Inspection·February 22, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/19/2023 at 12: 10 p.m., an interview was conducted with Staff F. She said she preferred to stands up while assisting residents with their meals. Staff F said she had never been told she could not stand up and assist residents with their meals. On 02/19/2023 at 12: 15 p.m., an interview was conducted with Staff G. She said she always stood up while assisting residents with their meals. Staff G said she had never been told she had to sit down while assisting residents with their meals. On 02/21/2023 at 11:00 a.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA said her expectation was that staff needed to sit down next to the resident and not stand up over them while assisting residents with their meals. Review of the facility policy and procedures, titled, Meal Supervision and Assistance, dated 10/2022. Showed the resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. Compliance Guidelines 14. Provide a relaxing, enjoyable environment during mealtime. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 2 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure timely completion of a comprehensive assessment for one (Resident #223) of 44 sampled residents. Findings included: A review of Resident #223's medical record revealed Resident #223 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, Alzheimer's disease, dementia, and depression. A request was made on 2/21/2023 at 3:40 PM for Resident #223's admission Minimum Data Set (MDS) assessment. The assessment was not provided by the facility. A review of Resident #223's medical record revealed an open MDS admission assessment with an Assessment Reference Date (ARD) of 2/13/2023. The medical record also revealed Resident #223's admission MDS assessment was due on 2/20/2023. An interview was conducted on 2/21/2023 at 3:41 PM with the facility's Regional Clinical Reimbursement Nurse (RCRN), who stated Resident #223's admission MDS assessment should have been completed on 2/20/2023. The RCRN was not able to state why Resident #223's admission MDS assessment was not completed timely. A review of the facility policy titled MDS 3.0 Completion, last revised in January 2022, revealed under the section titled Policy residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy also revealed, under the section titled Policy Explanation and Compliance Guidelines admission Assessments are completed within 14 days of admission counting the day of admission as day #1 when the resident has no prior admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 3 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for eight (Residents #19, #12, #48, #101, #50, #47, #74, and #78); and 2.) ensure the accuracy of a PASARR Level I for two (Residents #24 and #223) of ten residents admitted with mental health diagnoses sampled for PASARR. Findings include: 1. Review of the clinical record revealed Resident #19 was admitted to the facility on [DATE], with a readmission on [DATE], and a primary diagnosis of Diabetes according to the admission face sheet. Further review of the admission face sheet revealed subsequent diagnoses that included Bipolar disorder (as of 12/6/2013) and Major Depressive Disorder (as of 11/16/2021). Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed under Section I, diagnoses that included Depression and Bipolar Disorder; and under Section N, antidepressant medications were received during seven of the past seven days. Review of Psychiatry Note dated 02/15/2023 showed diagnoses that included Major Depressive Disorder, recurrent, moderate. Review of a PASARR Level I dated 12/05/2013 revealed Section 1A marked 'N/A' [not applicable] and Section II Part A checked 'no.' Continued review of the clinical record revealed a PASARR Level I dated 09/26/2017 with Section 1A marked through with a line, and Section II Part A checked 'no.' The clinical record did not reveal any additional PASARR (Level I nor Level II) assessments. 2. Review of the clinical record revealed Resident #12 was admitted to the facility on [DATE], with a readmission on [DATE], and a primary diagnosis of Hemiplegia according to the admission face sheet. Further review of the admission face sheet revealed subsequent diagnoses that included Delusional Disorders (as of 02/17/2014) and Major Depressive Disorder (as of 02/17/2014). Review of the annual MDS dated [DATE] for Resident #12 revealed under Section I, diagnoses that included Depression and Psychotic Disorder (other than schizophrenia); and under Section N, antidepressant medications were received during seven of the past seven days. Review of Psychiatry Note dated 02/01/2023 showed diagnoses that included Major Depressive Disorder, recurrent, moderate, and Other Specified Persistent Mood Disorders. Review of a PASARR Level I dated 08/12/2013 revealed Section 1A marked 'N/A' and Section II, Part A is checked 'no.' The clinical record did not reveal any additional PASARR (Level I nor Level II) assessments. During an interview with the Nursing Home Administrator (NHA) on 02/20/23 at 04:14 PM, she stated she was unable to provide any additional PASARR (Level I or II) information related to Resident #19 or Resident #12. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 4 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 02/21/23 at 02:25 PM an interview was conducted with the Social Services Director (SSD). The SSD said the PASARR was not her responsibility, and she was not sure who was responsible for ensuring PASARR assessments were completed when a new mental health diagnosis was identified for a resident, or for ensuing PASARR assessments completed pre-admission to the facility were accurate. On 02/21/23 at 02:36 PM an interview was conducted with the NHA and the SSD. The NHA stated she and the Director of Nursing (DON) were responsible for reviewing PASARR assessments for accuracy pre-admission to the facility. The NHA was unable to explain the process for reassessing a resident following a new mental health diagnosis, and confirmed the facility did not have a process in place to identify the need for PASARR reassessments when a resident had a new mental health diagnosis. Review of facility-provided policy titled 'Resident Assessment - Coordination with PASARR Program,' dated 11/2020 and revised/reviewed 10/2022 revealed: Policy: The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggestion the presence of a mental disorder (where dementia is not the primary diagnosis). 