position) unless they are on seizure precautions. When asked if they monitor or assess for the bedrails, she said yes, but most of those residents are ambulatory and we just check on the resident every 2 hours. She said they check every morning during rounds to see if the bed is okay. When asked about documentation regarding bedrails, she said if the bed is okay and you have a reason to put in a nursing note for a resident, you can document it in the note. If the siderail (bedrail) is not okay, she would put it on the sheet for maintenance to check or she may call maintenance also to alert them of the issue. An interview was conducted on 01/25/24 at 11:50 AM with Staff A, LPN Unit Manager (LPN/UM), who stated he has worked at the facility since August or September 2023. When asked about bedrails, he said, 'what do you mean'. When asked if beds have bedrails, he said, 'no'. He said very few beds have a siderail (bedrail). The only beds with a siderail are the beds that have the control incorporated into the siderail. When asked if the residents are assessed for bedrails he said, 'yes, upon admission and an assessment for siderails are completed in the residents' chart. When asked if the bedrails are monitored, he stated, 'yes, we nurses walk around and look at the beds'. When asked where the documentation of the monitoring of bedrails is, he said, 'no, we do not document that'. When asked if maintenance inspects the beds, mattresses, or bedrails, he said, 'he has never seen that'. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 42 of 89 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 01/25/2024 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to maintain the daily posted nurse staffing information, as observed during the survey week. Residents Affected - Few The findings included: Upon entering the facility on 01/22/24 at 7:00 AM, the surveyors did not observe that the 'daily nurse staffing' was posted at the front desk. Throughout the first day of the survey on 01/22/24 from 7:00 AM until approximately 6:30 PM, the surveyors did not observe that the 'daily nurse staffing' in the facility was posted. Throughout the day on 01/23/24 and 01/24/24, the surveyors continued to not see the daily posted nurse staffing at the front desk or anywhere else in the facility. An interview was conducted on 01/24/24 at 2:37 PM with the facility's Nurse Staffing Development Coordinator. She stated the daily staffing numbers are to be posted daily at the front desk. The surveyor and the Nurse Staffing Development Coordinator walked to the front desk together and saw that the sign containing the daily staffing numbers was located behind the front desk, not visible to residents and visitors, and the paper inside the sign was dated 01/23/24. At that time, the receptionist stated the staffing had not been updated for the day and that she had told the Staffing Coordinator that morning. An interview was conducted on 01/24/24 at 2:40 PM with the facility's Staffing Coordinator. She confirmed she was responsible for updating the posted staffing daily and that she had not been able to change the posting for that day. The surveyor asked to see the posted staffing sheets from the two weeks prior to ensure she had been up to date on this task. After approximately 10 minutes, the Staffing Coordinator was only able to produce 3 posted staffing sheets, dated 01/22/24, 01/03/24, and 12/26/23. She was unable to provide a reason for why the other sheets were not found. An interview was conducted on 01/24/24 at 2:56 PM with the facility's Director of Nursing. The surveyor explained the above concern and she stated she understood. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 43 of 89 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide physician ordered medications to one (Resident #3) of three residents sampled for pharmacy services. Findings included: A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of dementia, cerebral infarction, cognitive communication deficit, seizures, and depression. A review of Resident #3's physician's orders summary revealed the following medication orders: - An order, dated 2/13/2024, for lacosamide 200 milligrams (mg), one tablet by gastric tube (GT) two times a day (9:00 AM and 5:00 PM) for seizures. The order remained active until 3/25/2024. - An order, dated 3/25/2024, for lacosamide 10 mg per milliliter (ml), give 10 ml GT two times (6:00 AM and 6:00 PM) a day for seizures. - An order, dated 2/13/2024, for phenobarbital 100 mg GT one time a day at bedtime (9:00 PM) for seizures. The order remained active until 4/1/2024. A review of Resident #3's Medication Administration Record (MAR) for March 2024 revealed the following related to Resident #3's order for phenobarbital 100 mg GT one time a day at bedtime for seizures: - No documentation of administration on 3/2/2024 and 3/10/2024. - A documented code of 41 on 3/14/2024. The Chart Codes section of the MAR revealed 41=Behavior / Side Effect Did Not Occur. - A documented code of 5 on 3/15, 3/21, and 3/22/2024. The Chart Codes section of the MAR revealed 5=Hold/ See Progress Notes. - A documented code of 9 on 3/16, 3/17, 3/26, 3/27, 3/29, and 3/31/2024. The Chart Codes section of the MAR revealed 9=Other / See Progress Notes. - The medication was documented as administered on 3/1, 3/3, 3/4, 3/5, 3/6, 3/7, 3/8, 3/9, 3/11, 3/12, 3/13, 3/18, 3/19, 3/20, 3/23, 3/24, 3/25, 3/28, and 3/30/2024. A review of Resident #3's MAR for March 2024 revealed the following related to Resident #3's order for lacosamide 200 mg, one tablet GT two times a day (9:00 AM and 5:00 PM) for seizures: - No documentation of administration on 3/2/2024 at 5:00 PM and 3/10/2024 at 5:00 PM. - A documented code of 9 for the 9:00 AM dose on 3/3, 3/4, 3/5, 3/10, 3/12, 3/14, 3/16, and 3/21/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 44 of 89 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 01/25/2024 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 0755 - A documented code of 9 for the 5:00 PM dose on 3/5, 3/9, 3/15, and 3/16/2024. Level of Harm - Minimal harm or potential for actual harm - A documented code of 5 for the 9:00 AM dose on 3/7, 3/9, 3/13, 3/17, 3/18, 3/22, and 3/23/2024. - A documented code of 5 for the 5:00 PM dose on 3/6, 3/7, 3/8, 3/17, 3/21, and 3/22/2024. Residents Affected - Few - A documented code of 2 for the 9:00 AM dose on 3/25/2024. The Chart Codes section of the MAR revealed 2=Drug Refused. - The medication was documented as administered for the 9:00 AM dose on 3/1, 3/2, 3/6, 3/11, 3/15, 3/19, 3/20, and 3/24/2024 and for the 5:00 PM dose on 3/1, 3/3, 3/4, 3/11, 3/12, 3/13, 3/14, 3/18, 3/19, 3/20, 3/23, and 3/24/2024. A review of Resident #3's MAR for March 2024 revealed the following related to Resident #3's order for lacosamide 10 mg per ml, give 10 ml GT two times (6:00 AM and 6:00 PM) a day for seizures: - A documented code of 9 for the 6:00 AM dose on 3/27 and 3/31/2024. - A documented code of 9 for the 6:00 PM dose on 3/26, 3/27, and 3/31/2024. - The medication was documented as administered for the 6:00 AM dose on 3/26, 3/28, 3/29, and 3/30/2024 and for the 6:00 PM dose on 3/25, 3/28, 3/29, and 3/30/2024. A review of Resident #3's MAR for April 2024 revealed the following related to Resident #3's order for lacosamide 10 mg per ml, give 10 ml GT two times (6:00 AM and 6:00 PM) a day for seizures: - A documented code of 9 for the 6:00 AM dose on 4/1 and 4/2/2024. - A documented code of 5 for the 6:00 PM dose on 4/1/2024. A review of Resident #3's progress notes revealed the following medication administration notes related to Resident #3's order for lacosamide 200 mg one time a day, which remained active until 3/25/2024: - 3/8/2024 10:58 PM: on order. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/9/2024 9:52 AM: Awaits pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/9/2024 10:24 PM: medication unavailable. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/10/2024 1:43 PM: medication unavailable. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/12/2024 4:04 PM: awaiting med. The note did not reveal an attempt to notify the pharmacy or the resident's physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 45 of 89 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm - 3/13/2024 1:07 PM: awaits pharmarcy (pharmacy). The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/13/2024 10:53 PM: on order. The note did not reveal an attempt to notify the pharmacy or the resident's physician. Residents Affected - Few - 3/14/2024 10:07 AM: Pharmacy scripts (prescriptions) to f/u (follow-up) with md (Medical Doctor). The note did not reveal an attempt to notify the resident's physician. - 3/15/2024 5:00 PM: medication not available, reordered and MD notified and gave order to hold medication until arrival. Review of Resident #3's medical record did not reveal the order for lacosamide 200 mg being placed on hold status at any time. - 3/16/2024 11:52 AM: med not available on hold [per] MD until delivery from pharmacy. Review of Resident #3's medical record did not reveal the order for lacosamide 200 mg being placed on hold status at any time. - 3/16/2024 7:06 PM: waiting on medication pharmacyb (pharmacy) notified. The note did not reveal an attempt to notify the resident's physician. - 3/17/2024 1:21 PM: awaits pharmarcy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/17/2024 7:43 PM: medication n/a (not available). The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/18/2024 08:21 AM: Medication on hold per doctor order, until arrival from pharmacy. - 3/20/2024 11:31 PM: on order. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/21/2024 10:58 AM: medication unavailable, pharmacy contacted and they need a script, MD notified. - 3/21/2024 9:01 PM: patient needs a new script, MD notified. - 3/22/2024 09:47 AM: medication unavailable, patient needs a script, MD notified. - 3/22/2024 5:40 PM: medication unavailable, patient needs a script, ARNP (Advanced Registered Nurse Practitioner) was notified. - 3/23/2024 9:54 AM: awaiting med. The note did not reveal an attempt to notify the pharmacy or the resident's physician. A review of Resident #3's progress notes revealed the following medication administration notes related to Resident #3's order for lacosamide 10 mg per ml, give 10 ml GT two times a day: - 3/26/2024 8:01 PM: on order from pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 46 of 89 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm - 3/27/2024 6:00 AM: Awaiting arrival from pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/27/2024 6:53 PM: Awaits pharmarcy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. Residents Affected - Few - 3/31/2024 6:02 AM: Awaiting delivery. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/31/2024 6:42 PM: Awaiting arrival from pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 4/1/2024 7:34 AM: Waiting for delivery. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 4/1/2024 5:39 PM: Awaiting arrival from pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 4/2/2024 6:38 AM: Waiting for delivery. The note did not reveal an attempt to notify the pharmacy or the resident's physician. A review of Resident #3's progress notes revealed the following medication administration notes related to Resident #3's order for phenobarbital 100 mg GT one time a day at bedtime: - 3/15/2024 9:38 PM: medication not available, reordered and MD notified ordered ordered to hold until received. Review of Resident #3's medical record did not reveal the order for phenobarbital 100 mg being placed on hold status at any time. - 3/16/2024 10:00 PM: medication not available pharmacy notified. The note did not reveal an attempt to notify the resident's physician. - 3/17/2024 10:16 PM: medicament (medication) n/a. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/20/2024 11:31 PM: on order from pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/21/2024 9:00 PM: patient needs a new script, MD notified. - 3/22/2024 8:40 PM: medication unavailable, patient needs a script, ARNP was notified. - 3/26/2024 10:49 PM: phenobarbital on order. