Inspection·July 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some underneath to catch dripping water, and the control panel appeared to be broken or dislodged. Photographic evidence was obtained. On 7/26/23 and 7/27/23 the North Wing shower room was observed to have a shower chair with bio-growth on every joint of the chair. The shower also has bio-growth growing on the caulk around the shower. On 7/27/23 at 9:30 a.m. the North Wing shower unit was observed to have used washcloths and a bag of dirty clothes left in the room. The showerhead was also observed to be leaking. Photographic evidence was obtained. During an interview on 07/27/23 at 10:05 a.m., Staff E Licensed Practical Nurse (LPN), Unit Manager stated the shower room should always remain locked. Staff E LPN confirmed the North Wing shower room door was not locking. Staff E, LPN, UM stated the wet washcloth hanging over the handrail and the bag of dirty clothes laying on the floor should not have been there and taken out after use. The bathroom should be sanitized after each use. Housekeeping should be cleaning the bio growth off the shower chairs and around the shower room. She said Certified Nursing Assistants (CNA) clean the chair between each resident use, but deep cleaning is done by housekeeping. She confirmed dirty clothes and linens should not be left in rooms or shower rooms. On 7/27/23 at 1:40 p.m. an interview was conducted with the Maintenance Director. He stated they have air conditioner vent cleaning in their automated maintenance system to complete every quarter. He said he has worked at the facility for three months and it hasn't been done during that time. He was not aware when the last time they were cleaned. When discussing bio-growth on the units, the Maintenance Director stated, I understand the seriousness. Regarding the North Wing shower room, he said no one has told him about the leaking showerhead. As for storing extra equipment around the facility the Maintenance Director said they do not have enough storage room. He said some rooms are being used for temporary storage, but they should be closing and possibly locking doors, so it isn't visible to residents. He said staff also leave broken items in the hall for him, but they don't leave notes or anything telling him what the issues is. He said staff will catch the maintenance staff in the hallway and say things that need to be fixed instead of putting it into their official systems. He said a lot of issues he is just now hearing about. The Maintenance Director said, It is a communication issue. On 7/27/23 at 1:45 p.m. an interview was conducted with the Environmental Services (EVS) Director. He said the facility has not had a floor tech in a long time. He said he is trying to hire someone so they can get resident rooms caught up. He said he tries to strip and wax the hallways each month, but resident rooms have not been done. As far as the shower chair in the North Wing shower room having bio-growth on it, he said the CNAs clean the chairs. The EVS Director said they have a guy that comes on Wednesdays and Thursdays to clean the shower. He was unaware the shower and chair had bio-growth and he will get it cleaned. A facility provided job description titled Plant Operations Director, dated April 2020, was reviewed. The job description stated the following: Summary: -Maintain the building(s), equipment, and utilities in good working order and ensure facility grounds are properly maintained in accordance with facility policies and state and federal regulations. -Essential Duties & Responsibilities: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 2 of 18 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 07/27/2023 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 0584 -Perform repairs and maintenance on equipment and supplies. Level of Harm - Minimal harm or potential for actual harm -Maintain the building in good repair and keep free of hazards such as those caused by electrical, plumbing, heating, and cooling systems. Residents Affected - Some -Perform monthly maintenance checks. -Coordinate maintenance work with other departments. A facility provided job description titled, Environmental Services Manager, revised 6/2020, was reviewed. The job description stated the following: Job Summary: The goal is to create a clean and orderly environment for our residents that will become a critical factor in maintaining and strengthening our reputation. Responsibilities: -Ensure all clean and soiled rooms are cared for and inspected according to standards. -Protect equipment and make sure there are no inadequacies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 3 of 18 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 07/27/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm 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 residents were free from accident hazards. 1) The facility failed to ensure three residents (# 9, # 8 and # 1) of three residents reviewed for falls, were free from multiple falls, and facility fall protocol was followed. 2) The facility failed to secure one shower room (North Wing) out of four shower rooms located in the facility. 