3. Review of Resident #24's medical record was conducted. The admission record revealed an initial admission date of 02/15/2019, a re-admission date of 08/06/2019 and diagnoses that included, dementia, major depressive disorder with psychotic symptoms, disruptive mood dysregulation disorder, anxiety disorder, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] revealed active diagnoses that included, dementia, anxiety disorder, depression, and psychotic disorder. The PASARR Level I document for Resident #24's initial admission, dated 02/14/2019, had no diagnoses documented in Section I, all questions in Section II were documented as no, and section IV was documented as No diagnosis or suspicion of SMI (serious mental illness) or ID (intellectual disability) indicated. Level II PASRR evaluation not required. The PASARR document for Resident #24's re-admission, dated 06/05/2019, had no diagnoses documented in section I, question 3 in section II regarding whether the resident had received psychiatric treatment more intensive than outpatient care was documented as yes, questions 5-7 in section II were not answered. There were no other Level I or Level II PASARR documents in Resident #24's record. Interviews with the NHA and SSD conducted on 02/21/2023 at 2:24 p.m. confirmed no additional PASARR screens had been completed for Resident #24. 4. Review of Resident #48's medical record was conducted. The admission record revealed an initial admission date of 02/14/2020, a re-admission date of 06/23/2021, and diagnoses that included generalized anxiety disorder, major depressive disorder, and schizophrenia. The onset date for the schizophrenia diagnosis was documented as 12/07/2021. The quarterly MDS assessment dated [DATE] revealed active diagnoses that included, anxiety disorder, depression, schizophrenia. There was only one PASARR document, a Level I screen, in the record and it was dated 02/13/2020. There were no diagnoses documented on the screen, all questions in Section II were documented as no, and Section IV was documented as, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 5 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Level II PASRR evaluation not required. Interviews with the NHA and SSD conducted on 02/21/2023 at 2:24 p.m. confirmed no additional PASARR screens had been completed for Resident #48. 5. A review of Resident # 50's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Schizophrenia, Unspecified, and Major Depressive Disorder. A review of the quarterly MDS dated [DATE], Section C- Cognitive Patterns showed Resident #50 had a Brief Interview for Mental Status ( BIMS), score of a 15, which indicated intact cognition. A review of the Preadmission Screening and Resident Review (PASRR) Level II Determination Summary report showed Resident #50 met the state definition of Serious Mental Illness and a Level II determination was made on 3/21/2022. A review of the Psychiatry Subsequent Note dated 2/15/2023 showed Resident #50 was receiving psych services for Depression, anxiety and bipolar disorder and medication management. A review of the medical record for resident # 50 revealed the facility did not have a Level II PASRR for Resident # 50. 6. Resident # 101 admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to Cognitive Communication, Schizophrenia, Unspecified, and Aphasia. A review of the quarterly MDS dated [DATE], Cognitive Patterns showed Resident #101's Cognitive Skills for Daily Decision Making was coded as a 3 which indicated severe cognitive impairment. A review of the Preadmission Screening and Resident Review Level II dated 04/28/2022 results showed that Resident # 101 met the state definition of Serious Mental Illness, and a Level II determination was made on 4/28/2022. A review of the Psychiatry Subsequent Note dated 01/18/2023 showed that Resident # 101 was receiving psych service for Paranoid schizophrenia and mood disorder, and medication management. A review of the medical record for resident #101 revealed the facility did not have a Level II PASRR for Resident # 101. An interview was conducted with the Social Service Director, SSD. The SSD said she was not aware that she was responsible with following up and obtaining residents PASRR's. An interview was conducted with the Nursing Home Administrator, NHA. She said she did not have a system in place regarding following up and obtaining resident PASRRs in the facility but moving forward she would implement a process. 7. A record review of Resident #47's medical record showed a diagnosis of Specified Dementia, unspecified severity, with agitation and onset date 10/01/22, Generalized Anxiety Disorder, Unspecified with onset date 12/02/19 and Schizoaffective Disorder, Unspecified with onset date 12/02/19. An annual minimum data set (MDS) dated [DATE] showed Resident #47 had Anxiety Disorder and Schizophrenia in section I. A Psychiatric Note stated, Diagnostic Assessment: Generalized Anxiety Disorder, Unspecified dementia, unspecified severity, with other behavioral disturbances and Paranoid Schizophrenia. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 6 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Level I PASARR dated 12/05/19 stated Resident #47 required a Level II PASARR to be completed but no level II PASARR was available in the medical record. 