Health inspection·May 27, 2021

F 0584 to be able to sleep at night and early in the a.m. without any loud noises. Level of Harm - Minimal harm or potential for actual harm A review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. A review of the MDS Quarterly assessment, dated 5/12/2021, revealed a BIMS score of 7 out of 15. This score indicated that the resident was lower cognitive functioning but was able to make his needs known. This resident was also the roommate of Resident #57. Residents Affected - Few A review of the medical record for Resident #6 revealed the resident was admitted to the facility on [DATE]. A review of the current Minimum Data Set (MDS) Annual assessment, dated 3/7/2021, revealed a Brief Interview Mental Status (BIMS) score of 14 out of 15. This score indicated that resident had higher cognitive functioning and was able to make her needs known. A review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. A review of the current MDS Quarterly assessment, dated 5/17/2021, revealed a BIMS score of 9 out of 15. This score indicated that the resident had some cognitive deficits but was able to make her needs known. A review of the medical record for Resident #65 revealed the resident was admitted to the facility on [DATE]. A review of the current MDS Annual assessment, dated 5/6/2021, revealed a BIMS score of 11 out of 15. This score indicated that the resident had higher cognitive functioning and was able to make her needs known. A review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. A review of the MDS Quarterly assessment, dated 3/9/2021, revealed a BIMS score of 14 out of 15. This score indicated that the resident had higher cognitive functioning and was able to make her needs known. During an interview with Staff A, Certified Nursing Assistant (CNA) on 5/25/21 at 8:36 a.m., an interview on 5/26/21 at 7:20 a.m. with, Staff B, CNA, Staff C, CNA and an interview on 5/26/21 at 12:09 p.m. with the Care Plan Coordinator it was confirmed that Resident #57 calls out and yells and screams all day and he does this repetitively. They confirmed that once they visit him, he quiets down, but will soon start again. They confirmed that one could hear him throughout the facility but more so in [NAME] Hall. Staff A, B, and C did not know of what else to do but confirmed he was care planned for this behavior and has been seen by the physician and psych services. Review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. Review of the diagnosis. sheet revealed diagnoses to include dementia with behavioral disturbance, schizoaffective disorder bipolar type, anxiety, PVD (peripheral vascular disease), major depression, pseudobulbar affect. Review of the medical record contained an Incapacity Statement signed and dated by the MD (medical doctor) on 10/27 (The year was not readable). However, the Incapacity Statement was dated in the electronic record on 3/20/2020. Review of the current Minimum Data Set (MDS) assessment Medicare 5 day, dated 5/3/2021 revealed, resident did not have a BIMS score, but was coded with Short Term/Long Term memory loss, and with severely impaired decision-making skills. The assessment also indicated Resident #57 exhibits with mood and behaviors to include screaming and disruptive sounds daily. 2. On 5/24/2021 at 6:30 a.m., 5/25/2021 at 7:01 a.m., 5/26/2021 at 7:00 a.m., and 5/27/2021 at 7:08 a.m. Staff I, Housekeeping Floor Tech was observed utilizing a very loud mechanical high speed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 2 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm buffing machine throughout the facility to include [NAME], Canterbury, and [NAME] Halls. He was noted pushing the machine up and down the main hallways of these halls several times and while residents were still in their rooms sleeping. During these observations, there were over twelve resident rooms that were observed with the doors open and with the lights off in the room, while residents were in bed with their eyes closed. Residents Affected - Few Random interviews on 5/25/21 between 9:30 a.m. and 10:14 a.m. with Residents #6, #5, #65, #13, and #8 all revealed they were aware of the housekeeping staff using a loud machine very early in the morning. They further revealed that they have not complained because they did not know they had that right when it comes to how early staff clean the floors. They continued to say that they would like for the noises to decrease during the early times of the morning. 