3) The facility failed to secure chemicals on one nursing unit (secured unit) out of four nursing units located in the facility. Findings included: A review of the Resident #9's medical record showed an admit date of 01/16/19. Resident #9's diagnoses included: polyosteoarthritis, aged related osteoporosis without current pathological fracture, dementia in other diseases, without behavioral disturbance, and heart failure. Resident #9's Facesheet revealed Resident #9 had a Power of Attorney (POA) for health care. Physician orders indicated, Admit to Compassionate Care Hospice on 05/21/23 related to diagnosis of cerebral arthrosclerosis. The care plan revealed a care area focus of At risk for falls and fall related injury related to impaired mobility, initiated date 09/23/22. The goal was Minimize risk for falls and fall related injuries though next review date. The interventions included: Anticipate needs, provide prompt assistance, bilateral floor mats, ensure call light is within use and encourage use for assist with standing/transferring and ambulation and follow facility fall protocol. The Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 0 (severe cognitive impairment). A Post Fall Evaluation was completed on Resident #9's 07/25/23 fall which indicated an unwitnessed fall occurred on 07/25/23 at 5:00 a.m. Neurochecks were marked as abnormal with no changes observed. Notifications included the Advanced Registered Nurse Practitioner (ARNP) and the POA. A progress noted, dated 07/25/23, indicated Patient returned from ER via stretcher with no new orders, per hospital nurse family refused work up at hospital. Family, Hospice, and NP aware of patient return to facility. NP to write new orders. maintain comfort measures and begin morphine and ativan every 4 hrs. A review of the facility's Incident Log revealed, Resident #9 had documented falls. The dates were as followed: Unwitnessed Fall on 07/25/23 Witnessed Fall on 07/23/23 An observation on 07/26/23 at 3:30 p.m., was conducted. Resident #9 was resting in bed with bilateral floor mats in place. During an interview on 07/26/23 at 3:40 p.m., Staff C Licensed Practical Nurse (LPN) stated Resident #9 had an unwitnessed fall on 07/25/23, however no one said neurochecks were needed. Staff C, LPN provided Surveyor with a blank copy of a Neuro Check Assessment Form and stated neuro checks for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 4 of 18 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 07/27/2023 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 0689 residents would be completed on the form if completed. Photographic evidence was obtained. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/26/23 at 3:42 p.m., Staff D Registered Nurse (RN) stated because Resident #9 had an unwitnessed fall neurochecks should have been completed. Staff D, RN stated neurochecks should be completed on any resident with an unwitnessed fall or head injury. Residents Affected - Some During an interview on 07/26/23 at 3:45 p.m., Staff B Registered Nurse (RN) Unit Manager stated facility protocol was to complete neurochecks after any unwitnessed fall however no neurochecks were completed after Resident #9's fall on 07/25/23. During an interview on 07/27/23 at 8:30 a.m. the Director of Nursing (DON) stated she had heard about the neurochecks not being completed for Resident #9, so she went ahead and put in an order in Resident #9's medical record this morning 07/27/23 that stated no neurochecks, just provide comfort measures only. A review of Resident #8's medical record revealed an admit date of 07/01/23. Resident #8's diagnoses included: Major Depressive Disorder, single episode, severe with psychosis, heart failure unspecified, Parkinson's Disease, abnormal gait and mobility, anxiety disorder unspecified and unspecified atrial fibrillation. Resident #8's Facesheet indicated Resident #8 had a health care proxy. Physician orders indicated admitted to Vitas Hospice services since 07/17/23 with a diagnosis of Heart Failure. The care plan revealed a care area focus of At risk for falls related to gait/balance problems, initiated date 06/20/23. The goal was Will be free of falls through the review date. The interventions included: Anticipate and meet the residents needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance, ensure resident's frequently used items are kept within close reach, Hospice evaluation and med review related to terminal restlessness and offer to assist resident with toileting before bedtime. The Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). A Post Fall Evaluation was completed on Resident #8's 07/26/23 fall indicating an unwitnessed fall occurred on 07/26/23 at 11:15 a.m. Description of fall read, Patient observed on the mat on floor in front of bed. Neurochecks were marked as normal with no changes observed. Notifications included the Advanced Registered Nurse Practitioner (ARNP) and the Health Care Proxy. A review of the facility's Incident Log showed, multiple dates Resident #8 had documented falls. The dates were as followed: 07/26/2023- unwitnessed 07/23/2023- unwitnessed - 07/17/2023- witnessed - 07/15/2023- unwitnessed - 07/07/2023- unwitnessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 5 of 18 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 07/27/2023 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 0689 - 07/06/2023- unwitnessed Level of Harm - Minimal harm or potential for actual harm During an interview on 07/26/23 at 3:55 p.m., Staff A Licensed Practical Nurse (LPN) stated Resident #8 did have an