8. A record review of Resident #74's medical record showed a diagnosis of Unspecified Mood (Affective) Disorder with onset date 12/03/19, Brief Psychotic Disorder with onset date 12/03/19 and Generalized Anxiety Disorder with onset date 12/03/19. An annual minimum data set (MDS) dated [DATE] showed Resident #74 had anxiety disorder and psychotic disorder in section I. A Psychiatric Note stated, Diagnostic Assessment: Major depressive disorder, recurrent, moderate, Dementia with behavioral disturbance and Other specified persistent mood disorders. A Level I PASARR dated 11/21/19 was completed with no additional PASARR completed after new psychiatric diagnoses. During an interview on 02/21/23 at 2:25 PM, the Social Worker (SW) stated, I have never had to deal with PASARR. The SW stated that when hired in January 2022, I had no training. She stated she never saw the PASARR when residents were admitted as the PASARR always went straight to admissions. She stated that should another PASARR be required she would not know how to complete it because she had no experience with PASARR. During an interview on 02/21/23 at 2:34 PM, Nursing Home Administrator (NHA) stated that PASARR was completed on admission. NHA stated that if a PASARR needed to be completed, the NHA or the DON would complete it. NHA stated that right now the facility didn't have a process in place for PASARR's, but the facility would put one in place immediately. 9. A review of Resident #223's medical record revealed Resident #223 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, anxiety disorder, dementia, and depression. A review of Resident #223's PASARR assessment, dated 2/3/2022 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Anxiety Disorder and Depressive Disorder were not checked. 10. A review of Resident #78's medical record revealed Resident #78 was admitted to the facility on [DATE] with a diagnosis of generalized anxiety disorder. The following diagnoses were added to Resident #78's medical record: - A diagnosis of delusional disorder on 6/17/2020. - A diagnosis of mood disorder on 6/19/2020. - A diagnosis of schizoaffective disorder on 4/29/2021. A review of Resident #78's MDS assessment, dated 11/23/2022, revealed under Section I: Active Diagnoses, Resident #78 had diagnoses of Non-Alzheimer's dementia, anxiety disorder, psychotic disorder, mood disorder, and schizophrenia. A review of Resident #78's PASARR assessment, dated 5/28/2020, revealed under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Anxiety Disorder, Schizoaffective Disorder, and Other (specify) were not checked. A review of Resident #78's medical record did not reveal any additional PASARR assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 7 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 record review, observations, interviews, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to ensure the development and/or implementation of comprehensive care plans was completed for five (Resident #5, #12, #41, #81, and #82) of 44 sampled residents. Findings included: 1. A review of Resident #41's medical record revealed Resident #41 was admitted to the facility on [DATE] with a diagnosis of a nondisplaced intertrochanteric fracture of the left femur. A review of Resident #41's Minimum Data Set (MDS) assessment, dated 1/23/2023 revealed, under Section M: Skin Conditions, Resident #41 was admitted to the facility with one unstageable pressure ulcer. A review of Resident #41's physician's orders revealed a treatment order, dated 2/14/2023, for an unstageable wound to the right heel to cleanse the wound with normal saline, apply Santyl to the wound bed, cover the wound with hydrogel, and secure with a bordered gauze every day shift. A review of Resident #41's care plan did not reveal a focus area related to Resident #41's pressure wound. 2. A review of Resident #82's medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), atrial fibrillation, major depressive disorder, hyperlipidemia, and benign prostatic hyperplasia. A review of Resident #82's MDS assessment, dated 2/1/2023 revealed, under Section I: Active Diagnoses, Resident #82 had diagnoses of hyperlipidemia, depression, COPD, atrial fibrillation, and benign prostatic hyperplasia. A review of Resident #82's care plan did not reveal focus areas related to Resident #82's diagnoses of hyperlipidemia, depression, COPD, atrial fibrillation, or benign prostatic hyperplasia. A review of the facility policy titled Comprehensive Care Plan, last revised in January of 2022 revealed, under the section titled Policy it is the policy of this 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. 3. Review of the clinical record revealed Resident #12 was admitted to the facility on [DATE], with a readmission on [DATE], and a primary diagnosis of Hemiplegia and subsequent diagnoses that included Delusional Disorders (as of 02/17/2014) and Major Depressive Disorder (as of 02/17/2014), according to the admission face sheet. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #12 revealed under Section I, diagnoses that included Depression and Psychotic Disorder (other than schizophrenia); and under Section N, antidepressant medications were received during seven of the past seven days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 8 of 20 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 105455 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 Review of Psychiatry Note dated 02/01/2023 for Resident #12 showed diagnoses that included Major Depressive Disorder, recurrent, moderate, and Other Specified Persistent Mood Disorders. Level of Harm - Minimal harm or potential for actual harm Review of the Physician Order Summary for Resident #12 revealed: Residents Affected - Some -Paroxetine 40 milligrams (mg) orally at bedtime for depression, start date 02/02/2023 -Depakote 250 mg orally twice daily for mood disorder, start date 02/08/2023 -Carbamazepine 600mg orally twice daily for epilepsy, start date 02/26/2014 Review of the care plan for Resident #12 located in the electronic health record (EHR) showed focus areas that included: -resident has presented with multiple inappropriate behaviors, initiated 06/10/2015 -resident has behavior problem of grabbing/touching others inappropriately with interventions that include monitor/document