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/27/2024 8:56 PM: await pharmarcy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. - 3/29/2024 8:28 PM: Awaiting arrival from pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 47 of 89 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - 3/31/2024 8:41 PM: Awaiting arrival from pharmacy. The note did not reveal an attempt to notify the pharmacy or the resident's physician. An interview was conducted on 4/2/2024 at 1:00 PM with Staff N, Licensed Practical Nurse (LPN). Staff N, LPN stated Resident #3 had orders for phenobarbital and lacosamide, but the medications had not arrived from the pharmacy. Staff N, LPN also stated she was not sure what to do if a resident has an order for a medication that was not available. An interview was conducted on 4/2/2024 at 1:11 PM with Staff I, LPN. Staff I, LPN stated Resident #3's prescriptions for phenobarbital and lacosamide had not arrived from the pharmacy and the medications would not be available in the facility's emergency drug kit (EDK). During the interview, the facility's Director of Nursing (DON) arrived to the unit and was interviewed. The DON stated she would expect nursing staff to call the pharmacy and check on the status of the medication if it had not arrived to the facility and call the resident's physician if a new prescription is needed. A follow up interview was conducted on 4/3/2024 at 1:34 PM with the DON. The DON stated she would expect nursing staff to follow up with the pharmacy if a prescription for a new medication was needed and contact the resident's physician. The DON also stated a medication should not be documented as administered unless it was actually administered to the resident by the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 48 of 89 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 01/25/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review, the facility failed to ensure a resident's medication regimen was free from unnecessary medications for 1 of 5 residents sampled for unnecessary medications (Resident #20). Residents Affected - Some The findings included: The policy of the facility titled, Medication Regimen Review implemented 5/2021 and revised 6/2023 revealed The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. A record review was conducted for Resident #20. Resident #20 was initially admitted to the facility on [DATE]. On 03/09/21 per hospital record review, the resident was transferred from the facility to the hospital for acute chest pain and acute urinary tract infection. The resident was treated and discharged back to the facility on [DATE]. A review of the discharge medications list revealed Apixaban (Eliquis) 5 milligrams (mg) 2 tablets (tabs) PO (by mouth) daily until 03/19/21 and then 1 tablet PO twice daily. Resident #20 had a Brief Interview for Mental Status of 3 per the quarterly Minimum Data Set with an assessment reference date of 10/20/23. This indicated the resident had severe cognitive impairment. An interview was conducted with the resident on 01/24/24 at 10:15 AM which revealed the resident was not able to answer questions without going off topic. An interview was conducted with the Medical Director who is the resident's physician on 01/25/24 at 1:30 PM to discuss the resident's current medication list. The list of medications that were reviewed with the Medical Director were: 1) ELIQUIS (Apixaban) TAB 2.5MG Give 1 tablet orally two times a day for ACUTE EMBOLISM AND THROMBOSIS OF RIGHT POPLITEAL VEIN. The Medical Director stated this should be revisited if greater than 6 months, she may not need it. 2) LACTULOSE SOLUTION 10GM/15 ml Give 45 ml orally three times a day for encephalopathy. The Medical Director stated this diagnosis should say metabolic encephalopathy and should be revisited. 3) VALPROIC ACID CAPSULE 250MG Give 2 capsules orally three times a day for Epilepsy, not intractable, without status epilepticus. The Medical Director stated the diagnosis for Valproic acid should be for behaviors not epilepsy and the diagnoses should be changed. 4) TOPIRAMATE TAB 200MG Give 1 tablet orally two times a day for EPILEPSY. The Medical Director stated this is correct. 5) CALDYPHEN LOTION 1-8% Apply to affected area topically as needed for itching three time daily. The Medical Director stated this should be addressed by the pharmacist with the as needed medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 49 of 89 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 01/25/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6) SODIUM CHLORIDE TAB 1GM (gram) Give 1 tablet orally one time a day for supplement. The Medical Director stated since the resident's sodium level is normal with the 1 tab a day, it is correct. 7) NITROGLYCERN 0.4MG Give 0.4 mg sublingually as needed for Chest Pain ONE TABLET SUBLINGUALLY AS NEEDED EVERY 5MINS IF PAIN CONTINUES CALL MD (Medical Doctor). The Medical Director stated this medicine can stay since it is an as needed medication. The Medical Director was also asked where his notes are located to be reviewed in the medical record and he stated that in the previous electronic health record he could not upload notes but in this current electronic health record he has been able to upload notes for the past 6 months but there are notes that he has not uploaded yet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 50 of 89 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 01/25/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to preserve the nutritional value of food items in the puree diet. This had the potential to affect ten (10) of 10 residents who were on a puree diet. Residents Affected - Few The findings included: Record review of the facility's meal tracker, week 3, showed the following menu items for Monday, 01/22/24: roast chicken, seasoned cornbread, stuffing, and collard greens. In an observation conducted on 01/22/24 at 7:30 AM, a full-size stainless steel 6-inch deep steam table pan was noted on top of the stove. Closer observation showed cooked collard greens. In this observation, the Certified Dietary Manager (CDM) said this was the cooked collard green vegetables on the pureed diet for today's lunch meal. In an observation conducted on 01/22/24 at 7:35 AM, Staff L, Dietary Cook, placed the already-cooked collard greens in the warmer. Staff L stated that she cooked the vegetables for the pureed diet a little earlier, and when she is done with the breakfast tray line, she will puree the cooked collard greens. When asked about the breakfast tray line, she said that it starts at about 7:20 AM and it takes about one hour to finish the breakfast tray line. In an interview conducted on 01/25/24 at 12:20 PM with the Certified Dietary Manager, she stated that she was unaware that cooking raw vegetables and pureeing them too early in the day causes them to lose nutritional value. The surveyor expressed concern that cooking / pureeing cooked vegetables causes them to lose nutrients, especially when prepared too far in advance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 51 of 89 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 01/25/2024 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the appropriate orders for 3 of 32 sampled residents, for fluids, as prescribed by the attending physicians, Resident #74 and Resident #40; and failed to provide adequate hydration for Resident #53. The findings included: 1. Record review showed that Resident #74 was admitted to the facility on [DATE] with diagnoses of Diabetes, Anemia, and Hyperlipidemia. During the dining observation on 01/23/24 at 8:28 AM, Resident #74 was noted in his room with the breakfast tray. The breakfast meal ticket showed a regular, mechanical, soft diet with thick nectar liquids. Closer observation of the meal tray revealed a 12-ounce Styrofoam cup of water that was not thickened and placed near the breakfast tray. In this observation, Resident #74 was asked by the surveyor if he was aware that he was on a specific fluid consistency restriction, and Resident #74 could not answer. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses of Dementia and Behavioral Disturbances. Resident #40 started in hospice on 07/05/23. The Quarterly Minimum Data Set assessment dated [DATE] revealed that Resident #40 has a Brief Interview of Mental Status (BIMS) score of 99, indciating the score could be obtained. In an observation conducted on 01/22/24 at 12:43 PM, Resident #40 was in her room with her lunch tray. Staff P, a Hospice Registered Nurse (RN), was observed in the room assisting Resident #40 with her lunch meal. Closer observation showed a regular pureed diet meal ticket with thick nectar liquids. The lunch tray was noted with pureed roast turkey, pureed collard green, and 8 ounces of iced tea that was not thickened. During this observation, the surveyor asked Staff P if she knew Resident #40 was on nectar liquids. Staff P stated that she was unsure and proceeded to look at the meal ticket near the tray. An interview was conducted on 01/25/24 at 11:42 AM with the Certified Dietary Manager (CDM) who stated that any residents with specific fluid orders would be shown on the meal ticket. It is placed in the meal tracker system to reflect the correct diet and runny consistency. They have a machine in the kitchen that thickens the liquids that are placed on the meal trays. If the residents want other fluids that do not come from the kitchen, like coffee or juice, the nursing staff would thicken the liquids on the units. The staff has thickened liquid packets in the nourishment room and on the beverage carts on the floors. The CDM stated that the staff used to have a list of residents who were on thickened liquids, so staff would identify who was on restricted liquids. In an interview conducted on 01/25/24 at 2:30 PM with Staff, I, Certified Nursing Assistant (CNA), stated that every staff member on the floor can provide water to residents. She stated she offered water in Styrofoam cups to her residents this morning. When asked how staff knows if any residents are on specific types of liquids, she said they need to look at the meal tickets. If they provide water or other liquids during meals, then staff needs to check the diet order before giving the liquids to residents and know if they need to be thickened or not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 52 of 89 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 01/25/2024 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of the facility's policy, titled, Hydration with a reviewed/revised date of 11/29/23, included: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Offer the resident a variety of fluids during and between meals. Provide assistance with drinking. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility, and Unspecified Hearing Loss Bilateral. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #53 revealed in Section C, a BIMS score of 1, indicating severe cognitive impairment. In Section GG, it revealed, for toilet hygiene, the resident had a performance of partial / moderate assistance for walking 10 feet, walking 50 feet with two turns and walking 150 feet. Review of the Physician's Orders for Resident #53 revealed an order dated 05/26/23 for regular diet, mechanical soft texture, thin consistency, large portion, and fortified foods. Review of the Physician's Orders for Resident #53 revealed an order dated 12/04/23 for Med Pass (or calorie/protein equivalent) three times a day for weight loss/low BMI (Body Mass Index) 90ml (Milliliters) TID (Three times daily). [This equals just over 1 cup of fluid per day]. Review of the CNA Tasks for Nutrition-Fluids dated 12/27/23 - 01/25/24 documented that the resident received the following milliliters: 12/27/23 - 720 12/28/23 - 260 12/29/23 - 900 12/30/23 - 940 12/31/23 - 400 01/01/24 - 484 01/02/24 - 840 01/03/24 - 840 01/04/24 - 9 01/05/24 - 600 01/06/24 - 640 01/07/24 - 720 01/08/24 - 480 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 53 of 89 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 01/25/2024 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 0807 01/09/24 - 480 Level of Harm - Minimal harm or potential for actual harm 01/10/24 - 125 01/11/24 - 1,440 Residents Affected - Few 01/12/24 - 640 01/13/24 - 720 01/14/24 - 484 01/15/24 - 480 01/16/24 - 4 (refused fluids x2) 01/17/24 - 500 01/18/24 - 700 01/19/24 - 840 01/20/24 - 840 01/21/24 - 1,080 01/22/24 - 480 01/23/24 - 964 01/24/24 - 540 01/25/24 - 480. This indicates the resident received an average of 621 milliliters (just over 2.5 cups) of liquid per day. When combined with the med pass, this indicated an average total of just over 3.75 cups per day. Review of the Care Plan for Resident #53 dated 06/08/23 had a focus on 'the resident remains at risk for nutritional decline r/t (related to) clinical condition'. The goal was for the resident to 'continue to consume adequate calories to meet energy needs. He will be free of all avoidable weight loss. Resident will be free of all s/s (signs/symptoms) of dehydration or fluid overload.' The interventions included: Provide and encourage extra fluids. Monitor for any s/s of dehydration or fluid overload. Review of the Care Plan for Resident #53 dated 06/01/23 had a focus on 'the resident has potential / actual impairment to skin integrity r/t fragile skin.' The goal was for the 'resident to be free from injury through the review date.' The interventions included: Encourage good nutrition and hydration in order to promote healthier skin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 54 of 89 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 01/25/2024 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 0807 Level of Harm - Minimal harm or potential for actual harm On 01/22/24 at 7:44 AM, an observation was made of Resident #53 sitting on the side of his bed. There was no water or beverage of any type, nor any cup at the bedside. On 01/22/24 at 11:00 AM, an observation was made of Resident #53 lying in bed with no water or beverage of any type, nor any cup at the bedside. Residents Affected - Few On 01/22/24 at 2:35 PM, an observation was made of Resident #53 lying in bed with no water or beverage of any type, nor any cup at the bedside. During an interview conducted on 01/25/24 at 10:30 AM with Staff D, CNA, she stated she has been working at the facility for 2months. When asked how often water is provided to a resident, she stated water is provided to all residents unless they are not supposed to have water. Staff D stated a CNA is assigned Ice daily for each shift, and it is their responsibility to pass water for each resident on the floor. Staff D clarified, when assigned Ice, the water is passed or offered at the end of the shift by the assigned CNA. The water is provided in large white Styrofoam cups with a lid and a straw. When questioned, Staff D did not know the size of the Styrofoam cup and guessed it to be 360 mls. She stated they document all liquids the residents consume, including water and the beverages on the meal trays under fluids in the resident's chart (Electronic Medical Record). An interview was conducted on 01/25/24 at 11:00 AM with Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. When asked about water or beverages for the residents, the LPN stated the CNAs primarily pass water in the beginning of the shift each day, and the nurses can get water for residents also. An interview was conducted on 01/25/24 at 11:30 AM with Staff B, LPN, who stated she has worked at the facility for 1 year. When asked about water or beverages for the residents, the LPN stated the CNAs, from the 11:00 PM to 7:00 AM shift, make sure each resident has a cup for water and it is labeled with the room number and the date. She also stated any staff member can offer water to a resident. An interview was conducted on 01/25/24 at 11:50 AM with Staff A, LPN/Unit Manager (LPN/UM) who stated he has worked at the facility since August / September of 2023. When asked how often residents are provided with water, he said the residents are not provided with cups in the rooms because of their cognition. They are provided with 120 ml (milliliters) of water every 2 to 4 hours filled from a pitcher, usually by a CNA, but anyone can provide a resident with water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 55 of 89 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 01/25/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow the therapeutic diets as per physician's orders for 2 of the 32 sampled residents (Resident #86 and Resident #55). The findings included: A review of the facility's policy, titled, Meal Supervision and Assistant, revised on 11/29/22, showed, in part, that staff needs to check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. 