unwitnessed fall at 11:15 a.m. today. Staff A, LPN stated she had not competed the Neuro Check Assessment Form yet. Staff A LPN stated she had all the of Resident #8's checks on a piece of paper but now she could not find that paper so it was lost. Staff A LPN was asked how she was going to complete the Neuro Check Assessment Form with no accurate information. Staff A LPN stated she was just going to have to complete the form and write neurochecks not completed from 11:15 a.m. to 4:00 p.m. on 07/26/23. Staff A LPN stated, I don't have those vitals, I am just going to have to let the Nurse Practitioner know I just don't have them. Residents Affected - Some During an interview on 07/27/23 at 8:30 a.m. the Director of Nursing (DON) stated she had not heard about any neurochecks problems regarding Resident #8. The DON stated after Staff A LPN spoke with Advanced Registered Nurse Practitioner (ARNP) yesterday it was decided Resident #8 was very restless and terminal so neuro checks were not needed and there was no need to arouse Resident #8. The DON stated she went ahead and put in an order in Resident #8's medical record this morning, 07/27/23, stating no neurochecks, just provide comfort measures only. During an interview on 07/27/23 at 11:05 a.m. Staff A Licensed Practical Nurse (LPN) stated I initiated the protocol of notifying family and the hospice nurse after Resident #8's fall. Staff A LPN stated she was very busy, had to prioritize tasks and was just an honest mistake. Staff A LPN stated around 4:00 p.m. on 07/27/23 she went right to North Wing to speak with Advanced Registered Nurse Practitioner (ARNP) about the neuro checks not being completed. Staff A LPN stated the ARNP directed Staff A LPN to go ahead and discontinue the neuro checks as of 4:00 p.m. on 07/26/23. A review of Resident #1's medical record revealed an admit date of 04/05/23 and a discharge date of 06/27/23. Resident #1's diagnoses included: tachycardia, Abdominal Aortic Aneurysm without rupture, Paroxysmal Atrial Fibrillation, Bell's Palsy, dementia without behavioral disturbance and repeated falls. Resident #1's Facesheet indicated Resident #1 had a Power of Attorney (POA) and Health Care Surrogate. A physician order dated 06/23/23 read, admitted to Compassionate Care Hospice. The Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status score of 12 (moderately cognitively impaired), no behaviors and required one to two persons assist for bed mobility, transfers, dressing, toilet use and personal hygiene. The care plan focus areas for Resident #1 included: discharge with family members home with healthcare services, Neurological diagnosis of Bell's Palsy and Dementia, and a risk of falls and fall related injury related to impaired mobility and dementia. The care plan indicated a focus area as Risk of falls and fall related injury related to impaired mobility and dementia The goal stated, Minimize risks for falls and fall related injuries through next review date The Interventions included: Anticipate needs, provide prompt assistance, Ensure call light is within use and encourage use for assist with standing/transferring and ambulation, follow facility fall protocol, Keep frequently used items within reach, Referral for screen and treatment as needed physical therapy/occupational therapy/speech therapy, and report falls to physician and responsible party. A review of the facility's Incident Log revealed, multiple dates Resident #1 had documented falls. The dates were as followed: Unwitnessed Fall on 05/21/23 at 1:41 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 6 of 18 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 07/27/2023 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 0689 - Level of Harm - Minimal harm or potential for actual harm Unwitnessed Fall on 06/02/23 at 6:00 p.m. - Residents Affected - Some Abrasion on 06/18/23 at 1:45 a.m. Unwitnessed Fall on 06/19/23 at 9:40 a.m. Unwitnessed Fall on 06/21/23 at 8:15 p.m. Skin tear on 06/24/23 at 2:51 p.m. A review of the facility's Incident Reports revealed reports as followed: Fall report dated 05/21/23. Fall report dated 06/02/23. Abrasion report dated 06/18/23. Fall report dated 06/19/23. Fall report dated 06/21/23. Skin Tear report dated 06/24/23. Further review of Residents #1's medical record progress notes revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 7 of 18 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 07/27/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm A progress note dated 5/21/2023, Received resident on floor in front of w/c in room. Resident stated he had to go to the bathroom. Resident observed for injuries, nonapparent at this time. Neuros within normal limits. ROM same as before fall. No c/o pain. Resident stated he did not hit his head. Resident helped to bathroom and back into w/c. Message left for responsible party to return call. Frequent rounds being made, resident in dining room area for monitoring. Residents Affected - Some A progress note dated 06/02/23, [Certified Nursing Assistant] CNA approach and verbalized resident got a fall, when into resident room observed resident in front of bed of another resident rooms, wheelchair besides him. He verbalized that he was trying to get to the wheelchair. assessment where perform, skin evaluation, pain assessment, neuro check. No abnormal findings. [Power of Attorney] POA