3. On 5/26/2021 at 9:28 a.m. Resident #57's room was approached. Prior to getting to the room Resident #57 was overheard calling out and yelling loudly. Upon reaching the room door, a machine was overheard coming from inside the room. Staff I, Housekeeping Floor Tech was in the room and utilizing a very loud high speed buffing machine to buff the floors in the room. Resident #57 was seated in a specialized chair positioned between his bed and his roommate's bed. The roommate was observed in the room, as well, and was in bed. Staff I continued to buff the floors with this machine in the room for about four minutes. He was observed maneuvering the machine at and around Resident #57 as he was yelling and screaming out loud. Once Staff I was finished in the room he was interviewed. Staff I revealed he generally knocks on the door and goes in to buff the floors. He did not know if there were any residents in the building that are afraid or get agitated with loud noises. He did confirm that Resident #57 was yelling out and he just thought that he just does that. Staff I revealed nobody ever told him or housekeeping of any residents who are afraid of loud noises. On 5/27/2021 at 1:20 p.m. the Director of Nursing (DON) provided the Resident Rights policy and procedure, with an effective date of 11/30/2014, that did not indicate any specific areas for dignity. However, an interview with the DON and the Nursing Home Administrator at this time revealed that resident's dignity should be maintained and free from loud noises, and constant noises. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 3 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and medical record review, the facility did not ensure a comprehensive person-centered care plan was developed for bed rail/bed enablers and failed to implement interventions for bed positioning and reducing loud noises to prevent agitation for one resident (#57) of thirty-one sampled residents for three days (5/24/2021, 5/25/2021, and 5/26/2021) of four days observed. Findings included: A review the Plans of Care policy and procedure, with a last revision date of 9/25/2017, revealed: Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedure section revealed: Develop and implement an individualized person-centered comprehensive plan of care by interdisciplinary team that includes but not limited to - the attending physician, a registered nurse with responsibility of the resident, a nurse aide with responsibility for the resident, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident and, to extent practicable, the participation of the resident and resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). The policy further revealed; The individualized person centered plan of care may include but is not limited to the following: - Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. - Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths and desired outcomes. On 5/24/2021 at 6:45 a.m., and 8:30 a.m.; 5/25/2021 at 7:38 a.m., 10:45 a.m., and 11:40 a.m.; and 5/26/2021 at 7:20 a.m., 8:30 a.m.; and 10:00 a.m., Resident #57 was observed in his room, lying either flat on his back with his head on a pillow at twenty to thirty degrees, or seated flat in bed and upright at forty-five degrees. Resident #57 had been observed with calling out and repetitive yelling behaviors throughout the day, each day observed. During each observation, the resident was observed in his bed and both bed rails were observed up and locked into position. During each observation, the bed was observed raised to approximately three feet up from the ground level. The bed was never observed in the lowest position. Interviews were attempted several times during the above observations with Resident #57. Resident #57 was not able to respond with relation to his care and services. The observations were as follows: 1. 5/24/2021 at 6:45 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 4 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 The bed was not in the lowest position. Level of Harm - Minimal harm or potential for actual harm 2. 5/24/2021 at 8:30 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. Residents Affected - Few 3. 5/25/2021 at 7:38 a.m. the left bed rail was now locked in an upright position, indicating a ½ rail position. The right bed rail was locked in an upright position, indicating a ¼ rail position. The bed was not in the lowest position. 4. 5/25/2021 at 10:45 a.m. the left bed rail was locked in an upright position, indicating a ½ rail position. The right bed rail was locked in an upright position, indicating a ¼ rail position. The bed was not in the lowest position. 5. 5/25/2021 at 11:40 a.m., and 12:20 p.m. the left bed rail was locked in an upright position, indicating a ¼ position. The right bed rail was locked in an upright position, indicating a ¼ position. The bed was not in the lowest position. 6. 5/26/2021 at 7:20 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. 7. 5/26/2021 at 8:30 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. 8. 