1 . Resident #86 was admitted to the facility on [DATE] with diagnoses of Parkinson's, Dementia, and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Review of the physician's orders, dated 12/04/23, revealed an order for regular texture, thin liquids, and fortified foods with meals. In an observation conducted on 01/24/24 at 8:40 AM, Resident #86 was noted eating her breakfast from the tray in her room. Closer observation showed a meal ticket with the following: regular diet, baked omelet, sausage patty, toast, and hot cereal. The meal ticket did not mention any fortified foods to be provided. The breakfast plate consisted of one serving of omelet, sausage patty, and 6 ounces of hot cereal. In an observation conducted on 01/24/24 at 12:27 PM, Resident #86 was in the room eating her lunch meal. Closer observation showed 8 ounces of shepherd's pie, 4 ounces of corn, and one serving of dinner roll. No fortified food item was noted on the lunch tray or on the meal ticket. 2. Resident #55 was admitted on [DATE] with diagnoses of Anemia, Dysphagia, and Depression. Review of the physician's orders revealed an order dated 08/16/23 for regular texture, thin liquids, and large portions of protein at meals. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 has a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. In an observation conducted on 01/24/24 at 8:44 AM, Resident #55 ate his breakfast meal independently. The meal ticket revealed the following: low concentrated sweet, large protein, one serving of omelet (average serving), and 1 ounce of sausage patty (average serving). Observation of the breakfast plate did not show that Resident #55 received a large portion of protein. In an observation conducted on 01/24/24 at 12:24 PM, Resident #55 was eating his lunch meal. Closer observation showed that he received 8 ounces of shepherd's pie (normal serving), 4 ounces of corn and a dinner roll. Closer observation did not show that any large portion of protein was provided. In an interview conducted on 01/25/24 at noon, the Certified Dietary Manager (CDM) stated that they have a designated staff member who checks the tray line trays and meal tickets to ensure accuracy. Sometimes, food items are missed during the tray line, so nursing staff should also check the meal tickets for accuracy and notify dietary for any changes or missing items. When asked what extra (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 56 of 89 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 01/25/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm protein was served on the lunch meal on 01/24/24, she said it was about 12-16 ounces of the Shepard pie and not the normal portion of 8 ounces. As for the fortified food items, she stated that they are hot cereal or eggs for breakfast, mashed potatoes for lunch, and pudding for dinner. The CDM stated that when a diet order is changed in the electronic system, a communication slip is provided by nursing so they can place the new order in the meal tracker to reflect the changes on the meal ticket. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 57 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety. Residents Affected - Few The findings included: A tour of the main kitchen conducted on 01/22/24 at 7:14 AM and accompanied by the Certified Dietary Manager (CDM) showed the following: 1. No hairnets or facial hairnets were noted outside the main kitchen doorway. 2. A dirty rag was noted on the main production counter that was not in any buckets or solutions. 3. Four large rolls of pork loin were noted in the walk-in refrigerator and placed on a metal tray. The metal tray had a label of pork dated 01/18/24. In this observation, the CDM stated that the pork loin was placed in the walk-in refrigerator to thaw and that it is for the lunch meal tomorrow, 01/23/24. 4. Four large rolls of raw beef (approximately 10 pounds each) were placed in the walk-in refrigerator on a metal tray that needed to be labeled and dated. They did not have a sticker with a date indicating when they were placed in the walk-in refrigerator. 5. The walk-in freezer noted four packs of waffles that needed to be dated and labeled. 6. The walk-in freezer was noted to have a large bag of frozen chicken that needed to be dated and labeled. 7. The dry storage area noted a 6-pound 12-ounce large can of beef ravioli that was dented. 8. Two can openers were sitting in a clear container with an unidentified liquid. In this observation, the CDM said she placed the two can openers earlier in a container with a degrease solution and some water. 9. Partially opened garbage lid in the food production area. 10. A used blue cutting board with a knife, a spatula, and a used whisk sitting on top of the cutting board was not in use or in any other cleaning solution. 11. The exhaust above the dishwasher machine was rusty and filled with debris. 12. A tray was noted with 12 (4-ounce cup) fruits and puddings that needed to be dated and labeled. Photographic Evidence Obtained. In an observation conducted on 01/22/24 at 3:14 PM in the 2nd-floor Nourishment room, a tray was noted with ½ prepared sandwiches in the refrigerator that were not labeled or dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 58 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 In an interview conducted on 01/25/24 at 5:00 PM with the facility's Administrator, he was told of the findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 59 of 89 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 01/25/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to dispose of and maintain garbage and refuse in a sanitary manner. Residents Affected - Some The findings included: In an observation conducted on 01/22/24 at 7:04 AM of the outside dumpster area, the following were noted: 2 large dumpster bins, with one open bin and garbage overflowing outside. Closer observation showed debris that consisted of dirty gloves, linens, plastic utensils, and plastic bottles. Three large garbage bags were sealed and placed near the first closed dumpster. The two dumpster bins were located right outside the entrance to the central kitchen. Photographic Evidence Obtained. In an interview conducted on 01/22/24 at 8:00 AM, Staff K, Certified Nursing Assistant (CNA), stated that the dumpster bins get picked up daily. When asked if they are also picked up on the weekend, she said: Not always. Staff K reported that she usually gets to the facility around 6:15 AM and that by 6:30 AM, they come to empty the dumpsters. Another observation conducted on 01/22/24 at 7:41 AM, accompanied by the Certified Dietary Manager (CDM) revealed two large dumpster bins, one closed and the other opened, with garbage overflowing at the top. Closer observation showed dirty gloves, plastic medicine cups, and other debris behind the two large dumpsters. In this observation, the CDM said the garbage dumpsters get picked up three times a week, on Mondays, Wednesdays, and Fridays. Photographic Evidence Obtained. In an observation conducted on 01/22/24 at 4:28 PM, one dumpster was opened with debris and carton boxes overflowing on the top. Other debris and carton boxes were noted all around the dumpster. Continued observation showed three large round bins with garbage inside and no lids. Photographic Evidence Obtained. A further observation on 01/23/24 at 8:12 AM revealed debris of dirty used gloves, plastics, and wood. Further observation showed two large round garbage bins with garbage inside and no lids. In an interview with the facility's Administrator on 01/25/24 at 5:00 PM, he was told of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 60 of 89 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 01/25/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to administer the facility in a manner that enables the effective and efficient use of its resources. Residents Affected - Few The findings included: A review of the Administrator's job description revealed the following: 1. Lead and direct the facility's overall operations in accordance with customer needs, government regulations, and Company policies, focusing on maintaining excellent care for the residents while achieving the facility's business objectives. 2. Manage facility budgets and business practices to include labor costs, payables, and receivables. 3. Consult with department managers concerning the operation of their departments to assist in eliminating/ correcting problem areas and/or improving services. 4. Verify that the building and grounds are maintained appropriately, that equipment and work areas are clean, safe, and orderly, and that any hazardous conditions are addressed. 5. Monitor each department's activities, communicate policies, evaluate performance, provide feedback, and assist, observe, coach, and discipline as needed. 6. Oversee regular rounds to monitor the delivery of nursing care, operations of support departments, cleanliness and appearance of the facility, morale of the staff, and ensure resident needs are being addressed. In an interview with the Maintenance Director on 01/25/24 at 8:06 AM, he stated that he had worked in the facility for the last six weeks. He oversees the facility and ensures everything is in operation and working order. The staff will complete a working order request on any issue that needs fixing. The order forms are placed in a bin outside the central supply office, which he checks daily. He only has one assistant to help him complete all the work that is needed around the facility, and that, at times, is not enough. When asked by the Surveyor if he ever attended a Quality Assurance Performance Improvement (QAPI) meeting, he said no. The Maintenance Director reported that some significant issues around the facility needed to be addressed, and he brought it up to the Administrator. He was told by the Administrator that he would contact Corporate for budget approval and that he would let him know. The Administrator told him that Corporate did not approve some of the issues, that his hands were tied, and that he could not do anything. According to the Maintenance Director, this is why he is leaving the facility; tomorrow is his last day. The Administrator was able to give him an allowance to buy the supplies needed for some of the repairs but was told that Corporate did not approve other maintenance. When asked if any audit sheets or forms are completed by the Administrator overseeing his job or his progress in the facility, he said no. The Maintenance Director further said he contacted some previous vendors for needed work around the facility, for example pest control. The vendors told him they would come into the facility once older invoices for work were paid. In an interview conducted on 01/25/24 at 5:15 PM, the Administrator stated that as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 61 of 89 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 01/25/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator, he is responsible for taking all feedback from his staff and residents. He uses QAPI to keep track of all the issues and areas of resident care around the facility. He determined how staff did their job by conducting physical rounds, looking at patient outcomes, and interviewing department heads. Regarding oversight of the Maintenance Department, he stated that they have weekly maintenance checklists that he and the Maintenance Director fill out. He also has a budget credit card that is used for emergency purchases for any emergency items that need to be bought. The Administrator reported that the Maintenance Director had never approached him in the past regarding supplies that he needed and denied telling him that they didn't have a budget for supplies. Event ID: Facility ID: 105428 If continuation sheet Page 62 of 89 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 01/25/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on interviews and record review, the facility failed to communicate effectively between the Administrator and the Governing Body regarding the overall management and operation of the facility. The findings included: A review of the Quality Assurance and Performance Improvement Plan (QAPI) dated 2023 revealed that the QAPI Plan and program were reviewed and approved by The Committee of the Governing Body. The Governing Body of our facility has ultimate responsibility and leadership over our QAPI program, working with input from staff, residents, and resident representatives. The Governing Body designates a QAPI Steering Committee (Administrator, Director of Nursing, and Medical Director). The Governing Body ensures that the QAPI program has sufficient resources, facility-wide QAPI training occurs that policies are in place to sustain the program despite personnel changes, supports a culture of resident-centered rights and choices, holds staff accountable for