Inspection·July 23, 2024

F 0569 Level of Harm - Minimal harm or potential for actual harm said, I did not issue a check, because the money was not put in the patient trust, but in the safe. The BOM was observed to review the receipt, and then state, it looks like one of the staff gave him $4 from the $15.00, and so it would be $11.00. The BOM confirmed the $4 dollar amount was not signed by either the resident or the staff member, but, written on the receipt, $4 4/26. The BOM stated she did not know who had written that, it should not be like that. Residents Affected - Few On 07/23/2024 at approximately 11:00 a.m., the NHA stated she would initiate training on the missing items and grievances. She also stated a check would be issued to Resident #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 2 of 6 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 07/23/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a functioning grievance process for three (Resident #1, #2, and #9) of three residents sampled for grievance process. Findings included: On 07/22/2024 the facility was requested to provide the grievance log for 08/01/2023 through the date of survey, 07/22/2024. 1.On 07/22/2024, the facility provided the grievance log which reflected two grievances listed for Resident #1 during the reviewed period. One dated 11/15/2023 regarding hydration preference and one dated 11/15/2023 regarding room cleanliness. Both grievances were documented to have been resolved. On 07/22/2024 at 3:06 p.m., an interview was conducted with the Social Service Director (SSD). When asked if she had received any grievance regarding missing clothing for Resident #1, she provided a post note for review. The SSD said she had been told a concern by Resident #1's family member regarding missing clothes and she had written it down on the post note about a week ago. A review of the post-note reflected no name the note referred to, no date the concern was received: Missing Clothes items (8), name, black jean, blue jean, polo's. (Photographic evidence obtained). The SSD said, she puts the information on a missing items list. When asked how long she had to respond to the missing item concern, she stated she did not have the answer for that, but grievances were within 3 days. During the interview, the missing items list was requested for Resident #1, #2, and #9. On 07/23/2024 at 9:26 a.m. an interview was conducted with the SSD and the Social Services Assistant (SSA). A review of the 07/2024 Missing Item Tracker sheet, documented an entry, dated 07/10/2024 for Resident #1. The item description was black, blue, greens [NAME] shirts, shorts, 3 PJ's. the resolution documented with no date assigned was offered $100.00 given to family. During the interview, the SSD stated the 07/10/2024 entry was the only entry she had. It came from the (family member). When the SSD was asked if the clothing listed on the post-note was the same missing items, she stated, Well, she told us some stuff yesterday. When asked, what did she tell you yesterday? The SSD said, 2-Shirts, 4-shorts, 3-pajama pants and a 1-jacket. These items were new yesterday. When asked what the items were missing on 07/10/2024, the SSD said, black jeans, 2 pairs; 2 pairs of blue jeans, and the rest were [NAME]. She did not give colors. She said he had his name in them. The SSD said, for the 07/10/2024 missing items, I looked in the missing item closet that has clothes in it. I also offered it to her to look through it, but she said she did not find it. We offer the money verbally. When asked when was the $100.00 offered, the SSD said, Yesterday, when she reported the other missing items. When asked if there was any documentation of the providing the money, the SSD provided progress note, dated 07/22/2024, 15:59, This writer spoke with the (family member) of (Resident #1) in regard to missing items. She informed this writer the amount of the items and this will be forward to the administrator. No documentation of the money being provided to the family member was presented for review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 3 of 6 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 07/23/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2.During a phone interview conducted with (Resident #2's family member), she stated Resident #2 had a balance of $11.00 in his personal trust account that was not returned to him. She stated during Resident #2's stay at the facility, his wallet had gone missing with $26.00 in it. The wallet was located, but the money was gone. She stated she had told the Nursing Home Administrator, the Social Service Assistant, and the Social Service Director. The (family member) said, he (Resident #2) is missing 2 pair of cargo shorts, one pair of long slacks, 3 shirts-button down shirts. Yes, she had filled out a grievance. A review of Resident #2's clinical chart, the face sheet, documented an admission to the facility on [DATE], and subsequent discharge of 04/27/2024. On 07/22/2024, a review of the facility grievance log reflected one grievance on file for the reviewed period of 08/01/2023 through the date of survey, 07/22/2024, for Resident #2. A review of the grievance form, dated 05/01, reflected no documentation of the person making the complaint and relationship to resident, the area was blank. The grievance: Money was taken and clothes returned. Person investigating grievance: Social