5/26/2021 at 10:00 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. (Photographic Evidence was Obtained) Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. Review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include dementia with behavioral disturbance, schizoaffective disorder bipolar type, anxiety, PVD (peripheral vascular disease), major depression, pseudobulbar affect. Review of the medical record contained an Incapacity Statement signed and dated by the MD (medical doctor) on 10/27 (The year was not readable). However, the Incapacity Statement was dated in the electronic record on 3/20/2020. Review of the current Minimum Data Set (MDS) Medicare 5-day assessment, dated 5/3/2021 revealed, a Brief Mental Interview Status (BIMS) with no score. However, it coded Resident #57 with short term/long term memory loss, with severely impaired decision making skills; Mood - Yes to little interest, Yes to trouble sleeping, Yes, Restless 2 - 6 days, Yes short tempered/easily annoyed; Behaviors - Verbal behaviors exhibited 1- 3 days, to include screaming and disruptive sounds daily; Activities of Daily Living ADL Extensive to total dependence with all ADLs (activities of daily living); B&B (bowel & bladder) - Always incontinent of bladder, Always incontinent of bowels; Bed Rails - Not Used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 5 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 the MDS assessment significant change, dated 4/26/2021, revealed bed rails - Not Used. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment Quarterly, dated 2/3/2021, revealed bed rails - Not Used. Residents Affected - Few Review of the nurse progress notes dated 5/26/2020 through 5/25/2021, did not indicate any notes related to use of bed/side rails. Review of the current care plans, with a next review date of 8/2/2021, did not indicate any problem area or interventions to any problem areas with utilization of bed rails or bed enablers. The current care plan revealed the following areas: - Resident with dementia and behaviors. Confused and rarely understands and is rarely understood. Requires extensive to total care with his needs and mobility. He is totally incontinent of bowel and bladder. Decline expected. Can be aggressive, agitated, combative and resistive to care. Significant decline in function and is currently not propelling self around unit. Interventions to include monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. - Behavior problems r/t (related to) dx (diagnosis) of dementia, schizophrenia, mood anxiety. Hx (history) of wandering/exit seeking. Increase in agitation, yelling, crying, constantly fluctuating mental status. History of attempts to get out the emergency doors and pulling fire alarms. Easily overstimulated, doesn't do well in groups or loud noises. Crying frequently with an intervention in place of anticipate and meet the resident's needs. -Risk for falls and fall related injuries r/t dementia. Has weak and impaired balance and mobility and requires extensive to total care with his needs and mobility. Is totally incontinent of Bowel and Bladder . Can be aggressive, agitated and combative and resistive to care, with interventions in place to include but not limited to: Keep bed in low position, with initial date 7/30/2019. Review of the nurse progress notes dated from 1/1/2021 through to current 5/26/2021 did not reveal any behaviors of falling out of bed, nor any documentation that indicated Resident #57 had falls. On 5/25/2021 at 8:36 a.m. an interview and observation with Resident #57's assigned aide, Staff A, Certified Nursing Assistant (CNA) was conducted. Staff A was observed to go in the room and check on him. Staff A was observed to come back out from the room about two minutes later and she explained that they are to keep them (bed rails) up when in bed. She did not know why the bed rails were used and only knew the bed rails should be up. She did not know if the ¼ rails should be up or the ½ rails should be up when Resident #57 was in bed. She did confirm that both ½ bed rails were up and locked while Resident #57 was in bed at this time. During this interview on 5/25/21 at 8:36 a.m. with Staff A, Certified Nursing Assistant (CNA)., an interview on 5/26/21 at 7:20 a.m. with, Staff B, CNA, Staff C, CNA and an interview on 5/26/21 at 12:09 p.m. with the MDS/Care Plan Coordinator it was confirmed that Resident #57 calls out and yells and screams all day and he does this repetitively. They confirmed that once they visit him, he quiets down, but will soon start again. They confirmed that one could hear him throughout the facility but more so in [NAME] Hall. Staff A, B, and C did not know of what else to do, but confirmed he was care planned for this behavior and has been seen by the physician and psych services. On 5/26/2021 at 8:15 a.m. two CNAs, Staff B, and Staff C were interviewed. Staff C and Staff B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 6 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 - Few confirmed Resident #57's bed rails were up and locked into position. They confirmed one was at the ½ rail position, and the other was at the ¼ rail position. Staff C revealed she does not have Resident #57 on her normal assignment and did not lock the bed rails in position. Staff B revealed Resident #57 is normally on her assignment and she was assigned to care for him today. Staff B confirmed that both bed rails were up but did not know exactly why. She stated, They told me to put them up, so I do. She was not able