and [Advanced Practice Registered Nurse] APRN notified. A progress note dated 06/18/23, Resident got up from bed and attempted to wake up resident in 221 D. Redirected resident to bed. However, this nurse observed a bump on the left side of his forehead. This nurse was stationed right outside room [ROOM NUMBER] but did not hear a fall or see a fall. Full body assessment revealed no other injuries. Started neuros. A progress noted dated 06/18/23, Resident got up OOB and attempted to wake up his roommate. This nurse was sitting in the hallway across from room [ROOM NUMBER] at the time. I redirected resident back to his bed, and that was when I observed a bump o resident's forehead, left side. I attempted to apply ice, but resident refused. CNA, [name of CNA], assisted, but resident again refused. Resident states he was unaware he had a bump on his forehead. A progress note dated 06/18/23, Attempted to apply ice pack multiple times, but resident refused stating it hurts. A progress note dated 06/18/23, Reported blood pressure readings from neuros to APRN. Advised to push oral fluids and to continue to monitor. Patient is alert and oriented to self only. Patient is very restless and frequently trying to ambulate independently. [Name of APRN] APRN ordered Ativan for patient, but script was written for 06/19/2023 and pharmacy will not process until tomorrow. ARNP called in Ativan 0.5 mg but strength not available in cubix. She was then asked to call in Ativan 1mg as that strength is available to administer. Awaiting response from pharmacy. A progress note dated 06/19/23, Resident yelling for help upon arrival to room. Patient observed on fall on left side of bed. Abrasion to [right] Rt. Knee [both] x2. Transferred back to bed. Neuros initiated. [name of APRN], ARNP notified. Will continue to monitor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 8 of 18 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 07/27/2023 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 0689 - Level of Harm - Minimal harm or potential for actual harm A progress note dated 06/21/23, [Name of APRN] APRN and [Name of Hospice Nurse] with [Name of local Hospice Company] was made aware of elevated heart rat ad blood pressure. Residents Affected - Some No progress notes available related to Resident #1's fall on 06/21/23. No progress notes available related to Resident #1's fall on 06/24/23. Further review of Resident #1's medical record revealed Post Fall Evaluations were completed, as the nursing assessment of Resident #1 post fall for the dates of 05/21/23 and 06/02/23. There were no Post Fall Evaluations completed for Resident #1's additional falls on 06/19/23, 06/21/23 and 06/24/23. During an interview on 07/27/23 at 1:45 p.m. the Director of Nursing (DON) stated the first step after a resident fall was to complete a post fall assessment. DON stated this assessment would be completed by a nurse in the medical record and list as the Post Fall Evaluation. The DON confirmed there were no Post Fall Evaluations completed for Resident #1's falls 06/18/23, 06/19/23 and 06/21/23 but neurochecks were initiated and completed for those dates. During an interview on 07/27/23 at 2:20 p.m. Advanced Registered Nurse Practitioner (ARNP) stated, she was Hospice Board Certified and she could ensure she had in depth conversations with families when a resident was admitted to hospice services. ARNP stated, once a resident is placed on hospice, the resident was to never go to the hospital emergency department again. The ARNP stated, Resident # 9 had a fall yesterday 07/26/23. Resident #9 was sent out to the emergency room (ER) but should not have been. ARNP stated all Residents on Hospice should not have neurochecks because What is the point in doing the neurochecks if they are not going out to the ER. Neuro checks are pointless if we are not going to send them to the ER. ARNP stated, for example another resident, Resident #8, was terminally agitated and continued to fall out of bed. ARNP stated because Resident #8 was restless there was no sense in neurochecks, so I just heavily medicate him, so he is comfortable. ARNP stated, she remembered Resident #1's wife Was on board for everything, but the rest of the family was not. ARNP stated, a resident who is on hospice, We will just make them comfortable with medication, there is always tweaking of the medications. ARNP stated when a resident is on hospice, they are not to have neurochecks completed and even if a resident falls and had a fracture, I will order in house x-ray, but they will not and should not be sent the hospital, they will just be heavily medicated for the pain. ARNP stated residents on Hospice are actively dying so we keep them comfortable until they pass. Reviewed the facility schedules for 06/24/23. Identified staff on duty that day included Staff F, Registered Nurse (RN), Staff G, Certified Nursing Assistant (CNA) and Staff H Certified Nursing Assistant (CNA). During an interview on 07/27/23 at 4:23 p.m., Staff F Registered Nurse (RN) stated, she remembered Resident #1 was doing fine for a while then started to decline rather quickly. Staff F RN stated Resident #1 had his mattress on the floor on 06/24/23, although it was uncommon to see mattresses on the floor, that was what the doctor ordered. Staff F RN stated Resident #1 kept falling so, The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 