quality in an environment free of retaliation; ensures staff is educated and proficient in their duties. A review of the 2024 QAPI Plan provided to the Surveyor on 01/25/24 at 4:50 PM revealed that the Governing Body is responsible and accountable for overseeing the QAPI program. The Governing Body is responsible and accountable for ensuring that an ongoing QAPI program is defined, implemented, maintained, and addresses identified priorities. The QAPI program is sustained during transitions in leadership and staffing. It further revealed corrective actions address system gaps and evaluate the QAPI programs' effectiveness. In an interview conducted on 01/25/24 at 8:06 AM, the facility's maintenance director stated that the facility had major issues that needed to be addressed right away and that he brought them up with the administration. The Administrator was able to give him the allowance to buy some of the materials that were needed for some of the repairs, but he was told that Corporate did not approve other repairs. Some of the issues he reported were the air conditioning on the roof that is not working, the downstairs door frame being busted and needs to be fixed immediately, and the sprinkler system being red-tagged. He was also told by the vendors that the corporation would not pay them for the work done and would only come into the facility once older invoices for work that was done were paid. The maintenance director reported that the residents' beds in the facility were of all sizes and types and that they needed to follow the directions for using each bed type. When asked if there is a system to check the bed rails and ensure that the frame and mattress fit the bed, he said no. In an interview conducted on 01/25/24 at 1:40 PM with the facility's Medical Director, he stated that he is part of the Governing Body with the Administrator and the Director of Nursing. The goal of the Governing Body is to communicate effectively and to work as a team to treat patients and take ownership of their roles. When asked who is responsible for reporting to him on various issues and concerns in the facility, he said the Director of Nursing (DON). According to the Medical Director, the DON will contact him and discuss any issues that may need addressing. Together, they will decide if performance improvement projects (PIP) must be started. The Surveyor asked if he knew the facility had pest control issues, and he said no. The Medical Director was not told that nurses needed to follow the Physician's orders regarding tube-feeding residents. He was aware of residents who had significant weight losses but needed to know if they were addressed in a timely manner by the facility's Registered Dietitian. According to the Medical Director, he knew that the facility had issues with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 63 of 89 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 01/25/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the contracted hospice companies and that care plans were not completed on time. He had to reach out to the hospice companies himself to discuss the problem. The Medical Director stated that the DON should keep a log of all the communications between them and that he did not have a written log. In the past, residents' care was affected because of a lack of supplies. He has received calls from the hospital regarding the overall care of his residents. He was told by hospital staff that his residents were not being cared for medically while in the facility. In an interview conducted on 01/25/24 at 2:49 PM with the Regional Director of Operation/Owner, she stated that she is part of the Governing Body and is responsible for overseeing the facility and providing any support it may need. When asked who else is part of the Governing Body, she said the following: Regional Minimum Data Set Coordinator, Regional Nurse Consultant, Regional Plant Operations, Regional Risk Management, Chief Executive Officer, and [NAME] President of Operation. They took over as a new management/ownership around June 2023. She oversees the budget and ensures the staffing is appropriate. The Regional Director of Operations reported that she communicates daily with the facility's Administrator. The Administrator is responsible for reporting any negative outcome regarding the point of care to her. When asked if the Administrator or Medical Director had contacted her in the past regarding not having supplies, she said no and that she would have taken care of the issues right away. A review of the facility's assessment revealed that the facility's Chief Operating Officer oversees shared services managers. At the same time, the Administrator manages the management team, which is responsible for the facility's day-to-day operations. The Medical Director oversees medical practice and the clinical policies and programs of the facility. In a phone interview with the pest control company on 02/01/24 at 12:40 PM, the representative stated that the facility had not been paying their invoices since October 2023 and was 90 days behind. It was further reported that no payments were made since October of 2023 and that they finally paid all their due balances on January 31, 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 64 of 89 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 01/25/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain the medical records for 7 of 32 sampled residents, Resident #80, 88, 93, 153, 94, 57, and 34 in a manner that was complete, accurate, and systematically organized. The findings included: Review of the facility's policy titled Documentation in Medical Record, dated 09/2023 revealed the followingeach resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 1) Resident #80 was admitted to the facility on [DATE]. She had a medical history significant for Depression and Schizophrenia. During the initial tour of the facility conducted on 01/22/24 at 7:35 AM, the surveyor noted a paper taped inside the nurse's station, titled Unit Update for 1st Floor Supervision that documented Resident #80 was ordered to have every 30-minute checks. This paper did not specify the reason for the increased supervision. A Quarterly Minimum Data Set (MDS) done on 12/13/23 documented Resident #80 had a Brief Interview of Mental Status (BIMS) score of 1, which indicates she was severely cognitively impaired. Review of Resident #80's Care Plans revealed Resident #80 had a history of aggressive behaviors toward other residents and that she was identified as an elopement risk. Review of Resident #80's physician orders revealed an order was written from 12/05/23 to 01/08/24 for continue Q15 [every 15] minute behavior monitoring every shift and a new order was written on 01/08/24 for continue Q30 minute behavior monitoring every shift. An interview was conducted on 01/23/24 at 8:34 AM with Staff F, Certified Nursing Assistant (CNA). She explained that the CNAs perform the ordered checks and that they document them on a clipboard that is kept behind the nurse's station. She said every day the forms are collected by the nurse manager and are taken somewhere, but she did not know where. She said she did not know why Resident #80 was on safety checks. She said she was not performing the safety checks that day and was unable to tell the surveyor which staff member was. An interview was conducted on 01/24/24 at 10:08 AM with Staff G, CNA. Staff G was observed holding a purple clipboard and she confirmed she was tasked with performing the safety checks for the day. She said Resident #80 required safety checks because she falls. She stated she did not know where the safety check sheets were kept after they were removed from the clipboard. An interview was conducted on 01/24/24 at 10:35 AM with Staff B, Licensed Practical Nurse (LPN). She confirmed she was assigned to Resident #80 and that the safety checks were ordered because she gets up on her own a lot. She said the safety check sheets were uploaded into the Documents tab on the electronic health record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 65 of 89 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 01/25/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the behavior monitoring sheets revealed there was not consistent documentation of these physician ordered behavior monitoring checks. Of the 50 days (from 12/05/23 to 01/24/24) Resident #80 had behavior monitoring checks ordered, there were 28 forms documented. This indicates the documentation of the ordered behavioral checks was not accurate for Resident #80. 2) Resident #88 was admitted to the facility on [DATE]. He had a medical history significant for Encephalopathy, Dementia, Anxiety, and Depression. During the initial tour of the facility conducted on 01/22/24 at 7:35 AM, the surveyor noted a paper taped inside the nurse's station, titled Unit Update for 1st Floor Supervision that documented Resident #88 was ordered to have every 1-hour checks, document if there is any inappropriate sexual behavior. A Quarterly MDS done on 12/21/23 documented Resident #88 had a BIMS score of 7, which indicates he was severely cognitively impaired. Review of Resident #88's Care Plans revealed Resident #88 had a history of hypersexual and physically aggressive behaviors toward other residents. Review of Resident #88's physician orders revealed an order was written from 12/05/23 to 12/08/23 for behavior monitoring Q30 minutes every shift, then from 12/08/23 to 01/01/24 for increased supervision every 1 hour checks for safety every shift, then from 12/21/23 to 01/03/24 for 1 on 1 close observation every shift for behavior monitoring, then from 01/03/24 to 01/08/24 for 15 minute check with supervision every shift for behavior monitoring, then from 01/08/24 to 01/18/24 for 30 minute check with supervision every shift for behavior monitoring, and finally 01/18/24 for Q1 hour checks for increased supervision every shift for behavior monitoring. An interview was conducted on 01/23/24 at 8:34 AM with Staff F, CNA. She explained that the CNAs perform the ordered checks and that they document them on a clipboard that is kept behind the nurse's station. She said every day the forms are collected by the nurse manager and are taken somewhere, but she did not know where. She said she did not know why Resident #88 was on safety checks. She said she was not performing the safety checks that day and was unable to tell the surveyor who was. An interview was conducted on 01/24/24 at 10:08 AM with Staff G, CNA. Staff G was observed holding a purple clipboard and she confirmed she was tasked with performing the safety checks for the day. She said Resident #88 required safety checks because he walks a lot. She then clarified Resident #88 was an elopement risk. She stated she did not know where the safety check sheets were kept after they were removed from the clipboard. She said she was unaware of his hypersexual behaviors. An interview was conducted on 01/24/24 at 10:39 AM with Staff C, LPN. She confirmed she was assigned to Resident #88 and that the safety checks were ordered because he was at risk of wandering and elopement. She said she was unaware of his hypersexual behaviors. Review of the behavior monitoring sheets revealed there was not consistent documentation of these physician ordered behavior monitoring checks. Of the 50 days (from 12/05/23 to 01/24/24) Resident #88 had behavior monitoring checks ordered, there were 28 forms documented. This indicates the documentation of the ordered behavioral checks was not accurate for Resident #88. 3) Resident #93 was admitted to the facility on [DATE]. He had a medical history significant for Encephalopathy, Dementia, Alzheimer's Disease, and Bipolar Disorder. During the initial tour of the facility conducted on 01/22/24 at 7:35 AM, the surveyor noted a paper taped inside the nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 66 of 89 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 01/25/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm station, titled Unit Update for 1st Floor Supervision that documented Resident #88 was ordered to have every 15-minute checks. This paper did not specify the reason for the increased supervision. A Quarterly MDS done on 12/18/23 documented Resident #93 had a BIMS score of 3, which indicates he was severely cognitively impaired. Residents Affected - Some Review of Resident #93's Care Plans revealed Resident #93 had a history of attempted facility elopement. Review of Resident #93's physician orders revealed an order was written from 01/10/24 to 01/10/24 for 1:1 check with supervision every shift and then on 01/18/24 for Q15 minute checks for increased supervision every shift for monitoring. An interview was conducted on 01/23/24 at 8:34 AM with Staff F, CNA. She explained that the CNAs perform the ordered checks and that they document them on a clipboard that is kept behind the nurse's station. She said every day the forms are collected by the nurse manager and are taken somewhere, but she did not know where. She said she did not know why Resident #93 was on safety checks. She said she was not performing the safety checks that day and was unable to tell the surveyor who was. An interview was conducted on 01/24/24 at 10:08 AM with Staff G, CNA. Staff G was observed holding a purple clipboard and she confirmed she was tasked with performing the safety checks for the day. She said Resident #93 required safety checks because he sometimes fights with other residents. She stated she did not know where the safety check sheets were kept after they were removed from the clipboard. She said she was unaware that Resident #93 was an elopement risk but that there was an additional CNA used daily as a hall monitor to ensure residents did not elope. An interview was conducted on 01/24/24 at 10:39 AM with Staff C, LPN. She confirmed she was assigned to Resident #93 and that the safety checks were ordered because he was at risk of wandering and elopement. Review of the behavior monitoring sheets revealed there was not consistent documentation of these physician ordered behavior monitoring checks. Of the 14 days (from 01/10/24 to 01/24/24) Resident #93 had behavior monitoring checks ordered, there were 11 forms documented. This indicates the documentation of the ordered behavioral checks was not accurate for Resident #93. 