effectiveness, monitor/document side effects, initiated 05/12/2022 The care plan did not contain evidence of care planning for use of psychotropic medications. Review of the annual MDS dated [DATE] for Resident #12 revealed under Section I, diagnoses that included Depression and Psychotic Disorder (other than schizophrenia); and under Section N, antidepressant medications were received during seven of the past seven days. On 02/20/23 at 04:14 PM a paper copy of the care plan provided by the Nursing Home Administrator (NHA) was reviewed; it revealed focus areas which included: -at risk for complications related to use of antidepressant medications, initiated on 02/20/23 by Staff E, Licensed Practical Nurse (LPN). -diagnosis of seizure disorder and at risk for injury, initiated on 02/20/23 by Staff E, LPN. On 02/21/23 at 11:34 AM an interview was conducted with Staff J, LPN. The LPN confirmed the resident was on psychotropic medications and does have a mental health diagnosis. During an interview with Staff I, Regional Clinical Reimbursement Nurse (RCRN) and the Director of Nursing (DON), the RCRN said Staff E, LPN was not currently in the facility and was unavailable for interview. The RCRN confirmed the additional care plan focus areas were added on 02/20/2023 and should have been on the care plan prior to that date so the care plan was be up-to-date and reflected current care and interventions. The DON confirmed it was her expectation use of psychotropic medications, including interventions to monitor effectiveness and side-effect, should be identified on the resident's care plan. 4. Review of the facility Resident Matrix document revealed Resident #5 identified as having post traumatic stress disorder (PTSD)/Trauma. Review of Resident #5's medical record revealed an admission record which documented an admission date of 01/29/2019 and diagnoses including dementia, generalized anxiety disorder, insomnia, and mood disorder with depressive features. Section I of the Minimum Data Set (MDS) assessment dated [DATE] revealed anxiety disorder and depression but did not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 9 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 PTSD selected as a diagnosis. Review of the most recent Psychiatry consultant notes for the previous year revealed that care included treatment for nightmares and persistent anxiety. There was one document titled , OC Trauma Informed Care Evaluation dated 02/10/2023, all responses to questions regarding trauma were documented as no except for a question regarding whether the resident had been diagnosed with COVID-19, that was documented as yes. Review of Resident #5's care plan revealed no focus areas for PTSD/Trauma or trauma-informed care. An interview was conducted with the facility Social Services Director (SSD) on 02/21/2023 11:37 a.m. The SSD confirmed that she was not aware that Resident #5 had any identified PTSD/Trauma. The facility Director of Nursing (DON) was interviewed on 02/21/2023 at 1:13 p.m. She confirmed PTSD/Trauma was identified for Resident #5 on the facility Resident Matrix document. She stated the resident had nightmares and neither the resident nor the son was forthcoming about any details other than evening and nighttime were an anxious and stressful time for her. The DON stated Resident #5 had not been forthcoming with anyone about the cause of her nightmares. The DON reported that because of the nightmares and because of being treated for them with medication in the past, she had been identified as having PTSD/Trauma. The DON provided documentation from Resident # 5's medical record on the Medication Administration Record (MAR) of treatment with Prazosin at bedtime for nightmares from 08/23/2022 - 01/19/2023. The DON reviewed the Trauma Informed Care Evaluation document dated 02/10/2023 and said, because she's not forthcoming, I don't know that she would have said anything during this evaluation. I know what I know because I've taken care of her and because of some of the conversations I've had with her son. The DON stated, she triggered as PTSD/Trauma because she did have the diagnosis of PTSD and nightmares when she was taking that medication. The DON reviewed Resident #5's care plan and confirmed there was no focus area specific to PTSD/Trauma. An interview was conducted with Staff I, RCRN, on 02/21/2023 at 3:43 p.m. She reported that trauma informed care was the responsibility of Social Services personnel and stated, they do the assessment, they are responsible for that being entered as a focus area of the care plan. Staff I confirmed that trauma informed care should be an individual focus area on the care plan. Review of facility policy titled, Comprehensive Care Plans revised 01/2022 revealed the following: Trauma -informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. 3. The comprehensive care plan will describe, at a minimum, the following: .g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger- specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 5. An observation on 02/19/23 at 12:12 PM, showed Resident #81 had an oxygen concentrator at bedside with a humidifier bottle attached. A record review of Resident #81's medical record showed a physician order dated 01/22/23 that stated, Oxygen at 2 liters/ min via nasal cannula humidification: Yes. A review of the comprehensive care plan showed no focus, goal or intervention for oxygen administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 10 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 During an interview on 02/20/23 at 3:00 PM, Staff E Licensed Practical Nurse (LPN) stated that when a resident was ordered and administered oxygen it should be care planned. Staff E LPN stated that oxygen was added to the care plan as of 02/20/23. During an interview on 02/21/23 at 3:48 PM, Staff I Regional Clinical Reimbursement Nurse stated that anytime a resident was on oxygen, oxygen administration and usage should absolutely be on the care plan. A review of the facility's policy titled, Oxygen Administration