to explain who they were. On 5/26/2021 at 8:42 a.m. an interview with the floor nurse, Staff D, Agency Licensed Practical Nurse (LPN) to confirm the bed positioning (in lowest position) for Resident #57. She looked and stated, I think it is. The bed surface was observed positioned up at least three feet from off the floor. She added, I'm not sure, I am agency and don't know how the beds should be positioned. At this time Staff A, CNA and Staff B, CNA were in the immediate area and were asked to confirm if Resident #57's bed was in the lowest position. Staff A and B both confirmed that the bed was not in the lowest position and that it should be. They responded that when providing care and services, they do raise the bed so they can reach the resident easier. They both confirmed that at the time Resident #57 was not receiving care and or services. On 5/26/2021 at 12:09 p.m. the MDS/Care Plan Coordinator was interviewed related to Resident #57's bed rail use, and not identified anywhere in the record. The MDS/Care Plan Coordinator revealed the resident's bed rails are supposed to be used as enablers. She did confirm that there are so many types of bed rails in the building and some of them may work as ½ rails. She confirmed that Resident #57's rails can be adjusted to ¼ rails and did not know why staff had those specific rails positioned in a manner that displayed ½ rails on each side. She also confirmed that Resident #57 was and has been extensive assist with two person assist with bed mobility. She also revealed that Resident #57 cannot reposition himself and even if the rails were in a ¼ position, he still would not be able to use them as an enablers. The MDS/Care Plan Coordinator, through review of Resident #57's medical record, confirmed there were no consents, assessments, orders, or care plans related to use of bed rails, or bed enablers. On 5/26/2021 at 1:00 p.m. an interview with the MDS/Care Plan Coordinator confirmed that when Resident #57 was in bed, the bed should be lowered to the lowest position, as per the fall risk care plan interventions. She revealed he has not had a fall recently and does not get out of bed on his own, but the bed was still care planned to be in the lowest position for safety. On 5/26/2021 at 9:28 a.m. Resident #57's room was approached. Prior to getting to the room Resident #57 was overheard calling out and yelling loudly. Upon reaching the room door, a machine was overheard coming from inside the room. Staff I, Housekeeping Floor Technician was in the room and utilizing a very loud high speed buffing machine to buff the floors in the room. Resident #57 was seated in a specialized chair positioned between his bed and his roommate's bed. The roommate was observed in bed. Staff I continued to buff the floors with this machine in the room for about four minutes. He was observed maneuvering the machine at and around Resident #57 as he was yelling and screaming out loud. Once Staff I was finished in the room he revealed that he generally knocks on the door and goes in to buff the floors. He did not know if there were any residents in the building that are afraid or get agitated with loud noises. He did confirm that Resident #57 was yelling out and he just thought that he just does that. Staff I revealed nobody ever told him or housekeeping of any residents who are afraid of loud noises. On 5/26/2021 at 11:00 a.m. an interview with the MDS/Care Plan Coordinator and at 1:00 p.m. with the Nursing Home Administrator, both confirmed Resident #57 yells a lot, and he is care planned with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 7 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 numerous interventions to reduce the yelling, but he continues to do so repetitively. Level of Harm - Minimal harm or potential for actual harm On 5/27/2021 at 1:20 p.m. the Director of Nursing (DON) provided the Resident Rights policy and procedure, with an effective date of 11/30/2014, that did not indicate any specific areas for dignity. However, an interview with the DON and the Nursing Home Administrator at this time revealed that resident's dignity should be maintained and free from loud noises, and constant noises. Residents Affected - Few A review of the policy and procedure titled, Side Rail/Bed Rail, with an effective review date of 4/19/2018, revealed: Policy: The center, will attempt alternative interventions, and document in the medical record, prior to use of side rail/bed rail. The Policy further revealed, Side rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. The procedure section of the policy revealed the following: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/ or resident representative. 3. Obtain consent from the resident/ and or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and [NAME]. 6. Re-Evaluate the use of side rail/bed rail, quarterly, with a change of condition or as needed. 