4) Record review for Resident #57 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease, Bipolar Disorder, Dementia, Post-Traumatic Stress Disorder, and Anxiety. Review of the Minimum Data Set (MDS) for Resident #57 dated 12/09/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impact. Review of the Physician's Orders for Resident #57 dated 07/05/23 for Do Not Resuscitate (DNR). Review of the Care Plan for Resident #57 dated 06/27/23 with a focus on the resident has an established CPR (Cardiopulmonary Resuscitation) (Full Code) order in place. The goal is to make the resident wishes for code status to be followed through the next review date. The Interventions included: Activate the resident's advanced directives as indicated. Notify the physician of resident's wishes regarding life prolonging procedures. This indicates the advance directive care plan regarding code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 67 of 89 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 01/25/2024 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 0842 status for Resident #57 was never updated to reflect the DNR status. Level of Harm - Minimal harm or potential for actual harm Review of the DNR form in the resident's Electronic Medical Record (EMR) was unsigned by the physician. Review of the Do Not Resuscitate (DNR) form had no physician signature on the DNR form in the yellow DNR binder located in the medication room. The SSD stated there has been a back log of uploading documents into the EMR from the old system prior to switching to the current EMR system they are using. Residents Affected - Some An interview was conducted on 01/24/24 at 9:16 AM with the Social Service Director (SSD) who stated she has worked at the facility for 4 years. She stated upon the admission of a resident, the code status is addressed, and it is verified with the resident/resident representative. The SSD stated the quarterly care plans will readdress unresolved advance directive concerns/issues. For a resident who want a code status of DNR (Do Not Resuscitate) the resident or the family will sign the yellow DNR form, she then gets the physician to sign it and the nurse will get the order for the DNR and will put that into the resident's EMR (Electronic Medical Record). In the state of Florida to legally be a DNR they have to have the physician order and the yellow form with Florida insignia on it signed by the responsible party and the physician. There was a physician who signed the DNR form dated 07/04/23 (before the resident was admitted to the memory care unit at the facility). On 06/14/23 there was a Certification of Incapacity to Make Informed Healthcare Decision signed by physician (prior to admission to the memory care unit at the facility) and based on this form the facility reached out to the daughter of Resident #57 about the code status for the resident. When the SSD spoke to the daughter, the daughter was adamant the resident was a DNR status. The facility obtained verbal consent from the daughter for the DNR status, and the form needed to be signed by the physician. The SSD verified the DNR form in the resident's EMR was unsigned by the physician. The SSD stated all DNRs are in the yellow binder in the med room. The SSD stated she is the person responsible to make sure the DNR binder is updated at all times. The SSD verified there was no physician signature on the DNR form in the yellow DNR binder located in the medication room. During an interview conducted on 01/24/24 at 10:30 AM with Staff A Licensed Practical Nurse/Unit Manager (LPN/UM) who stated he has been working at the facility since August 2023. When asked where he would look to know the code status of a resident, he stated it is at the top of the computer for each resident. During an interview conducted on 01/24/24 at 10:35 AM with Staff C Licensed Practical Nurse (LPN) who stated she has worked at the facility for 2 months. When asked where she would look to know the code status, she said she would look the resident up in the computer and it is at the top of the computer under the resident's name. 5) Record review for Resident #94 revealed the resident was admitted to the facility on [DATE] with diagnosis that included: Vascular Dementia Mild With Agitation. Review of the MDS for Resident #94 dated 10/23/23 revealed in Section C a Brief Interview of Mental Status score of 0, indicating severe cognitive impairment. Review of the Physician's orders for Resident #94 revealed an order dated 11/28/23 for Resident is on 1:1 for 7-3 and 3-11 and 15 mins at night. The order was discontinued on 12/05/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 68 of 89 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 01/25/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Review of the Physician's orders for Resident #94 revealed an order dated 12/05/23 for Resident is on 1:1 for 7-3 and 3-11 and 30 mins at night shift. The order was discontinued on 12/08/23. Review of the Physician's orders for Resident #94 revealed an order dated 12/08/23 for Resident is on 1:1 for 7-3 and 3-11 and every 1 hr. (hours) at night shift. The order was discontinued on 12/11/23 Residents Affected - Some Review of the Physician's orders for Resident #94 revealed an order dated 12/11/23 for Resident is on 1:1 for 7-3 and 3-11 until Resident Goes to Bed. The order was discontinued on 12/20/23. Review of the Physician's orders for Resident #94 revealed an order dated 12/20/23 for Resident is on 1:1 for 7-3 and 3-11 until Resident Goes to Bed Once resident in bed change to 15min checks. The order was discontinued on 01/03/24. Review of the Physician's orders for Resident #94 revealed an order dated 01/03/24 for Resident is on 1:1 for 7-3 and 3-11 until Resident Goes to Bed. The order was discontinued on 01/18/24. Review of the Physician's orders for Resident #94 revealed an order dated 01/18/24 for 7-3 Q 15-minute checks, 1:1 supervision for 3-11 until he goes to bed. Review of the Care Plan for Resident #94 dated 10/24/23 with a focus on the resident is resistive to care, shower, getting changed, and dressed, disrobes throwing BM (Bowel Movement), combative with staff swinging his arms resident has h/o of aggressive behaviors, prior to admission was on hospice for behavior management. Resident attempts to push other residents. Aggressive with his roommate. The goal is for the resident to cooperate with care through the next review date. The interventions included: 15 minute check 7-3, 1:1 3-11 until resident goes to bed. Allow the resident to make decisions about treatment regime, to provide sense of control. If the resident resists with ADLs, reassure the resident, leave, and return 5-10 minutes later and try again. Psych consult with medication adjustments. Redirect resident from pushing others, resident enjoys music and dancing. Review of the Safety Check Logs for Resident #94 from 11/13/23 to 01/22/24 revealed no Safety Check Logs for the following dated: 11/16/23, 11/17/23, 11/23/23, 11/24/23, 12/7/23, 12/08/23, 12/11/23, 12/12/23, 12/13/23, 12/16/23, 12/23/23, 12/28/23, 12/29/23, 12/31/23, 01/02/24, 01/03/24, 01/04/24, 01/05/24, 01/06/24, 01/07/24, 01/08/24, 01/10/24, 01/11/24, 01/20/24, and 1 Safety Check Log had no date. This indicated, not all of the Safety Check Logs are in the EMR for Resident #94. During an interview conducted on 1/25/24 at 11:00 AM With Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. When asked about residents who are on 1:1 observations or observations every 15 minutes, where is this documented, the LPN stated for resident who are on 1:1 or every 15-minute observations, they are monitored by the Certified Nursing Assistants (CNAs) and document on an observation sheet. The CNA will notify the nurse of any issues. During an interview conducted on 01/25/24 at 11:30 AM with Staff B, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 1 year. When asked about the documentation for residents who are on 1:1 or every 15-minute observations, she stated the residents who are on 1:1 or every 15 minute checks are done by the CNA or a nurse and it is documented on the observation sheet and if any issue the CNA will report to the nurse. During an interview conducted on 01/25/24 at 11:50 AM with Staff A, Licensed Practical Nurse Unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 69 of 89 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 01/25/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Manager (LPN/UM), who stated he has been with the facility since August/September. When asked where the Safety Check Logs are located, he stated they should be in the resident's chart under documents. 7) A record review revealed that Resident #34 was readmitted to the facility on [DATE] with diagnoses of Gastrostomy, Psychotic disturbances, and Dementia. The Physician's orders showed the following: clarification order for Resident #34 to begin one meal a day- lunch: puree solids and thin liquids, dated 01/23/24. An order for tube feeding is to be administered with Jevity 1.2 (tube feeding formulary) continuously at 60 milliliters (ml) an hour for 24 hours/day, dated 12/31/23. Start tube feeding at 2:00 PM for 20 hours dated 01/05/24. Another order was noted for Nothing by Mouth, with the exception of the Speech Therapist to introduce food/fluids consistency for enteral feeding, which was started on 12/31/23 and discontinued on 01/23/24. An observation conducted on 01/22/24 at 12:28 PM showed Resident #34 with a lunch tray and the tube feeding on hold. Closer observation showed Staff X, Speech Language Pathologist, at the bedside assisting Resident #34 with her lunch tray. The lunch meal was noted with pureed roast turkey, pureed collard greens, pureed mashed potatoes, and a slice of soft cake. The meal ticket revealed the following: regular pureed with Nothing by Mouth (NPO), do not send tray, on the top and bottom of the meal ticket. In this observation, Staff X stated that Resident #34 was not eating by mouth until last Thursday and that she upgraded Resident #34 ' s diet. The diet was upgraded to a one-a-day, pureed diet with trials of mechanical soft. According to Staff X, they are trying to wean Resident #34 from tube feeding, so they started with one meal a day. When asked by the Surveyor if she was the only one who could assist Resident #34 with her lunch meals, she said no and that any staff members could help her during mealtimes. The Surveyor asked Staff X if she knew why it said NPO/do not send a tray on the meal ticket; she did not know. In an observation conducted on 01/23/24 at 12:30 PM, Resident #34 was noted in the main dining room on the 2nd floor. A closer observation showed Staff X sitting near Resident #34 and assisting her with the lunch meal. The Surveyor asked Staff X if she found out why the meal ticket still says NPO/do not send a tray. She said, You need to ask the main kitchen. They are the ones who print out the meal tickets. A review of the Medication Administration Record for the month of January 2023 showed that the orders to start the tube feeding at 2:00 PM for 20 hours were documented as done daily, and the tube feeding Jevity 1.2 to run for 24 hours at 60 ml an hour was documented as done on a daily basis. In an interview conducted on 01/24/24 at 1:42 PM with Staff L, Licensed Practical Nurse, she stated that when she was asked earlier if any staff member could assist Resident #34 during the lunch meal, and she said yes, it was incorrect. When asked by Surveyor as to why she marked both tube feeding orders as above as completed, she stated that it was an oversight on her part and that both tube feeding orders contradict each other. 6) Resident #153 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, Heart Failure, and Hypertension. He was admitted with a suprapubic catheter. During record review on 01/22/24 at 10:00 AM for Resident #153, there were no physician orders for catheter care. There also was no care plan for catheter care. A review of the order summary report revealed the orders for catheter care were initiated on 01/22/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 70 of 89 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 01/25/2024 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 0842 Discussed with the Director of Nurses on 01/22/24 at 4:00 PM. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 71 of 89 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 01/25/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have an integrative care plan and effective communication between the facility and the hospice provider for 1 of 1 resident reviewed for hospice (Resident #40). The findings included: A review of the facility policy titled, Coordination of Hospice Services, revised on 6/2023, revealed the following: when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff to promote the resident's highest practicable physical, mental, and psychosocial well-being. The facility and hospice provider will coordinate a care plan and implement interventions per the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/ practitioner and resident's representative to the extent possible. The plan of care will identify the care and services that each entity will provide to meet the needs of the resident and their expressed desire for hospice care. A record review revealed that Resident #40 was admitted to the facility on [DATE] with diagnoses of Dementia and Behavioral Disturbances. The most recent Quarterly Minimum Data Set assessment dated [DATE] shows that Resident #40 has a Brief Interview of Mental Status (BIMS) score of 99, which means that the score could not be obtained. A review of the Physician's order showed an order: referral for hospice consult, which was dated 07/05/23. Further review did not show an order to be admitted to hospice. Long-term care facility change in billing revealed that Resident #40 was admitted to Vitas Hospice effective 07/06/23. A progress note dated 07/05/23 showed Resident #40's spouse had concerns regarding possible hospice consultation. He related that he would like to have them notified. A review of the facility care plan did not show that a care plan was initiated and updated regarding hospice for Resident #40. A review of the hospice binder on the 2nd-floor Unit did not show documentation regarding care coordination between the facility and the hospice agency. Further review should have demonstrated that delegation of care was communicated between the facility and hospice. An interview conducted on 01/25/24 at 9:44 AM with Staff Q, Minimum Data Set (MDS) Coordinator, stated that when a resident gets admitted to hospice, they should always be admitted to hospice in the medical chart. She will review the Physician's orders and then knows that a care plan for hospice needs to be created. Social Services will also inform her if a resident was admitted to hospice. When asked why Resident #40 did not have a care plan for hospice, she did not have an answer. In an interview conducted on 01/25/24 at 9:15 AM, Staff J, Unit Manager, said that when residents are admitted to hospice, they will call the doctor to get an order to accept the resident to hospice, which is then placed as an order in the electronic system. The Social Worker communicates with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 72 of 89 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 01/25/2024 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 0849 hospice team and the nurse assigned to the resident. Level of Harm - Minimal harm or potential for actual harm In an interview conducted on 01/25/24 at 1:40 PM with the facility's Medical Director, he stated that he was aware that they had issues with the hospice agency not completing the care plan on time and not communicating with the nursing home. He had to call the hospice company in the past to discuss the issue. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 73 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interviews and record review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program. Residents Affected - Some The findings included: A review of the QAPI plan dated 2023 revealed the following: The plan provides a framework for a systematic, organization-wide improvement system specific to identifying aspects of quality needs and gaps in systems of care and management practices in our organization. Ensuring that all quality management initiatives regarding the delivery and management of care are clinically sound, promote consumer safety, and are based on current best practices. Which indicators of quality were evaluated during the quarter, and what were the results of the actions? What actions are planned and have been taken to improve quality and the results of those? Lessons learned from this process. Plan for sustained compliance. A record review of the previous Recertification survey dated 10/08/2021 revealed that the facility was found to be out of compliance under Physical Environment and cited at F925 and F921. The facility was found to be out of compliance under Comprehensive Resident Centered Care Plans and cited at F656. The facility was found to be out of compliance under Resident Rights and cited at F557. A record review of the facility's complaint history revealed a complaint dated 07/23/23 regarding pest control, which was substantiated and cited under Physical Environment. In an interview conducted on 01/25/24 at 1:40 PM with the facility's Medical Director, he stated that he was aware the facility had issues with not promptly completing care plans. He further said that he knew that the hospice contracted companies were not completing care plans regarding hospice care and that they were supposed to start a PIP (Performance Improvement Plan) on the issue. In an interview conducted during the QAPI task review on 01/25/24 at 5:36 PM with the facility's Administrator, he stated that they have been tracking and trending different care areas as needed. He has an open-door policy that enables communication between him and staff members as required. The Administrator reported that QAPI areas are started and continued for 90 days or until they feel the issue has been resolved. Any Performance Improvement Plan (PIP) goal is met at around 90%. They meet once a month with all department heads and the Medical Director. The Administrator stated that they last had a QAPI on pest control around September of 2023. They were cited under Physical Environment, and a QAPI was started, which tracked pest control and ended around September 2023. When asked to see documentation on continuous tracking and trending regarding the Physical Environment since September 2023, the Administrator did not have any. When asked to see if a QAPI was completed regarding incomplete care plans or timing of care plans in the last year, the Administrator could not provide any documents. In an interview conducted on 01/25/24 at 6:04 PM, the Infection Preventionist stated that they started a QAPI on staff not following the Physician's orders, which began on 11/30/23 and is ongoing at this time. When asked if a PIP was started on hospice care plans not completed on time, she said no. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 74 of 89 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 01/25/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 01/22/24 at 7:30 AM, an initial tour was conducted of the residential rooms on the second floor. Resident #153 was observed in bed with the catheter bag on the floor (photographic evidence obtained). Residents Affected - Some Resident #153 was admitted to the facility on [DATE] with a suprapubic catheter. 4) On 01/22/24 at 9:00 AM, Resident #155 was observed in bed being served breakfast. Staff L, a Licensed Practical Nurse, entered the room and gave Resident #155 an insulin injection into his left arm without wearing gloves. Based on observations, interviews and record review the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment for the laundry area, for 2 of 2 shower rooms located on the 1st floor; failed to ensure urinary catheter drainage bag was maintained off the floor for 1 sampled resident for catheter care (Resident #153); failed to utilize appropriate PPE (Personal Protective Equipment) during administration of an injectable for Resident #155; and failed to provide snacks in a sanitary manner for 1 of 36 sampled residents (Resident #86). The findings included: Review of the facility's policy titled, Infection Prevention and Control Program with a reviewed/revised date of 08/15/22 included: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standard and guidelines. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. c. All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. e. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department. 11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. b. Clean linen shall be separated from soiled linen at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 75 of 89 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 01/25/2024 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 0880 c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. Level of Harm - Minimal harm or potential for actual harm d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. Residents Affected - Some Review of the facility's policy titled, Administration of Injections with a reviewed/revised date of September 2023 included: Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Dispose of sharps in puncture resistant containers near the point of use. Review of the facility's policy titled, Personal Protective Equipment with a reviewed/revised date of May 2022 included: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious material is likely. 1) During an initial tour of the facility conducted on 01/22/24 from 7:30 AM to 11:40 AM the following observations were made in the 2 locked Bath (Shower) Rooms located on the 1st floor: In the Bath (Shower) Room located on the 1st floor across from room [ROOM NUMBER] there were 2 locked treatment carts, uncovered clean hanging resident clothing items, 2 1-gallon jugs of skin/hair cleaner on the shower stall floor, clean linens on a cart with no cover. There were 2 disposable sharps containers, both filled so full several razors were extended out of the sharps container, 1 of the 2 disposable sharps containers was not locked/secured in place, just set inside a bracket that was affixed to the wall and easily removed from the wall as instructed by Staff A Licensed Practical Nurse/Unit Manager who attempted to remove the unsecured sharps container and in doing so spilled several of the razors out onto the floor of the room. Photographic Evidence Obtained. In the Bath (Shower) Room located on the 1st floor across from room [ROOM NUMBER] there were 2 sharps containers, both resting on top of the locked base that was affixed to the wall. There were no paper towels or paper towel holder at the sink area. On the counter next to the sink were 2 unlabeled and uncovered hairbrushes with hair. Also, on the counter next to the sink in a small plastic 3 drawer bin which had an uncovered and unlabeled used toothbrush as well as 3 additional unlabeled used toothbrushes (2 of which were in the same drawer of the bin). There were 2 1-gallon jugs of skin/hair cleaner on the shower stall floor, clean linens on a cart with no cover, clean resident clothing hanging with no cover. Photographic Evidence Obtained. During an interview conducted on 01/22/24 at 9:05 AM with Staff A, Licensed Practical Nurse/Unit Manager, he acknowledged the 2 disposable sharps containers, both filled so full several razors were extended out of the sharp's container, 1 of the 2 disposable sharps containers was not locked/secured in place. He stated the disposable sharps containers should have been replaced. 2) During the laundry tour conducted on 01/22/24 from 12:00 PM to 2:50 PM with the Director of Plant Operations, Director of Maintenance, and the Director of Housekeeping present the following observations were made: In the laundry sorting room, there were 2 white bins with soiled linens uncovered and 2 yellow bins with clean mop heads uncovered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 76 of 89 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 01/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm In the washer room there were uncovered resident shoes sitting on the windowsill to dry, there was a missing ceiling tile above the washers. In the dryer room [ROOM NUMBER] out of 3 dryers had drums that were rusty and had melted debris inside. Residents Affected - Some In the folding room, none of the linens were covered. There was a small refrigerator with beverages, containers of food and an orange. During an interview conducted on 01/24/24 at 2:50 PM with the Director of Housekeeping who stated the girls who work in the laundry area have a refrigerator so they can have cold beverages to drink because it gets hot, and they can keep their lunch in there as well because when they put their lunch in the employee lounge it gets stolen. During an interview conducted on 01/24/24 at 3:45 PM with LPN/Infection Preventionist (LPN/IP) who stated she has worked at the facility for 4 years and has been the IP since 08/01/23. The interview was also conducted with the Director of Nursing (DON) who stated she has worked at the facility for 3 years. They both have been in the laundry room several times and routinely go once a week. They said they had never noticed any issues and always thought it was clean. The only issues she had were just in general how things get cleaned. The LPN/IP said she knew they had a refrigerator but did not think it was an infection prevention issue and always thought they just had water in the refrigerator. 5) During a tour of the facility conducted on 01/22/24 at 10:51 AM, the surveyor observed numerous residents on the first floor of the facility mingling in the milieu. Staff A, Licensed Practical Nurse Unit Manager was assisting the staff by passing out snacks to the residents. Resident #86 asked Staff A for a snack. Staff A retrieved a snack package from the nutrition room and attempted to open it for Resident #86. After some difficulty, Staff A used his teeth to open the snack package. He began to hand the opened snack package to Resident #86 when the surveyor intervened, pointing out what he had done and asked if it was appropriate for Resident #86 to receive this snack package. Without responding, Staff A retrieved a new snack from the nutrition room and gave it to Resident #86, who proceeded to walk into the dining room for an activity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 77 of 89 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 01/25/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide documentation of offering/acceptance/declination of the pneumococcal vaccine for 4 out of 5 sampled residents reviewed for vaccines (Residents #9, #53, #69, and #94). Residents Affected - Some The findings included: Review of the facility's policy titled, Pneumococcal Vaccine (Series) Policy with a reviewed/revised date of 01/31/22 included: It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. A pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations: a. For adults 65 years' or older who have not previously received any pneumococcal vaccine: Give 1 dose of PCV15 or PCV20. b. For adults 65 years or older who have only received a PPSV23: Give 1 dose PCV15 or PCV20. i. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. 1) Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. The resident is 65 years or older. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 78 of 89 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 01/25/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review for Resident #9 revealed the resident had historically received the Pneumococcal Vaccine (PPSV23) on 12/17/18 and was eligible to receive a pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. 2) Record review for Resident #53 revealed the resident was admitted to the facility on [DATE]. The resident is 65 years or older. Record review for Resident #53 revealed the resident had historically received the Pneumococcal Vaccine (PPSV23) on 09/22/20 and was eligible to receive a pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. 3) Record review for Resident #69 revealed the resident was admitted to the facility on [DATE]. The resident is 65 years or older. Record review for Resident #69 revealed the resident had not received the pneumococcal vaccine historically and was eligible to receive the pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. 4) Record review for Resident #94 revealed the resident was admitted to the facility on [DATE]. The resident is 65 years or older. Record review for Resident #94 revealed the resident had not received the pneumococcal vaccine historically and was eligible to receive the pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. During an interview conducted on 01/24/24 at 3:45 PM with the Licensed Practical Nurse/Infection Preventionist (LPN/IP), who stated she has worked at the facility for 4 years and has been the Infection Preventionist since 08/01/23. The interview was also conducted with the Director of Nursing (DON) who stated she has worked at the facility for 3 years. When asked about pneumococcal vaccines for residents, they stated the pneumococcal vaccine is offered annually at the same time as the influenza and it is offered on admission. To determine eligibility, they refer to the CDC guidelines and if it is unknown what previous vaccine the resident may have had, they would discuss with the physician to determine if the resident should have the vaccine. When asked if a resident or residents representative refused a pneumococcal vaccine while in the facility, how was this documented. The LPN/IP and the DON stated, if the resident or residents representative refuses a pneumococcal vaccine while in the facility, they would simply not check that the pneumococcal vaccine was accepted/administrated on the Vaccine Consent and Administration form the facility utilized. The refusal of a vaccine would be documented in the EMR (Electronic Medical Record) under immunization tab that the resident declined the vaccine. The DON stated the facility went back to using a consent/declination form for vaccines that had a separate section for influenza and pneumococcal, for the resident or resident representative to accept or decline each individual vaccine being offered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 79 of 89 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 01/25/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on interviews and record review, the facility failed to monitor inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program. Residents Affected - Few The findings included: Review of the facility's policy titled, Proper Use of Bed Rails with a reviewed/revised date of 07/25/22 included: If bed rails are used, the facility ensures correct installation, use and maintenance of the rails. Under the Section: Ongoing Monitoring and Supervision included: The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including but not limited to, the following information: a. The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring. Responsibilities of ongoing monitoring and supervision are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with the plan of care. b. A nurse assigned to the resident will complete assessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail. c. The interdisciplinary team will make decisions regarding when the bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the bed rail. d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. During an interview conducted on 01/25/24 at 8:30 AM with the Director of Maintenance (DOM), who stated he has been working at the facility for 1.5 months. When asked what kinds of beds they use, he stated there are all different kinds of beds. When asked if the facility uses bed rails, he said yes. He was told by the Regional person to remove the bed rails from all beds but leave the bed rails that have the bed controls incorporated into the bed rail. When asked if they perform any inspection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 80 of 89 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 01/25/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or compatibility of bed frame, mattresses, and bed rails, he said no. When asked if they have the manufacturers instruction for each type of bed, mattress and side rails used in the facility, he said they hardly have any instruction manuals for any equipment. He was asked to provide instruction manuals for the bed frame, mattresses and bed rails used by the facility. None were provided. The DOM stated the nurses should tell him if there are any bed rails in use. The DOM stated they have no system in place that he is aware of for checking the bed rails and he does not monitor bed rails. During an interview conducted on 01/25/24 at 11:00 AM With Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. When asked about bed rails, she stated most of the resident beds have at least 1 side rail. The nurse assesses the resident for side rail (bed rail) safety, there is an assessment in the computer, but she has not had to complete a form because those were done for the resident before she started working at the facility. If there is an incident such as a fall that happens then she would have to reassess for the side rails but that has not happened. During an interview conducted on 01/25/24 at 11:30 AM with Staff B, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 1 year. When asked about bed rails, she stated this floor does not use side rails (bed rails). She said all of the beds on this floor that have side rails (bed rails) are all down unless they are on seizure precautions. When asked if they monitor or assess for the bed rails, she said yes, but most of those residents are ambulatory and we just check on the resident every 2 hours. She said they check every morning during rounds to see if the bed is okay. When asked about documentation regarding bed rails, she said if the bed is okay and you have a reason to put a nursing note in for a resident you can document, it in the note. If the siderail (Bed rail) is not okay, she will put it on the sheet for maintenance to check or she may call maintenance also to alert them of the issue. During an interview conducted on 01/25/24 at 11:50 AM with Staff A, Licensed Practical Nurse Unit Manager (LPN/UM), he stated he has worked at the facility since August or September. When asked about bed rails, he said what do you mean. When asked if beds have bed rails, he said no. He said very few beds have a side rail (bed rail). The only beds with a side rail (bed rail) are the beds that have the control incorporated into the side rail (bed rail). When asked are residents assessed for bed rails he said yes, upon admission and an assessment for side rails (bed rails) are completed in the residents' chart. When asked if the bed rails are monitored, he stated yes, nurses walk around and look at the beds. When asked where the documentation of the monitoring of bed rails is, he said no we do not document that. When asked if maintenance inspects the beds, mattresses, or bed rails he said he never saw that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 81 of 89 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 01/25/2024 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 0918 Provide a bathroom in or located near each resident’s room. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure resident room is equipped with a working toilet or located near an accessible toilet for 1 of 100 residents screened (Resident #53). Residents Affected - Few The findings included: Review of the facility's policy titled, Safe and Homelike Environment with a reviewed/revised date of 04/11/23 included: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility, and Unspecified Hearing Loss Bilateral. Review of the Minimum Data Set for Resident #53 dated 11/19/23 revealed in Section C, a Brief Interview of Mental Status Score of 1, indicating severe cognitive impact. In Section GG it revealed for toilet hygiene the resident had a performance of partial/moderate assistance, for walking 10 feet, walking 50 feet with two turns and walking 150 feet the resident had a performance of partial/moderate assistance. On 01/22/24 at 7:45 AM, an observation was made of Resident #53 lying on his bed. Upon opening Resident #53's bathroom there was an overwhelming urine smell, the toilet was closed and covered with plastic over the toilet bowl. On 01/22/24 at 8:00 AM, an observation was made of the closest toilet to Resident #53 was in the Bath (Shower) room that was 8 rooms away on the opposite side of the hall and is always locked. On 01/22/24 at 11:00 AM, an observation was made of Resident #53 ambulating in room, no staff member present, and the toilet bowl continued to be covered in plastic. On 01/22/24 at 4:05 PM, an observation made of Resident #53's bathroom revealed the bathroom continued to smell of urine, toilet no longer covered with plastic but had brown fecal type matter on toilet seat and in the toilet bowl. On 01/23/24 at 9:00 AM, an observation was made of Resident #53 sitting on edge of bed, there was a sign on the resident's bathroom door that said out of order, toilet bowl covered with plastic and had an out of order sign placed on the toilet bowl. During an interview conducted on 01/22/24 at 7:48 AM with Staff E, Certified Nursing Assistant (CNA), who had entered Resident #53's room, she stated she has worked at the facility for 1 month. When asked if there was something wrong with the toilet, she said I think it is a little stopped. When asked how long the toilet has been like this, she said I think since Thursday or Friday. When asked if the resident uses the toilet, she said yes sometimes. When asked what happened when the resident had to use the toilet and it was not available, she said he has a brief. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 82 of 89 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 01/25/2024 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 0918 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview conducted on 01/22/24 at 9:30 AM with Resident #53's son, he stated when he visited his father, in early November 2023 the toilet was not working and would not flush. During an interview conducted on 01/22/24 at 4:10 PM with Staff A, Licensed Practical Nurse/Unit Manager, when asked about the broken toilet in Resident #53's bathroom, he stated it has been broken off and on for about a week. When asked what the resident does when he needs to use the toilet, he did not respond. During an interview conducted on 01/25/24 at 1:45 PM with the Director of Maintenance who was asked how long the toilet has not been working in Resident #53's room, he said they have had issues with that toilet off and on for a while. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 83 of 89 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 01/25/2024 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 0920 Level of Harm - Minimal harm or potential for actual harm Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observations, interviews, and record reviews, the facility needed to ensure adequate lighting in designated resident dining and activities rooms. Residents Affected - Few The findings included: A review of the facility's policy titled, Safe and Homelike Environment: revised on 04/11/23 revealed that in accordance with resident ' s rights, the facility will provide a safe, clean, comfortable, and homelike environment. It further showed providing adequate lighting, which means a level of illumination suitable to tasks the resident chooses to perform or the facility staff must perform. In a dining observation conducted on 01/22/24 at 7:50 AM, in the main dining room on the 2nd-floor, the following inadequate lighting was noted: The 4 round lights that are noted next to the main kitchen side had one light bulb working out of 4 light bulbs. The four lights noted near the outside window showed that only two bulbs were working out of 4 light bulbs. The dining room was noted to have 25 residents waiting for their breakfast meals. In this observation, Staff M, a Certified Nursing Assistant, was asked about the light bulbs not working. She then turned on the 8 square light bulbs in the middle of the dining room, and the lighting was still dim. In an observation conducted on 01/23/24 at 10:58 AM, on the 1st floor, in the Sunset room, two wall lamps were noted, with one missing a bulb, near the entrance door. The bathroom in the Sunset room was missing the ceiling light cover. In an observation conducted on 01/24/24 at 11:20 AM, in the main dining room on the 2nd floor, the following inadequate lighting was noted: The 4 round lights that are noted next to the main kitchen side had one light bulb working out of 4 light bulbs. The 4 round lights noted near the outside window showed that only two out of 4 light bulbs were working. In this observation, the Surveyor turned on the 8 square light bulbs in the middle of the dining room. Resident #7, sitting in the main dining