with revised date 05/04/22 stated, The resident's care plan shall identify the interventions for oxygen therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 11 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and, policy review, the facility failed to ensure there was ongoing communication and collaboration with the dialysis facility for one (Resident #59) of one resident reviewed for dialysis care and services. Residents Affected - Few Findings included: During an interview on 02/19/23 at 12:46 PM, Resident #59 stated that she went to Dialysis on Tuesdays, Thursdays, and Saturdays. A record review of Resident #59's medical record showed diagnoses of End Stage Renal Disease (Primary) and Dependence on Renal Dialysis. A physician order dated 02/03/23 showed the resident was to attend a local Dialysis Center on the days of Tuesday, Thursday, and Saturdays with transportation, location and times noted in the order. The five day minimum data set (MDS) dated [DATE] showed Dialysis treatment for Resident #59 in section O. The person-centered comprehensive care plan was developed with a focus of End Stage Renal Disease and Dialysis. Further record review of Resident #59's dialysis book showed blank Dialysis Communication Form. There was no completed Dialysis Communication Forms located in Resident #59's dialysis book. During an interview on 02/20/23 at 1:55 PM, Staff D Licensed Practical Nurse (LPN) stated that the dialysis communication form for Saturday 02/18/23 should have been completed and located in Resident #59's dialysis book. During an interview on 02/20/23 at 2:00 PM, the Director of Nursing (DON) stated there was probably no dialysis communication forms in the dialysis book because the forms get pulled immediately from the book and sent to medical records to be scanned. The DON stated the forms get scanned immediately so when the physicians come into the facility to see the residents, the dialysis information was available for review in the electronic medical record. The DON was asked to pull up the assessment tab for review of the dialysis communication forms scanned into electronic medical record. The DON found one Dialysis Communication Form scanned under the assessment tab dated 01/01/23. The DON was not able to provide any other completed Dialysis communication Forms in either Resident #59's dialysis book or in the electronic medical record. A review of the facility's policy titled, Hemodialysis with revised date 11/28/22 stated that the licensed nurse will communicate to the dialysis facility via written format, such as a dialysis communication form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 12 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than five percent. A total of 32 medication administration opportunities were observed with 2 errors, resulting in a medication administration error rate of 6.25%. Residents Affected - Few Findings included: A review of Resident #123's medical record revealed Resident #123 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (DM). A review of Resident #123's physician's orders revealed an order, dated 2/10/2023, for Humalog 100 unit/milliliter (ml) by KwikPen subcutaneous injection as per sliding scale every 4 hours at 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 12:00 AM, and 4:00 AM. An observation of medication administration for Resident #123 was conducted on 2/21/2023 at 9:17 AM with Staff B, Registered Nurse (RN). Staff B, RN performed a blood glucose check on Resident #123, which resulted in a reading of 194. Staff B, RN prepared Resident #123's Humalog KwikPen to administer 10 units to Resident #123. Staff B, RN removed the FlexPen from the medication cart and applied a needle to the tip of the FlexPen. Staff B, RN dialed the dosage selector to 10 and entered Resident #123's room. Staff B, RN administered the Humalog subcutaneously to Resident #123 and exited the resident's room. Staff B, RN did not prime Resident #123's Humalog KwikPen after applying the insulin needle and before administering the medication to Resident #123. An interview was conducted following the observation. Staff C, Licensed Practical Nurse (LPN) Unit Manager (UM) was also present for the interview with Staff B, RN. Staff B, RN stated she was not aware an insulin pen needed to be primed after applying the insulin needle and prior to administration to a resident. Staff C, LPN UM stated insulin needles needed to be primed before administration because not doing so could result in the resident receiving an inaccurate dose of insulin because insulin would be left in the needle. Staff B, RN and Staff C, LPN UM both addressed Resident #123's Humalog was administered late. Staff C, LPN UM stated Resident #123's Humalog was ordered for 8:00 AM administration and stated it should be administered before the resident's breakfast meal. An interview was conducted on 2/22/2023 at 10:51 AM with the facility's Director of Nursing (DON). The DON stated insulin needles used with insulin pens needed to be primed prior to administration to ensure an accurate dose is being administered to the resident. The DON also stated she would expect nurses to contact the residents physician if a medication is going to be administered outside of the normal administration timeframe and before the medication is administered to the resident. A review of the facility policy titled Medication Administration, last revised in January 2022, revealed under the section titled Policy mediations are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy also revealed, under the section titled Policy Explanation and Compliance Guidelines, nurses are to compare the medication source with the Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route, and time and are to administer medication within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. The policy revealed under the section titled Example guidelines for Medication Administration insulin is a medication which is to be administered on an empty stomach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 13 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm A request was made for contact information for the facility's Consultant Pharmacist to the facility's Nursing Home Administrator on 2/21/2023 at 11:18 AM. The facility did not provide contact information for the Consultant Pharmacist. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 14 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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** Based on observations, interviews, and record reviews, the facility failed to implement an effective Infection Control and Prevention program by 1.) failing to ensure hand hygiene was conducted during a dressing change for an intravenous (IV) line for one (Resident #224) and during medication administration for one (Resident #123), 2.) failed to ensure proper set up of a sterile field during a dressing change for an IV line for one (Resident #224), 3.) failed to ensure proper disinfection of point-of-care devices for one (Resident #123), and 4.) failed to ensure isolation precautions were followed for one (Resident #224) of forty four sampled residents. Residents Affected - Few Findings included: A review of Resident #224's medical record revealed Resident #224 was admitted to the facility on [DATE] with diagnoses of osteomyelitis, Methicillin-resistant Staphylococcus aureus (MRSA) infection, and pressure ulcer of the sacral region. A review of Resident #224's physician's orders revealed an order, dated 2/5/2023 for Contact isolation precautions related to (MRSA) infection of the sacral wound. An observation was conducted on 2/20/2023 at 9:52 AM of the door outside of Resident #224's room. An orange colored sign was observed outside of Resident #224's room indicating Resident #224 was on contact isolation precautions. Instructions on the sign revealed all staff and providers must do the following: - Put on gloves before room entry. Discard gloves before room exit. - Put on gown before room entry. Discard gown before room exit. An isolation caddy containing isolation gowns, surgical masks, and gloves was observed hanging from Resident #224's room door. An interview was conducted with Resident #224 following the observation. Resident #224 stated he was admitted to the facility with an infected wound on his coccyx and he was receiving IV antibiotic therapy, which was being administer via IV pump at the time of the interview. During the interview, Resident #224's IV pump began to make a loud beeping noise with a warning on the screen of the IV pump indicating an upstream occlusion of the IV line. Staff A, Registered Nurse (RN) entered Resident #224's room to address the IV pump alarm. Staff A, RN did not don gloves or an isolation gown before entering Resident #224's room. Staff A, RN restarted Resident #224's IV pump and exited the room. Resident #224's IV pump began alarming again approximately 15 seconds after Staff A, RN restarted the IV pump and indicated an upstream occlusion of the IV line. Staff A, RN returned to Resident #224's room donned in gloves and an isolation gown and flushed Resident #224's IV line and restart the residents IV pump. Resident #224's IV dressing was observed to be partially peeled off of his arm and the date which the dressing was last changed was not able to be read. Staff A, RN stated she would change the transparent dressing. An observation was conducted on 2/20/2023 at 11:10 AM outside of Resident #224's room. Resident #224's call light was activated outside of the room and the facility's admission Coordinator (AC) and Business Development Director (BDD) entered Resident #224's room. Neither staff member donned gloves or an isolation gown before entering Resident #224's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 15 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 An interview was conducted on 2/20/2023 at 11:21 AM with the AC and BDD outside of Resident #224's room. The AC stated he had consulted the facility's Director of Nursing (DON) prior to entering Resident #224's room and was instructed that gloves and an isolation gown were only required in the residents room if care was being provided to the resident. Both staff member addressed the signage posted outside of Resident #224's room and the instructions posted on the sign. Residents Affected - Few An observation was conducted on 2/20/2023 at 11:28 AM of a dressing change for Resident #224's IV line with Staff A, RN. Staff A, RN performed hand hygiene, donned clean gloves and an isolation gown, and entered Resident #224's room with an IV dressing kit. Staff A, RN explained the procedure to the resident before proceeding. Staff A, RN removed a television remote control and 2 beverage cups from Resident #224's bedside table and placed the IV dressing kit on the table. Staff A, RN did not sanitize Resident #224's bedside table before placing the IV dressing kit on it. Staff A, RN opened the IV dressing kit, removed the surgical mask from the kit, and placed it on Resident #224's face. Staff A, RN removed the sterile gloves from the IV kit and placed them on Resident #224's bedside table. Staff A, RN stated she needed a bigger pair of sterile gloves before beginning the procedure and exited the room. Staff A, RN returned to the room with another IV dressing kit and placed the kit on Resident #224's bedside table. Staff A, RN opened the IV dressing kit and placed the surgical mask inside of the kit onto Resident #224's bedside table. Staff A, RN removed the sterile drape from the kit and placed the drape, still folded in half, on top of the surgical mask and the sterile gloves that were on Resident #224's bedside table. Staff A, RN removed the sterile gloves from the IV kit, placed them on the drape, and opened the package outward. Staff A, RN removed Resident #224's IV dressing and discarded it in the trash. Staff A, RN removed her gloves and applied the sterile gloves. Staff A, RN did not perform hand hygiene after doffing the gloves or before donning the sterile gloves. After applying sterile gloves, Staff