7. Follow the manufacturer's recommendation and specifications for installing and maintaining side rails/ bed rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 8 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to provide wound care in a sanitary manner that would promote healing for two residents (#61 and #26) out of two residents as evidenced by cleaning and dressing three separate wounds at the same time; not completing hand hygiene between the cleaning and dressing of wounds; leaving wounds uncovered; and not wearing personal protective equipment during wound care. Residents Affected - Few Findings included: 1. The policy titled, Dressing Change, effective 11/30/2014 and revised 12/6/2017, identified that a clean dressing would be applied by a nurse to a wound as ordered to promote healing. A review of the admission Record for Resident #61 was admitted on [DATE], 3/22/19, and 4/23/21. The admission Record identified diagnoses not limited to Type 2 Diabetes Mellitus without complications, acquired absence of right leg above knee, and unspecified peripheral vascular disease. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident scored a 15 out of 15 for his Brief Interview of Mental Status (BIMS) score indicating the resident was cognitively intact. An observation was conducted, on 5/25/21 at 1:42 p.m., with Staff E, Licensed Practical Nurse (LPN) and Staff F, Certified Nursing Assistant (CNA). Staff E gathered the supplies necessary: - bottle of Dakins solution - 3 packages of Calcium Alginate - 2 rolls of gauze - 15 vials of Normal Saline - 12 packages of 4x4 inch gauze - 4 island dressings. Staff E, LPN obtained scissors from the Assistant Director of Nursing (ADON) and cleaned them with a Sani-cloth. She placed the supplies on a piece of wax paper, carried them into Resident #61's room, and placed it on the over-the-bed (obt) table. Staff E washed her hands and donned gloves. The LPN instructed Staff F to stay clean while she assisted the resident to his right side. Staff E removed the left and right ischiums and the sacral area dressings and placed them in a red biohazard bag. As she doffed her gloves, she instructed Staff F to open the gauze packages, and placed the biohazard bag in the trash receptacle near the door. The Staff F, CNA opened the packages and was observed flattening gauze packages with her right hand and Staff E asked her to cut a piece of rolled gauze from the roll and poured Dakins into the other package of rolled gauze. Staff E, LPN poured Dakins over the piece of Kerlix and patted the outside of the three wounds in the rotation of left ischium, sacrum, then right ischium. With the same piece of rolled gauze used to clean the outside of the wounds, Staff E patted the inside of the three wounds in the same rotation: left ischium, sacrum, and right ischium. After finishing the cleaning of the wounds, she used 4x4 gauzes, obtained from Staff F to pat dry all three wounds. Staff E packed the other roll of guaze that had been wettened with Dakins (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 9 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few into the left ischium and covered it with an island dressing, placed a 4x4 square of Calcium Alginate onto the sacral wound then covered it with an island dressing, and cut a piece of alginate, place it in the right ischium and after pushing the resident further onto his right side, she covered the wound with an island dressing. Staff E gathered and removed the trash of supplies and placed scissors onto the barrier. Staff E ungloved and washed her hands as Staff F placed the top onto the bottle of Dakins. After donning gloves, Staff E donned gloves and changed the resident's linens then moved the obt to the end of the bed. After sanitizing her hands and donning gloves, Staff E used scissors to cut the rolled gauze from the resident's left foot, ungloved, washed hands, and re-gloved. Staff E stated the wound was closed and sanguineous drainage was observed on the dressing that the staff had removed. The nurse irrigated the wounds on the resident's side of left foot and the left heel with normal saline, placed a piece of Calcium Alginate to the wound bed of the left heel and wrapped the foot with rolled gauze. The nurse removed her gloves, washed hands, donned gloves, and removed gauze from the resident's abdomen. She opened a package of gauze and vial of normal saline to the side of bed and placed a piece of Alginate to the suprapubic area of the abdomen. The nurse gathered the dirty supplies, leaving three packages of gauze and a package of an island dressing. She washed and re-gloved her hands then reached out the door and brought a Sani-cloth into the room, and used it to wipe down the obt, scissors then the bottle of Dakins. She then placed the scissors and bottle of Dakins on the treatment cart that was parked in the hallway outside of the resident's room. Immediately after leaving Resident #61's room, an interview was conducted with Staff E, LPN. The wound care observation was discussed, and the staff member stated that she had Staff F open up all the packages because she did not want to cross-contaminate