Inspection·September 25, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no documented assessments following a reported change in condition. There were no vitals recorded nor monitoring of temperature, blood pressure, oxygen, or respirations obtained when Staff A, CNA noticed the change on 07/26/2025 through 07/28/2025. Review of a progress note for Resident #1 dated 07/28/2025 at 6:40 p.m., Writer called (hospital) to check status on Resident #1, and ER nurse stated resident would be admitted for septic and dehydration. Review of a nursing progress note for Resident #1 dated 07/28/2025 at12:20 p.m. showed, Spoke with [Resident #1], resident seems more tired than normal, woke and responded appropriately if a little drowsy, resident stated she was not in pain, denied burning during urination, updated family member and who is requesting we call the physician and get urinalysis to check for UTI, notified physician and received orders for UA C&S and CBC, CMP. During an interview on 09/23/2025 at 2:31 p.m., Staff B, Licensed Practical Nurse (LPN) stated she was assigned to Resident #1 on the day she went out to the hospital. Staff B stated, I saw her that morning during medication pass. The only thing she complained about to me was she was really tired. I thought it was because her roommate liked to yell out at night and thought that maybe she didn't get very good sleep the night before. Towards the end of my shift the CNA (Certified Nursing Assistant) came and got me and the unit manager to check on Resident #1. I went in her room and Resident #1 was not responsive. She was septic. She was still breathing but was hot to the touch. I did not do any type of vitals or assessment. I could just tell she was not okay. Staff B stated when a resident leaves for the hospital, I complete a nurse's note, call the physician to get an order, complete the transfer from, notify the family, call the hospital and give report. Staff B asked, Did I not put a note in for Resident #1? Staff B stated a change of condition form is completed when a resident passes or when they go out to the hospital for an unknown injury, or for something that was not seen. Review of Resident #1's medical record revealed there was no documentation of Staff B, LPN assessing Resident #1 when the resident complained of being tired earlier that morning, nor when Staff A, CNA reported the resident was not herself. During an interview on 09/24/2025 at 12:34 p.m., Staff D, Licensed Practical Nurse (LPN) and Unit Manager (UM), stated Resident #1 was normally sitting up in bed watching her tablet or on the phone with her family. She was normally alert and oriented. She did have some weight loss and if she had to guess her weight she would say she was probably around 80 pounds. The dietician and restoratives are responsible for obtaining and monitoring weights for residents. On Monday (07/28/2025) Resident #1's family member called and said they thought Resident #1 was not doing well. Staff D said, I'm not sure of the time I got the call, but it was sometime in the morning. I went to Resident #1's room and spoke with her. She has a history of UTI's. I asked if she was having any pain while urinating, and if she slept well. She denied any issues with urinating. She was weak and tired. No, I did not do an assessment or check her vitals. I only went and checked on the resident because the family member called, and I wanted to make sure her Tablet and phone were charged. I called the family member back, and they wanted the provider to order a UA. I called the provider and got an order for a UA and labs. I put in the order and told the nurse. Later that day the nurse came and asked if I would help with obtaining the UA and labs. When we went in the room Resident #1 was very warm when I touched her. Staff D continued, I told the nurse, Oh my, she has had a change in condition, we need to send her out. Staff D stated calling the provider and got an order to send Resident #1 out to the hospital. At the time of transfer Resident#1 was responding but was slow to respond. She was sent out after lunch but before dinner, around 3:30 p.m. Staff D stated the nurses on the floor were responsible for assessing residents. When a resident goes out to the hospital the nurse does an assessment, calls the provider and calls either 911 or medical transportation. Staff D stated they complete an eINTERACT transfer form and prints off the resident's medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 2 of 5 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 09/25/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few list, labs and their code status. Staff D stated the nurses document the event in a progress note in the resident's chart. During an interview on 09/24/2025 at 12:44 p.m., the Director of Nursing (DON) stated Resident #1's family member called the facility and reported they felt she was not doing well. Staff D, UM went to check on her and made sure she had her phone. The DON stated Resident #1 told Staff D she didn't feel good and that she didn't sleep well last night. The DON stated they called the provider and got an order to do a UA, but the staff did not have any luck getting a UA from Resident #1. The DON stated , I believe they tried doing a straight Cath and that was not successful. She stated when staff went to check on Resident #1 around 12 p.m., she was not at her baseline. Throughout the day they were following interventions for her, and she rapidly declined. They sent her out to the hospital later in the day. The DON said, I did not work that day. This is what I was told happened. The DON stated the nurse are responsible for assessing residents. Doing an assessment or getting vitals for a resident going out to the hospital would depend on the acuity of the situation. If someone falls, you will not need to do a blood pressure at that moment. The DON said, I would think you would get basic vitals for any assessment. If they are just calling about a change of condition, I would not want them to prioritize getting vitals, you get to know the signs and symptoms, if you feel like someone is getting ready to code, call 911, don't worry about calling the physician. The DON stated it comes down to nursing judgement and the nurse who is responsible for the resident. There should be a progress note related to the change of condition or a change of condition form should be completed. The DON stated they did not have one specific way of documenting a change of condition for a resident going out to the hospital. The DON stated, You want to there to be a picture of what happened with the resident. Review of a Nutrition Risk Screen dated 03/07/2025 revealed the most recent weight 95 lbs. (pounds), obtained on 02/14/2025. The assessment showed - Mental status confused. Resident is at increased nutritional risk related to chronic medical condition, psychotropic medications that can affect weight, abnormal labs, therapeutic diet dx (diagnosis) HTN (hypertension), mechanically altered diet dx dysphagia. Body mass