room, said, Oh, this is much better. In an observation conducted on 01/23/24 at 12:30 PM, in the main dining room on the 2nd floor, 27 residents were eating their lunch meal. The 4 round lights that are noted next to the main kitchen side had one light bulb working out of 4 light bulbs. The 4 round lights noted near the outside window showed that only two out of 4 light bulbs were working. In a tour conducted on 01/25/24 at 9:00 AM, in the main dining room on the 2nd floor with the Maintenance director, the following were noted: the 4 round light bulbs were replaced on the right side, and only 2 out of the 4 round light bulbs were replaced on the left side near the window. In this observation, the Maintenance Director said that he had enough supplies to replace the light bulbs on most of the lights but needed another two light bulbs. When asked by Surveyor if he was aware that a light bulb was missing on the first floor in the Sunset room, he said yes and that he still needed to purchase the specific bulb for that type of lighting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 84 of 89 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 01/25/2024 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to equip corridors with securely affixed handrails on 1 of 2 floors of the facility (the First floor). Residents Affected - Few The findings included: Review of the facility's policy titled, Handrails with a reviewed/revised date of 04/02/23 included: The facility will equip corridors with a handrail on each side of the hall. All handrails will be firmly secured. During an initial tour conducted on 01/22/24 from 7:45 AM to 11:30 AM, on the first floor (Memory Unit), the handrails were observed to be loose and not firmly secured to the wall. During an interview conducted on 01/25/24 at 1:45 PM with the Director of Plant Operations, the Director of Maintenance, and the Maintenance Assistant they acknowledged the handrails were loose. The Director of Plant Operations stated the handrails are secured to the wall, it is just the part of the handrail you hold onto that is loose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 85 of 89 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 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Mariam Health and Rehabilitation Center 1801 N Lake Mariam Dr Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to have an effective pest control program. Residents Affected - Some The findings included: A review of the policy titled, Pest Control Program, revised on 01/06/23, revealed the following: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services regularly and regularly. The facility will maintain a reporting system of issues arising between scheduled visits with the external pest service and treat them as indicated. An observation conducted on 01/22/24 at 7:34 AM, in the main kitchen showed pests in all stages of life near the food production area. Continued observation showed pests in all stages of life in the dishwasher room on the floor. In this observation, the Certified Dietary Manager said that the pest control company comes into the kitchen twice a month to treat pests. An observation conducted on 01/22/24 at 3:05 PM, in the 2nd-floor Nourishment room revealed pests in all stages of life. An observation conducted on 01/22/24 at 3:12 PM, in the 1st-floor hallway, near the elevator showed a live pest. In an interview conducted on 01/22/24 at 3:20 PM with Staff A, the Unit Manager stated that he had not seen any sightings of pests on the 1st floor. He further said that if there are any sightings of pests, they will write them in the pest control book that is located on the unit. This is later reviewed by the pest control company when they come into the facility to spray. An observation conducted on 01/23/24 at 10:54 AM, in the 1st-floor unit, near room [ROOM NUMBER] revealed pests in all stages of life. In an observation conducted on 01/23/24 at 11:00 AM, in the elevator with Staff A present, a roach-like insect was seen moving on the elevator floor. Staff A then stomped on the insect and stated, I will have to put this in the pest control sighting book. A record review conducted on 01/24/24 of the insect log sighting book on the first floor revealed that the insect sighting in the elector was not documented by Staff A. An observation conducted on 01/23/24 at 11:01 AM, in the 1st-floor unit, near the fish tank revealed pests in all stages of life. In this observation, an additional sighting of pests in all stages of life was noted near the nurse ' s station. An observation conducted on 01/24/24 at 11:00 AM, on the 1st-floor unit, behind the fish tanks revealed pests in all stages of life. A record review of the Service Log located on the 1st floor revealed that Nursing reported a pest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 86 of 89 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 01/25/2024 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 sighting on the 1st floor near room [ROOM NUMBER] on 01/22/24, which did not show that the service was completed. A record review of the Pest Control Sighting Log revealed that eight pest sightings were documented on the type of pests, locations, and the person who reported the sighting. Further review did not show that it was addressed or treated by pest control. In an interview conducted on 01/25/24 at 8:06 AM, the Maintenance Director stated that he started working in this facility about six weeks ago. He noticed they had pest issues, which were mostly on the 1st floor. The Administrator gave him a contact number for a pest control company. He reached out and was told that because of pending invoices, they would not come anymore. The Maintenance Director expressed concern to the Administrator regarding the pending invoices that were not paid and that the pest company would not come to treat the affected areas. According to the Maintenance Director, a new pest control company treated the building this week and last. No current invoices were provided, the last invoice provided was dated 12/22/23. In an interview conducted on 01/25/24 at 5:15 PM, the Administrator stated that he was aware of pests sighting around the facility. When the pest control company comes in for their routine visits, they will first look in the pest control sighting log to spot-treat the specific areas as needed. After the areas are treated, the book is signed and dated as treated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 87 of 89 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 01/25/2024 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and policy review, the facility failed to follow their smoking policy for 2 of 9 residents identified as smokers (Resident #15 and #48). Residents Affected - Few The findings included: The facility's policy titled, Smoking Policy revealed All smokers will be supervised during smoking without exception. Metal ashtrays with self-closing covers are to be used to hold and dispose of cigarettes in smoking areas. Resident #15 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Chronic Obstructive Pulmonary Disease and Cognitive Communication Deficit. Her Brief Interview for Mental Status (BIMS) score from the annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/01/23 was 13, which indicated the resident was cognitively intact. Section J of the MDS assessment revealed she was a current tobacco user. Review of the resident's care plan revealed the resident must smoke with supervision. Resident #48 was admitted to the facility on [DATE] with diagnoses that included Cellulitis of Left Lower Limb, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease. His BIMS score was 13 on his annual MDS assessment with an ARD of 01/07/24. Section J of the MDS assessment revealed he was a current tobacco user. Review of the resident's care plan revealed the resident must smoke with supervision. On 01/22/24 at 11:20 AM, an observation was made of residents smoking on the smoking patio which is in front of the building. There was no supervision for the smoking residents. A review of the smoking times revealed the next smoking time to be 11:30 AM to 11:45 AM. An observation of the smoking patio revealed cigarette butts all over the stones in the front of the building and in the flower pots. There was no fire extinguisher present. There were 2 self-closing metal trash cans present. One was empty and the other had an empty cigarette box in it (photographic evidence obtained). An interview was conducted with Resident #48 at the time of the observation. Resident #48 was asked how he was able to be smoking before the staff came out to provide the cigarettes. Resident #48 stated there is a dollar store where cigarettes can be bought and we sign ourselves out and go there to buy cigarettes. On 01/22/24 at 11:35 AM, Staff V, a Certified Nursing Assistant (CNA), arrived on the smoking patio with the lock box of cigarettes and lighters. Staff V stated she was unsure if she should stay with the residents. She stated this was her second day on the job and she was not sure if she should give the whole bag of cigarettes to the residents or give them cigarettes one by one. Discussed observation of smoking area and residents smoking without supervision with the Administrator and Social Service Director on 01/22/24 at 4:00 PM. They acknowledged the residents were not supervised while smoking earlier today. They acknowledged all residents who are smoking should be supervised. They were asked if they were aware there are cigarette butts all over the front of the building and they acknowledged that they were aware and housekeeping should be cleaning them up. They were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105428 If continuation sheet Page 88 of 89 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 01/25/2024 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete also aware that the residents are buying their own cigarettes and pocketing them. They stated they have been trying to stop this practice but residents are still doing it. The residents were re-educated this morning on the smoking policy. An additional interview was conducted with Staff V on 01/24/24 at 10:28 AM. Staff V stated she was told the residents had set times for smoking and they have to be with them when they smoked. She knew the times but she did not know ahead of time that she would be supervising smoking. She arrived late because she was also doing patient care. She was told here is the box with the cigarettes and she was told she had to supervise them. Event ID: Facility ID: 105428 If continuation sheet Page 89 of 89

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Citations

50 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0001GeneralS&S Dpotential for harm
Establish an Emergency Preparedness Program (EP).
0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0712GeneralS&S Dpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0741GeneralS&S Dpotential for harm
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
0914GeneralS&S Dpotential for harm
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
0918GeneralS&S Dpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0919GeneralS&S Dpotential for harm
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
0923GeneralS&S Dpotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0657GeneralS&S Epotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0688GeneralS&S Dpotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0757GeneralS&S Epotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0808GeneralS&S Dpotential for harm
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
0812GeneralS&S Dpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0835GeneralS&S Dpotential for harm
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
0842GeneralS&S Epotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0867GeneralS&S Epotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0804GeneralS&S Dpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0559GeneralS&S Dpotential for harm
F559 - The right to share a room with his or her spouse when married residents live
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0687GeneralS&S Dpotential for harm
F687 - Foot care
Provide appropriate foot care.
0689SeriousS&S Kimmediate jeopardy
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0732GeneralS&S Dpotential for harm
F732 - Nurse Staffing Information
Post nurse staffing information every day.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0909GeneralS&S Dpotential for harm
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0920GeneralS&S Dpotential for harm
F920 - Dining and Resident Activities
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
0924GeneralS&S Dpotential for harm
F924 - Equip corridors with firmly secured handrails on each side
Put firmly secured handrails on each side of hallways.
0926GeneralS&S Dpotential for harm
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
0807GeneralS&S Dpotential for harm
F807 - Food and drink
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
0837GeneralS&S Dpotential for harm
F837 - Governing body
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
0925GeneralS&S Epotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
0814GeneralS&S Epotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.

FAQ · About this visit

Common questions about this visit

What happened during the January 25, 2024 survey of LAKE MARIAM HEALTH AND REHABILITATION CENTER?

This was a inspection survey of LAKE MARIAM HEALTH AND REHABILITATION CENTER on January 25, 2024. The surveyor cited 50 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LAKE MARIAM HEALTH AND REHABILITATION CENTER on January 25, 2024?

Yes, 50 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish an Emergency Preparedness Program (EP)."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·January 25, 2024