9 of 18 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 07/27/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mattress was on the floor, because he was not strong enough to get up off the floor. He could not get up and walk from the mattress on the floor as he could if it was on the bed. Staff F RN could not recall how long Resident #1 laid on the floor but stated, Whatever I said in the incident report is what happened. Staff F RN stated she continued to apologize to the family, got him dressed, placed back on the mattress, and took care of the wound. Staff F RN stated when Resident #1 went from the mattress to the floor on 06/24/23 that would have been considered a fall. Staff F RN stated the incident reported she completed was coded as a skin tear because he had one because of the fall. Staff F RN stated, I just coded the incident as a skin tear instead of fall. One was a result of another. A second review of Resident #1's medical record revealed no physician order for Resident #1's mattress to be placed on the floor. There was no care plan care area that addressed Resident #1's mattress should be placed on the floor for Resident #1's safety. There was no care plan for care areas specifically for behaviors that showed Resident #1 taking clothes off as an ongoing behavioral issue. There were no progress notes that showed behavioral concerns related to disrobing of clothes or the details of Resident #1's fall on 06/24/23. During an interview on 07/27/23 at 4:45 p.m., Staff G Certified Nursing Assistant (CNA) stated she remembered the day Resident #1's family came to the facility. Staff G CNA stated she saw the family in Resident #1's room but Staff F RN and Staff H CNA went into Resident #1's room with the family. Staff G CNA stated she believed Resident #1's mattress had been on the floor since Thursday, but survey team would need to talk with Staff I Certified Nursing Assistant (CNA) about Resident #1 as she was his full time CNA. During an interview on 07/27/23 at 5:00 p.m., Staff H, Certified Nursing Assistant (CNA) stated she remembered the day Resident #1's family came to the facility. Staff H, CNA stated the family was banging on the door of the locked unit so, I went to the door and then went to the room with the family. Staff H CNA stated Resident #1 was naked and laid on the floor beside the mattress. Staff H, CNA stated Staff F, RN tried to explain to the family why Resident #1 was naked, and Resident #1 taking off his clothes was his behavior lately. Staff H, CNA stated she helped Staff F RN get Resident #1 dressed and back on the bed. Staff H, CNA stated she was told the facility put Resident #1's mattress on the floor because he kept falling. During an interview on 07/27/23 at 5:15 p.m., Staff I, Certified Nursing Assistant (CNA) stated she was not working the day of the 06/24/23 fall. Staff I, CNA stated when Resident #1 first got to the facility he was walking without assistance. Staff I, CNA stated he walked without assistance but was confused and had wandering behavior. Staff I, CNA stated Resident #1's gait later became unsteady, so he then used a wheelchair. Staff I, CNA stated when Resident #1 first got to the facility he could also eat on his own but later required assistance. Staff I, CNA stated she tried to get close to her Residents and takes time to know her residents well. Staff I, stated the fall with his head injury happened when I wasn't working, but I observed a big lump on his head. Staff I, CNA stated, the mattress on the floor was so he would not fall from the bed to floor. Staff I, CNA stated after the fall, with his bump on his head, there was a decline and Resident #1 could no longer walk and toilet himself anymore. Staff I, CNA stated, Resident #1 was no longer steady when walking after the fall. Staff I, CNA stated, I was trying to figure out if he was over medicated or just a decline. Staff I, CNA stated, she was known as an advocate for residents and the administration listens to her when she brings concerns to them. Staff I, CNA stated, it appeared that When the resident fell and got that bump on the head, everything went downhill after that. An observation on 07/26/23 at 10:23 a.m., the North Wing Shower Room was unlocked. Inside the North (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 10 of 18 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 07/27/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Wing shower room revealed multiple razors that laid throughout the shower room floor. Photographic evidence was obtained. An observation on 07/27/23 at 9:28 a.m., the North Wing Shower Room remained unlocked. Inside the North Wing Shower room revealed multiple razors that laid throughout the shower room floor. Photographic evidence was obtained. During an interview on 07/27/23 at 10:05 a.m., Staff E, Licensed Practical Nurse (LPN), Unit Manager stated the shower room should always remain locked. Staff E, LPN confirmed the North Wing Shower Room door was not locking. Staff E, LPN stated the razors should not be on the floor and said there should be a sharps container in this shower room and there isn't one. Staff E, LPN stated she would get a sharps container and pick up the razors immediately. During an interview on 07/27/23 at 6:10 p.m. the Director of Nursing (DON) stated the North Wing Shower Room should have been