A, RN performed the remainder of the procedure without difficulty. Staff A, RN discarded the supplies, doffed the sterile gloves and isolation gown, and performed hand hygiene before exiting the room. An interview was conducted on 2/20/2023 at 11:48 AM with Staff A, RN. Staff A, RN addressed she did not sanitize Resident #224's bedside table prior to setting up a sterile field on top of the bedside table and stated she should have performed hand hygiene after doffing clean gloves and before applying sterile gloves. An observation of medication administration for Resident #123 was conducted on 2/21/2023 at 9:17 AM with Staff B, RN. Staff B, RN prepared five medications for administration to Resident #123 and removed a glucometer, a blood glucose test strip, and an alcohol prep pad from the medication cart before entering Resident #123's room. Staff B, RN administered the five medications to Resident #123 and applied gloves. Staff B, RN did not perform hand hygiene before applying gloves. Staff B, RN cleansed Resident #123's right middle finger with the alcohol pad before obtaining a blood sample for the blood glucose reading. After the procedure, Staff B, RN removed her gloves and placed the glucometer with the used blood glucose strip still in it onto her personal clipboard before exiting the room. Staff B, RN did not perform hand hygiene after the procedure or after leaving the resident's room. Staff B, RN then placed the clipboard with the glucometer on top of it onto the medication cart. Staff B, RN then grabbed the glucometer with an ungloved hand and grabbed the used blood glucose monitoring strip with an ungloved hand and discarded the strip. Staff B, RN then placed the glucometer back onto the medication cart. Staff B, RN did not perform hand hygiene after touching the used glucometer or after touching the used blood glucose monitoring strip. Staff B, RN then removed Resident #123's insulin pen from the medication cart and prepared 10 units of insulin for administration. Staff B, RN entered Resident #123's room and donned clean gloves. Staff B, RN did not perform hand hygiene before entering Resident #123's room or before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 16 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 Residents Affected - Few donning gloves. Staff B, RN administered insulin to Resident #123, doffed her gloves, and performed hand hygiene before exiting the resident's room. Staff B, RN grabbed the used glucometer on the medication cart with an ungloved hand and placed it back into the medication cart. Staff B, RN did not disinfect the glucometer before placing it back into the medication cart. An interview was conducted on 2/21/2023 at 9:30 AM with Staff B, RN. Staff B, RN stated nurses should perform hand hygiene before putting gloves on and stated she performed hand hygiene prior to the observation of medication administration and after the administration of insulin to Resident #123, but did not perform hand hygiene at any other time. Staff B, RN was not able to state whether or not she sanitized the glucometer after using it for Resident #123's blood glucose check and proceeded to remove the glucometer from the cart and wipe the glucometer down with a bleach wipe for approximately 15 seconds before placing it back onto the medication cart. Staff B, RN was not able to state how long the bleach product needed to stay in contact with the glucometer in order to properly disinfect it and stated she just wipes it down in order to disinfect it. Staff B, RN was not able to state the difference between cleaning and disinfecting. During the interview, Staff C, Licensed Practical Nurse (LPN) Unit Manager (UM) was in the unit hallway and stopped to participate in the interview. Staff C, LPN UM stated Staff B, RN should have placed a barrier down when setting the used glucometer down so it does not come into contact with other items, such as a personal clipboard or the medication cart, before sanitizing it. Staff C, LPN UM also stated they use the bleach wipes to sanitize glucometers, which must be in contact with the glucometer for 3 minutes in order to properly sanitize it, which is also labeled on the product. Staff C, LPN UM stated nursing staff should be performing hand hygiene whenever they are entering or exiting a resident's room. An interview was conducted on 2/22/2023 at 10:51 AM with the Director of nursing (DON). The DON stated Resident #224 was on contact isolation precautions for an infected would and did not need to be on contact isolation precautions because the wound was covered and contained by a wound vac. The DON also stated she began implementing stricter isolation precautions when she first started working at the facility in order to ensure new staff were following the protocols properly, but stated she might have been too strict. The DON stated nursing staff should be performing hand hygiene with any type of glove change and frequently during resident interactions. Nursing staff should not take personal items into rooms when performing a blood glucose checks and should use a barrier when handling a used glucometer. Glucometers should be sanitized properly after each use. A review of the facility policy titled Transmission-Based (Isolation) Precautions, last revised on 8/15/2022 revealed under the section titled Policy it is the facilities policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen modes of transmission. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines facility staff apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The policy defines Contact precautions as measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. The policy also revealed healthcare personnel caring for a resident on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. A review of the facility policy titled Standard Precautions Infection Control, last revised in October 2022 revealed under the section titled Policy Explanation and Compliance Guidelines personal protective equipment (PPE) is used by all staff who have contact with residents and/or their environment as appropriate during resident care activities and at other times in which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 17 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 Residents Affected - Few exposure to blood, body fluids, or potentially infectious materials is likely. Policies and procedures have been established for containing, transporting, and handling resident-care equipment and instruments/devices that may be contaminated with blood or body fluids. Wear PPE when handling resident-care equipment and instruments/devices that are visibly soiled or may have been in contact with blood or body fluids. The policy also revealed under the section titled Standard Precautions Infection Control Protocol hand hygiene should be performed after touching blood, body fluids, secretions, excretions, contaminated items; before and after removing PPE; between resident contacts; before meals and after using the restroom. The policy defines Hand Hygiene as a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). A review of the facility policy titled Glucometer Disinfection, last revised on 8/15/2022 revealed under the section titled Policy the purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines the facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The policy also revealed the following procedure: - Obtain needed equipment and supplies: gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. - Wash hands. - Explain the procedure to the resident. - Provide privacy. - Put on gloves. - Obtain capillary blood glucose sampling according to facility policy. - Remove and discard gloves, perform hand hygiene prior to exiting the room. - Reapply gloves if there is visible contamination of the device. - Retrieve 2 disinfectant wipes from container. - Using first wipe, clean first to remove heavy soil, blood, and/or other contaminants left on the surface of the glucometer. - After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. - Discard disinfectant wipes in waste receptacle. - Perform hand hygiene. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 18 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 interview, record review, and review of the facility's policy, the facility failed to ensure three (Residents #40, #13 and #88) of six residents reviewed for vaccine administration were offered and administered Pneumococcal vaccinations. Residents Affected - Some Findings include: Review of the clinical record for Resident #40 revealed the resident was admitted to the facility on [DATE], and readmitted on [DATE] according to the admission face sheet. Review of Immunization record located in the electronic health record (EHR) revealed the resident was offered and received a Pneumococcal vaccine (Pneumococcal polysaccharide - PPSV23) on 07/24/2015. Review of a vaccination declination form dated 10/14/2022 and provided by the Nursing Home Administrator (NHA) revealed a subsequent Pneumococcal vaccine was declined by the resident's family member. No additional information was available in the EHR detailing the reason for the seven-year delay between administration of the vaccine and offering the second vaccine dose. Review of the clinical record for Resident #13 revealed the resident was admitted to the facility on [DATE], and readmitted on [DATE] according to the admission face sheet. Review of Immunization record located in the electronic health record (EHR) revealed the resident was offered and received a Pneumococcal vaccine (PPSV23) on 07/29/2020. Review of a vaccination declination form provided by the NHA and dated 03/17/2022 revealed a document which was signed by an unidentified individual (not the resident's name), and the declination form did not identify any resident's name. During an interview with the NHA on 02/20/23 at 4:04 PM, she stated the declination form, for which a resident was unidentified, was for Resident #13. The NHA also confirmed no other Pneumococcal vaccine data was available for Residents #40 and #13. Review of the clinical record for Resident #88 revealed the resident was admitted to the facility on [DATE] according to the admission face sheet. Review of Immunization record located in the electronic health record (EHR) revealed the resident was offered and received a Pneumococcal vaccine (PPSV23)) on 12/05/2022; no additional information was available in the EHR detailing the reason for the one-year delay between admission and administration of the vaccine. On 02/21/23 at 10:42 AM, an interview was conducted with the NHA. She confirmed no other no other Pneumococcal vaccine data was available for Resident #88. On 02/22/23 at 10:24 AM., an interview was conducted with the Director of Nursing (DON), who was also the facility's Infection Control Practitioner. The DON stated she was aware the facility staff didF not always offer follow-up pneumonia vaccines as outlined in the facility's policy and CDC recommendations. The DON also confirmed all residents should be assessed and offered a Pneumonia vaccine on admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 19 of 20 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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 Review of facility-provided policy titled 'Pneumococcal Vaccine (Series) Policy' dated 11/2020, revised/reviewed 01/31/2022 revealed: Policy: It is our policy to offer our residents, staff, and volunteer workers immunization against Pneumococcal disease in accordance with CDC [Centers for Disease Control] guidelines and recommendations. 1. Each resident will be assessed for Pneumococcal immunization upon admission . 2. Each resident will be offered a Pneumococcal immunization unless it is medically contraindicated . 5. The type of Pneumococcal vaccine (PCV15, PCV20, or PPSC23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. 7. A Pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations: 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. ii. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 20 of 20