and had washed her hands before dressing the left ischium, right ischium, and sacrum. The LPN confirmed she probably should not have cleaned and dressed the three wounds at the same time. On 5/27/21 at 11:16 a.m., the Infection Control Preventionist (ICP)/ADON stated that Staff E should have dispensed the Dakins before entering the resident's room (not bringing in the whole bottle) and that the three wounds should have been cleaned and dressed separately. The ICP stated that handwashing should be done after cleaning the wound and putting dressing on. The Pressure Ulcer Wound Rounds and Wound Physician notes indicated the following areas and measurements of Resident #61's wounds: - dated 5/22/21, Stage IV Left Ischium: 9.0 x 6.0 x 3.0 centimeter (cm). - dated 5/17/21, Stage IV Left Ischium: 8.5 x 7.0 x 4.0 cm. - Wound Physician note dated 5/8/21, Stage IV Left Ischium: post-debridement 9.0 x 7.0 x 4.0 cm. No change. - dated 5/22/21, Stage IV Sacrum: 9.0 x 10.0 x 2.0 cm. - dated 5/17/21, Stage IV Sacrum: 8.5 x 9.6 x 0.5 cm. - Wound Physician note dated 5/8/21, Stage IV Sacrum: 9.0 x 9.7 x 0.5 cm. Improving. - dated 5/22/21, Stage III Right Ischium: 9.0 x 4.5 x 0.3 cm. - dated 5/17/21, Stage IV Right Ischium: 7.0 x 6.5 x 0.3 cm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 10 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 0686 - Wound Physician note dated 5/8/21, Unstageable: post-debridement 7.0 x 6.8 x 0.3 cm. Improving. Level of Harm - Minimal harm or potential for actual harm - dated 5/22/21, Stage IV Left Heel: 4.5 x 4.5 x 0.3 cm. - dated 5/17/21, Stage IV Left Heel: 5.5 x 4.5 x 0.3 cm. Residents Affected - Few - Wound Physician note dated 5/8/21, Stage IV Left Heel: post-debridement 2.0 x 0.4 x 0.3 cm. No change. Resident #61's care plan, initiated on 10/28/20 and revised on 5/6/21, indicated the resident had multiple pressure ulcers, was at risk for further skin issues related to paraplegia secondary to spinal infection. The interventions instructed staff to administer treatments as ordered and monitored for effectiveness. 2) On 5/26/21 at 12:40 p.m. Resident #26 was observed sitting in a wheelchair with the bedside table across the chair. The resident was eating lunch at the time. The resident had on a pair of slip-on shoes with her feet on the floor. The right foot was observed to have a large open wound, approximately four inches in diameter, exposed to the air with part of the slip-on shoe touching the wound bed. There was no dressing in place. The wound was observed to have a large amount of yellow colored drainage coming from the center of the wound. On 5/26/21 at 12:45 p.m. an interview was conducted with Staff O, LPN. The nurse was asked to observe the wound. She stated the resident should have a dressing in place. She stated she placed a dressing on the wound on each side of the foot the day before and she did not know why there was no dressing in place. The LPN stated the nurse's aide should have let her know if the dressing had come off when the resident was given the morning care. The LPN stated she would be doing wound care as soon as the resident finished the lunch meal. A review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including cerebral vascular disease, cerebral infarction, dementia, and hypertension. The order summary report, as of 5/27/21, revealed active orders for wound care consult; Prostat 30 milliliters twice a day for wound healing; cleanse right dorsal foot with Dakin's solution pat dry and apply Santyl and dry dressing to cover daily and as needed until resolved; Bactrim DS tablet 800/160 milligram one by mouth twice a day for wound infection; Vitamin C tablet 500 milligram one by mouth two times a day for wounds. A review of the pressure ulcer wound rounds notes for Resident #26 revealed the right dorsal foot wound was classified as a pressure wound measuring 2.0 length by 1.7 width by 0.5 depth and unstageable on 5/10/21. On 5/17/21 the wound measured 2.0 length by 1.5 width by 0.5 depth and was a stage IV. On 5/22/21 the wound measured 2.0 length by 1.5 width by 0.5 depth and was a stage IV. On 5/27/21 at 11:00 a.m. a wound care observation was conducted for Resident #26 with Staff O, LPN. Staff O, LPN set up supplies on a foil barrier over bed table in the resident room for the procedure. Supplies set up on the table included: 4 x 4 gauze sponges, normal saline bullets, Q-tip applicator, a tube of Santyl medication, a medicine cup with Santyl ointment in it, scissors, tape, Kerlex gauze, and an elasticized dressing. The LPN was observed to have on a surgical mask and no eye protection as she began to perform the wound care. Staff O, LPN proceeded to perform wound care for Resident #26 as ordered. After the procedure, Staff O, LPN removed the used supplies from the overbed table and returned the tube of Santyl medication to the wound care cart. An interview was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 11 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 0686 Level of Harm - Minimal