locked, there should have been a sharps container located in the bathroom for the razors and certainly the staff should not have left the razors on the bathroom floor just because there was no sharps container available. A review of the facility's job description for Certified Nursing Assistants indicated the following: Maintain established housekeeping standards with assigned duty areas. The facility's job description for Environmental Service Manager showed, Ensure all clean and soiled rooms are cared for and inspected according to standards. A review of the facility's policy titled, Fall Prevention Program, revised date 10/18/22, revealed the following: 7. When any resident experiences a fall, the facility will: a. Assess the resident. b. Initiate neuro checks if resident hits head and/or is unwitnessed. c. Complete an incident report. d. Notify physician and family. e. Review the Resident's care plan and update as indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 11 of 18 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 07/27/2023 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 0689 f. Level of Harm - Minimal harm or potential for actual harm Document assessments and actions g. Residents Affected - Some Complete a fall investigation which may include obtaining statements from the resident and/or witnesses. A review of the facility's policy titled, Coordination of Hospice Services, revised date 11/29/2022, revealed the following: 9. All residents receiving hospice will continue to receive the same facility services as residents who have not elected hospice. This includes but is not limited to the following: ongoing comprehensive and quarterly assessments, personal care/support with activities of daily living, medication administration, nutritional support and services, and ongoing monitoring of resident conditions. On 7/26/23 at 10:50 a.m. an observation was made on the locked unit, Happy Trails, of unsecured cleaning products. In the Happy Trail's day room multiple residents were sitting watching the television with no staff members present. The bank of cabinets under the television was observed to be unlocked and contained a spray bottle of Micro-Kill disinfectant, microdot Bleach Wipes, and a gallon jug of Hand Sanitizer 65% alcohol. Sitting on top of the cabinet was a broken hand sanitizing dispense with two large screws sticking out the backside. Photographic evidence was obtained. An interview was conducted on 7/27/23 at 5:45 p.m. with the DON. The DON was shown pictures of the items that were unsecured on the Happy Trails unit. She agreed those items should have never been left out, especially on that unit. She said that same room even contains a locked cabinet. The DON said she didn't know why they would have been put in that cabinet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 12 of 18 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 07/27/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure prescription medications were being administered by appropriate licensed personnel for three residents (#5, #7, and #6) of nine sampled residents. Findings included: On 7/26/23 at 10:57 a.m. an observation was made in Resident #5's room of a medication cup containing white powder sitting on the counter in front of the television, no staff were in sight of the room. Photographic evidence was obtained. The medication cup with powder remained in the room. At 12:40 p.m. Resident #5 stated the powder was what the nurse puts on her when she is itching. A review of records revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebra infarction, morbid obesity, and edema. A review of orders revealed the following order: Nystatin Powder. Apply to periwound to back wound topically every day shift for fungal for 14 days. Order date 7/13/23. There were no orders or care plans related to self-administration of medication. On 7/27/23 at 9:13 a.m. an observation was made in Resident #7's room of a medication cup containing white powder sitting on the bedside table. Resident #7 stated the powder in the cup is Nystatin powder. She said the nurse usually leaves it there and they put it on her when they change her. Photographic evidence was obtained. A review of records revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of skin, malignant neoplasm or unspecified site of female breast, and overactive bladder. A review of orders indicated the following: -Nystatin powder. Apply to groin topically every day and evening shift for rash for 14 days. Order date: 7/25/23. An interview was conducted on 7/26/23 at 12:45 p.m. with Staff J, Licensed Practical Nurse (LPN). Staff J, LPN said the white powder in the medication cup was Nystatin powder. She confirmed it was a prescription medication and should not be stored in the room. Staff J, LPN said she didn't know it was in there, she said she didn't leave it and hadn't noticed it there all day. An interview was conducted on 7/27/23 at 11:19 a.m. with Staff L, CNA. She stated some residents get Nystatin powder put on. The CNA said the nurses leave the medication in the resident rooms and the CNAs apply it to residents when they change them. She stated she knows Residents #5 and #7 get Nystatin powder applied. She said the nurses do not usually specify if it is once a shift or if it should be applied every time the resident is changed. Staff L, CNA said