index (BMI) continues low. Supplements have not shown to improve body weight. Consumes less than 25-75% of most meals. Goal: Weight gain is desirable for this resident. Review of Resident #1's record revealed there was no quarterly Nutrition Risk Screen documented for the months of June/July 2025. The review further showed there was no evidence Resident #1's POA was notified of the change in nutritional status. During an interview on 09/24/2025 at 2:00 p.m., the Registered Dietician (RD) stated he started the last week of July 2025. He had not seen Resident #1 since she went out to the hospital the same week he started. The RD stated if residents are found with any active weight loss, they would be on weekly weights or daily weights and then would go to every 30 days if stable. The RD stated with Resident #1's body mass index (BMI) being low, I would keep tabs on her a little longer and watch her weights. If her last quarterly assessment was in March, she would have needed another one in June or July.Review of Resident #1's Care Plan dated 07/02/2019 revealed a focus showing Resident #1 is at increased nutritional risk related to chronic medical condition, psychotropic medications that can affect weight, abnormal labs, therapeutic diet diagnosis of hypertension, and mechanically altered diet diagnosis of dysphagia. Interventions included to monitor dietary habits, intakes and weight trend/ lab results to assess for signs/symptoms of malnutrition/dehydration via reassessments per policy and to provide nutritional recommendations as needed. A second focus in the same care plan revealed Resident #1 was at risk for complications due to being incontinent of urine and bowel related to immobility, hemiplegia affecting left side, multiple sclerosis, abnormal posture and adult failure to thrive. Interventions included to encourage/assist with hydration throughout the day and while awake at night, observe for foul (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 3 of 5 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 09/25/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smelling, cloudy urine, fever, bladder distention, change in urinary output, mental status and/or changes in bowel pattern and report to nurse and physician as needed. A third focus revealed Resident #1 exhibits or is at risk for respiratory complications related to diagnosis of solitary pulmonary nodule. Interventions included to encourage the resident to express feelings of fear and anxiety and provide verbal and nonverbal support, monitor and report oxygen (O2) sat (saturation) levels via pulse oximetry as ordered and report prn; observe for increased wheezing and or lower activity tolerance and report to physician as indicated, observe respiratory rate, signs and symptoms of dyspnea, use of accessory muscles indicating respiratory distress and report to physician as indicated. Review of the facility Job Description for Registered Nurse revealed: Summary: Provide direct nursing care to the residents and provide clinical oversight of the day-to-day nursing activities performed by licensed practical nurses and/or certified nursing assistants and or patient care assistants. Clinical oversight must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern facility.Essential duties and responsibilities:. Complete accident/incident reports, as necessary. Complete and file required forms/charts upon residence admission, transfer, and or discharge. Document and EHR in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents response to the care following established facility charting and documentation policies. Fill out and complete transfer forms in accordance with the established procedures. Promptly respond to call lights and assist with other resident needs. Consults with the resident's physician in providing the residents care, and treatment. make periodic rounds to confirm that care and services are being properly administered by LPN's, CNA's to evaluate the residents physical and emotional status. Notify the residents attending physician and are responsible party when the resident is involved in an accident or incident or when there is a change in the residence condition. Review of the facility job description for Charge Nurse (LPN), revealed: Summary:Provide direct nursing care to the residents and provide oversight of the day-to-day nursing activities performed by certified nursing assistants and/or patient care assistants. Clinical oversight must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern facility.Essential duties and responsibilities:Ensure nursing personnel assigned to you comply with the written policies and procedures established by this facility.Cooperate with other resident services when coordinating nursing services and be certain that the residents total regimen of care is maintained.Admit, transfer, and discharge residents, as required. Complete accident incident reports as necessary.Complete and file required forms charts upon residence admission, transfer, and or discharge.Document and EHR and an informative and descriptive manner that reflects the care provided to the resident as well as the residents response to the care following established facility charting and documentation policies. Fill out and complete transfer forms in accordance with established procedures.Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.Make periodic rounds to confirm that care and services are being properly administered CNA's and PCA's and to evaluate the residents physical and emotional status.Monitor seriously still residents, as necessary. Review of the facility policy dated 11/3/2020 with the revision date of 11/16/2023 titled abuse, neglect and exploitation revealed: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions:. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.III. Prevention of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105455 If continuation sheet Page 4 of 5 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 09/25/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete abuse, neglect and exploitationThe facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:. B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and or misappropriation of resident property is more likely to occur with the development of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms;.D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;. IV. Identification of abuse, neglect and exploitationA. The facility will have written procedures to assist staff in identifying the different types of abuse, verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. Review of the facility policy dated 11/3/2023 with a revision date of 3/8/2023 titled Resident Rights revealed: Policy: the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident contact and responsibilities during the stay in the facility. Policy explanation and compliance guidelines. 11. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Event ID: Facility ID: 105455 If continuation sheet Page 5 of 5