Services. Grievance follow-up: This writer followed up with the sister of (Resident #2) to discuss ways to return missing money and clothes. The form was signed by the SSD. The form was blank in the area designated for notification of representative, name/date. The form was blank in the area to indicate if the grievance had been resolved. On 07/23/2024 at 10:10 a.m., the interview continued with the SSD regarding Resident #2: Reviewing the 05/01/2024 grievance. Money was taken, and clothes returned. When asked about the dollar amount of the money, the SSD confirmed she did not have documentation of the amount of money. The SSD stated the concern on 05/01/2024 came from (Resident #2's family member). She came in the office, and she said my brother is missing money. I do not recall the amount she said. We went to laundry. The SSD stated the money was replaced; the Business Office Manager (BOM) would have what we replaced. On 07/23/2024 at 10:25 a.m., an interview was conducted with the BOM regarding Resident #2. She presented a receipt, dated 04/24/2024, for $15.00. for the patient trust for Resident #2. The BOM said, We were going to deposit this into the patient trust. We never deposited the money. The resident discharged (04/27/2024). And the money is in the safe. They never came to pick it up. The BOM said, I did not issue a check, because the money was not put in the patient trust, but in the safe. The BOM was observed to review the receipt, and then state, it looks like one of the staff gave him 4$ from the 15.00, and so it would be $11.00. The BOM confirmed the $4 dollar amount was not signed by either the resident or the staff member, but, written on the receipt, $4 4/26. The BOM stated she did not know who had written that, it should not be like that. 3.On 07/22/2024, a review of the facility grievance log reflected two grievances on file for the reviewed period of 08/01/2023 through the date of survey, 07/22/2024, for Resident #9. A review of a grievance form, dated 06/18/2024, submitted by Resident #9, documented a grievance: AM meal is always (sic) last & cold. The form documented (Certified Dietary Manager) investigated the concern. The grievance official follow-up: I spoke with the resident. She is receiving her tray at the same time as her roommate. No other complaints. Date resolved 06/20/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 4 of 6 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 07/23/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm During the interview conducted on 07/23/2024 at approximately 10:10 a.m. with the SSD, she confirmed she could not see the resolution for the cold food portion of the complaint. A review of a grievance form, dated 06/25/2024, submitted by Resident #9, documented a grievance: Call lights being broken, and staff are taking a while to answer the bell. Residents Affected - Some The form had no staff member identified as to who investigated the grievance, it was blank in the designated area for this information. The grievance official follow-up: Call lights are being fixed; residents are given bells to help notify staff. CNA (certified nursing assistant) & nurses educated on customer service. The form was signed by the SSD. During the interview conducted on 07/23/2024 at approximately 10:10 a.m. The SSD stated customer service training had been conducted for the call bell light issue a she provided a Customer service in-service, sheet dated 06/24/2024, signed by twelve staff members, the positions on the form were not documented. An interview was conducted on 07/23/2024 at 11:54 p.m. with Resident #9. Resident #9 was observed dressed in seasonally appropriate clothing. She was asked about her grievances. She reported the call bell light situation had gotten better. She reported the breakfast meal was still cold; no one had followed up with her on her grievance about this. During the interview conducted on 07/23/2024 at approximately 10:10 a.m., with the SSD, she stated she attended the Quality Assurance and Performance Improvement (QAPI) meetings every month. She stated she did not take the grievances as a whole but broke them down into areas of concern. When asked if she takes the missing items list, she stated, no, I will write down the issues on my sheet. When asked if she talked about missing items each QAPI meeting, she stated no. On 07/23/2024 at approximately 11:00 a.m., the NHA stated she would initiate training on the missing items and grievances. She also stated a check would be issued to Resident #2. A review of the facility policy, Resident and Family Grievances, copy right 2021, the Compliance Store, LLC, documented the policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Policy Explanation and Compliance Guidelines included: .4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay. 10. Procedure: . e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 5 of 6 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 07/23/2024 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 0585 ii. Level of Harm - Minimal harm or potential for actual harm The steps taken to investigate the grievance. iii. Residents Affected - Some A summary of the pertinent findings or conclusions regarding the resident's concern(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. . 12. The facility will make prompt efforts to resolve grievances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 6 of 6