Resident #6 also gets Nystatin powder applied and the nurses always leave it in her room for the CNAs to apply. On 7/27/23 at 11:48 a.m. an observation was made in the room of Resident #6. The resident was sleeping, and no staff were present. The bedside tray table had nasal spray, an inhaler, and a plastic bag with capsules in it. No Nystatin powder was observed in the room at the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 13 of 18 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 07/27/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of records revealed Resident #6 was admitted on [DATE] with diagnoses including fracture of medial malleolus of right tibia, morbid obesity, asthma, Chronic Obstructive Pulmonary Disease (COPD,) and solitary pulmonary nodule. On 7/27/23 at 11:48 a.m. an interview was conducted with Staff M, CNA. She confirmed she was a CNA that regularly cares for Resident #6. Staff M, CNA said Resident #6 gets Nystatin powder applied. She stated the nurses leave the powder in the resident's room in a cup and she puts it on the resident any time she changes her. On 7/27/23 at 11:06 a.m. an interview was conducted with the Director of Nursing (DON.) She said medication should not be left in the resident rooms. The DON confirmed Nystatin is a prescription medication that should be administered by the nurses. When asked about CNAs administering Nystatin, she looked surprised and said the CNAs should not be applying the Nystatin or any medication. A facility policy titled Medication Administration, revised 5/3/22, was reviewed. The policy stated the following: Medications 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. 1. Keep medication cart clean, organized, and stocked with adequate supplies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 14 of 18 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 07/27/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility did not ensure medications were stored properly in three medication carts out of six, in four resident rooms (#5, #3, #7, and #6) out of nine residents sampled, and one nursing unit out of four units. Findings included: On [DATE] at 10:57 a.m. an observation was made in Resident #5's room of a medication cup containing white powder sitting on the counter in front of the television, no staff were in sight of the room. Photographic evidence was obtained. The medication cup with powder remained in the room at 12:40 p.m. Resident #5 stated the powder was what the nurse puts on her when she is itching. An interview was conducted on [DATE] at 12:45 p.m. with Staff J, Licensed Practical Nurse (LPN). Staff J, LPN said the white powder in the medication cup was Nystatin powder. She confirmed is was a prescription medication and should not be stored in the resident room. Staff J, LPN said she didn't know it was in there, she said she didn't leave it and hadn't noticed it there all day. A review of records revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebra infarction, morbid obesity, and edema. A review of orders revealed the following order: Nystatin Powder. Apply to periwound to back wound topically every day shift for fungal for 14 days. Order date [DATE]. There were no orders or care plans related to self-administration of medication. On [DATE] at 4:13 p.m. an observation was made in Resident #3's room of medications including acetaminophen, gummy vitamins, as well as prescription eye drops in a basket. The resident did not want the medication moved to be looked at. On [DATE] at 9:36 a.m. the basket of medication remained sitting at Resident #3's bedside. The medications Prednisolone eye drops, an antibiotic, ashwagandha root gummies, fiber gummies, acetaminophen, and additional prescription medications. Photographic evidence was obtained. A review of records revealed Resident #3 was re-admitted to the facility on [DATE] with diagnoses including orthopedic aftercare, dementia, cognitive communication deficit, depression, anxiety, and dysphagia. A review of orders revealed the following: -Acetaminophen tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed for pain. DO NOT EXCEED 3gm/24 hours. Order date: [DATE] -Acetaminophen tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed for temp > 100.4. DO NOT EXCEED 3 gm/24 hours. Order date: [DATE]. -Prednisolone Acetate Ophthalmic Suspension 1 %. Instill 1 drop in left eye four times a day for inflammation. Order date: [DATE]. -Multivitamin tablet. Give 1 tablet by mouth one time a day for supplement. Order date: [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 15 of 18 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 07/27/2023 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 0761 A review of orders did not show any orders for ashwagandha root gummies and fiber gummies. Level of Harm - Minimal harm or potential for actual harm A review of the Medication Administration Record (MAR) indicated the facility administered Acetaminophen to Resident #3 on [DATE] and [DATE]. The resident was also being administered Prednisolone Acetate Ophthalmic Suspension by the facility 4 times a day, as well as a multivitamin daily. There were no orders or care plans related to self-administration of medication. Residents Affected - Few On [DATE] at 11:12 a.m. an observation was made at the [NAME] unit nurses' station of a medication cart unlocked. There were no staff in sight of the cart. Four residents were sitting nearby, with the closest being less than five feet from the cart. This same medication cart was observed to be unlocked on [DATE] at 11:51 a.m. with no staff members present. On [DATE] at 9:13 a.m. an observation was made in Resident #7's room of a medication cup containing white powder sitting on the bedside table. Resident #7 stated the powder in the cup is Nystatin powder. She said the nurse usually leaves it there and they put it on her when they change her. Photographic evidence was obtained. A review of records revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of skin, malignant neoplasm or unspecified site of female breast, and overactive bladder. A review of orders indicated the following: -Nystatin powder. Apply to groin topically every day and evening shift for rash for 14 days. Order date: [DATE]. On [DATE] at 9:23 a.m. an audit was completed on the [NAME] Back Medication cart with Staff K, Registered Nurse (RN.) The medication cart contained five loose pills in the cart drawers. There was also a set of resident keys found in one of the drawers. Photographic evidence was obtained. Staff K, RN said the nurses look through their own medication carts on their down time. She said it is difficult because she doesn't consistently have the same cart each day. On [DATE] at 9:58 a.m. an audit was completed of the North Medication cart with Staff E, LPN, Unit Manager (UM.) The medication cart contained five loose pills in the cart drawer. The cart also contained a utility knife in one drawer and a plastic bag with a candy bar in another. A liquid medication was spilled out in a drawer causing the items around it to become sticky. Staff E, LPN, UM said the candy bar belonged to a resident and should not be in the medication cart. She stated she would have the nurse clean the cart immediately. On [DATE] at 10:16 a.m. an observation was made on the 200-hall close to the nurses' station of a white pill on the floor. Staff B, RN, UM confirmed the pill should not be on the floor. He was unable to identify what it was. He disposed of it immediately. On [DATE] at 10:28 a.m. an audit was completed of the East Medication cart with Staff B, RN, UM. There were eight loose pills in the drawers of the medication cart. Staff B, RN, UM said the night shift cleans the medication carts and nurses should also look at their own carts. He confirmed there should be no loose pills. On [DATE] at 11:48 a.m. an observation was made in the room of Resident #6. The resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 16 of 18 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 07/27/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sleeping, and no staff were present. The bedside tray table had nasal spray, an inhaler, and a plastic bag with capsules in it. A review of records revealed Resident #6 was admitted on [DATE] with diagnoses including fracture of medial malleolus of right tibia, morbid obesity, asthma, Chronic Obstructive Pulmonary Disease (COPD,) and solitary pulmonary nodule. A review of orders revealed the following: Breztri Aerosphere Aerosol 160-9-4.8 mcg/ACT. 2 puffs inhale orally two times a day for wheezing. RINSE MOUTH AFTER USE. DO NOT SWALLOW. Order date: [DATE]. No order for nasal spray was found. No order or care plan for self-administration of medication was found. On [DATE] at 11:50 a.m. an observation was made on the [NAME] unit of a treatment cart unlocked in the resident hallway. No staff were in sight of the cart. Residents were moving up and down the hall. On [DATE] at 11:06 a.m. an interview was conducted with the Director of Nursing (DON.) The DON said night shift usually goes through the medication carts to remove expired medication and clean the carts. She said pharmacy also comes in monthly to do audits. When asked if any pills should be loose in the medication carts she stated, Oh no of course not. She also confirmed items that are not medication should not be stored in the carts, such as keys, candy bars, and utility knives. The DON said they had issues with their medication carts previously, but she thought they had it all fixed now. The DON said the only way a resident should have medication in their room is if they have been evaluated to safely self-administer the medication. She said in that case, the doctor would be involved and their would be an order in the record. At 12:07 p.m. The DON confirmed they currently have no residents in the facility approved to self-administer medications. A facility policy titled Medication Storage, reviewed [DATE], was reviewed. The policy stated, It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy and/or mediation rooms, according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines continue: 1a. All drugs and biologicals will be stored in locked compartments under proper temperature control. A facility policy titled Medication Administration, revised [DATE], was reviewed. The policy stated the following: Medications 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 17 of 18 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 07/27/2023 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 0761 1. Keep medication cart clean, organized, and stocked with adequate supplies. 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: 105455 If continuation sheet Page 18 of 18