harm or potential for actual harm Staff O, LPN after the procedure. Staff O, LPN stated she did not have on eye protection while performing the wound care on Resident #26 and did not think she needed eye protection for wound care. The LPN verified she had taken the tube of Santyl medication into the room and placed it on the barrier. The LPN stated she understood the possible infection control concerns with exposure of the medication tube to the environment and then returning it to the treatment cart. Residents Affected - Few On 5/27/21 at 11:20 a.m. an interview was conducted with the ICP/ADON. The ICP/ADON stated eye protection needs to be worn during all resident care procedures including wound care. The ICP/ADON stated medication tubes are not to be taken into the room for wound care. A review of the policy entitled, Personal Protective Equipment, revised in October 2018 revealed the following: Policy statement: Personal protective equipment appropriate to specific task requirement is available at all times. Policy interpretation and implementation: 1 Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge. 2 Personal protective equipment provided to our personnel includes but is not necessarily limited to: d. eye wear (goggles and/or face shields). 3 Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required of ra task is based on: a) The type of transmission-based precaution b) The fluid or tissue to which there is a potential exposure c) The likelihood of exposure d) The potential volume of material e) The probable route of exposure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 12 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 0686 f) Level of Harm - Minimal harm or potential for actual harm The overall working conditions and job requirements. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 13 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to oxygen and humidification therapy, consistent with professional standards of practice for one resident (#15) of one resident investigated for respiratory care. Residents Affected - Few Findings included: On 5/26/21 at 11:30 a.m. an observation was conducted during tracheostomy care for Resident #15 with Staff O, Licensed Practical Nurse (LPN) who was assisted by Staff L, Registered Nurse (RN) unit manager. Resident #15 was observed seated upright in his bed. The tracheostomy site was open to air and had a dressing around the base of the tracheostomy between the device and the neck. There was an oxygen concentrator and humidifier set up in the room. The equipment was not connected to the resident and was not in operation. There was a nebulizer machine noted on a bedside table with the tubing and mask noted to be inside of a plastic wash bin mixed in with personal items for the resident. The tubing and mask were not properly stored in a clean separate bag. Resident #15 stated he had an infection in his tracheostomy site and was currently being treated with antibiotics for the infection. The resident stated he was unable to perform care for his tracheostomy and required the assistance of the staff for all respiratory care and services. Staff O, LPN prepared a clean table tray for the procedure and set up all the supplies to perform tracheostomy care. Staff O, LPN was noted to have on a surgical mask and no eye protection as she performed the procedure. The tracheostomy care was performed. On 5/26/21 at 12:00 p.m. an interview was conducted with Staff O, LPN and Staff L, RN Unit Manager. Staff L, RN stated Resident #15 was receiving nebulizer treatments as ordered and verified the tubing and mask for the nebulizer machine was not properly stored to reduce the risk of infection to the resident. Staff L, RN removed the tubing and mask from the machine to replace it. Staff L, RN stated the tubing and mask should be cleaned after each use and placed into a clean plastic bag that is dated for proper storage. Staff O, LPN stated she should have had on her goggles as part of the required personal protective equipment (PPE) needed to do the tracheostomy care. She pulled a clean pair of goggles out of her pocket and stated she just forgot to put them on. A review of the medical record for Resident #15 revealed an admission date of 8/31/2018 with diagnoses including tracheostomy, cerebral infarction, acute and chronic respiratory failure, and chronic obstructive pulmonary disease. A review of the current order summary report as of 5/27/21, for Resident #15 indicated active orders as: change inner cannula every day and evening shift and as needed; change tubing, mask, and nasal cannula weekly or as needed; check lung sounds pre nebulizer administration every 4 hours as needed; check pulse and respiration rates post nebulizer administration every 4 hours as needed; humidification via tracheostomy at 28% every shift; oxygen 4 liters via tracheostomy every shift; tracheostomy care twice daily and as needed with dressing change and tracheostomy ties as needed; Ipratropium-Albuterol solution 0.5-2.5 milligrams /3 milliliters one vial via trach every 6 hours as needed for shortness of breath. The comprehensive care plan, initiated 9/13/18 and revised 3/18/21, for Resident #15 revealed the following: Focus area: Resident #15 has oxygen as needed when short of breath. He has tracheostomy and history of respiratory failure and chronic obstructive pulmonary disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 14 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Goal: The resident will have no signs of symptoms of poor oxygen absorption through the review date. Level of Harm - Minimal harm or potential for actual harm Interventions: change oxygen and nebulizer tubing as ordered; give medications as ordered by physician; oxygen settings 4 liters per minute continuously via tracheostomy. Residents Affected - Few Focus area: Resident #15 has a tracheostomy #6 Shiley capped. Goal: The resident will have minimal signs and symptoms of infection through the review date. Interventions: humidification via tracheostomy as ordered; oxygen settings 4 liters per minute as needed via tracheostomy; use universal precautions as appropriate. A review of the May 2021 Medication Administration Record (MAR) for Resident #15 indicated the order for Humidification via tracheostomy at 28% every shift was documented as provided by nursing, and the order for Oxygen 4 liters via tracheostomy every shift was documented as provided by nursing. On 5/27/21 at 11:35 a.m. an interview was conducted with Staff L, RN unit manager. Staff L, RN verified the orders for oxygen and humidification were current for Resident #15. He stated the resident was not currently receiving the oxygen and humidification therapies as ordered. He stated the nurse is responsible for providing respiratory care as ordered by the physician. He stated he would need to get a clarification of the orders to determine if Resident #15 requires the treatments as ordered. A review of the policy entitled, Equipment Change Schedule, effective date of 11/30/2014 and revised date of 8/28/2017, indicated the following: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. Procedure: Nebulizer set-up once, every seven days along with equipment bag labeled with name, date, and room number. A review of the policy entitled, Tracheostomy Care, with an effective date of 11/30/2014 and a revised date of 8/24/2017 indicated the following: Procedure: Follow infection control procedures, as appropriate Aseptically don sterile gloves (gown and goggles as necessary) A review of the policy entitled, Personal Protective Equipment, revised in October 2018 revealed the following: Policy statement: Personal protective equipment appropriate to specific task requirement is available at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 15 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Policy interpretation and implementation: Level of Harm - Minimal harm or potential for actual harm 1 Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge. Residents Affected - Few 2 Personal protective equipment provided to our personnel includes but is not necessarily limited to: d. eye wear (goggles and/or face shields). 3 Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required of a task is based on: a) The type of transmission-based precaution b) The fluid or tissue to which there is a potential exposure c) The likelihood of exposure d) The potential volume of material e) The probable route of exposure f) The overall working conditions and job requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 16 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and medical record review, the facility failed to did not ensure an assessment for bed rails/enablers, a consent was received for use of bed rails/enablers or a physician order was received for bed rails/enablers for one resident (#57) of thirty-one sampled residents. Findings included: On 5/24/2021 at 6:45 a.m., and 8:30 a.m.; 5/25/2021 at 7:38 a.m., 10:45 a.m., and 11:40 a.m.; and 5/26/2021 at 7:20 a.m., 8:30 a.m.; and 10:00 a.m., Resident #57 was observed in his room, lying either flat on his back with his head on a pillow at twenty to thirty degrees, or seated flat in bed and upright at forty-five degrees. Resident #57 had been observed with calling out and repetitive yelling behaviors throughout the day, each day observed. During each observation, the resident was observed in his bed and both bed rails were observed up and locked into position. Resident #57 was observed and interviews were attempted several times with Resident #57 but he was not able to respond with relation to his care and services. The observations were as follows: 1. 5/24/2021 at 6:45 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. 2. 5/24/2021 at 8:30 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. 3. 5/25/2021 at 7:38 a.m. the left Bed Rail was now locked in an upright position, indicating a ½ rail position. The right Bed Rail was locked in an upright position, indicating a ¼ rail position. 4. 5/25/2021 at 10:45 a.m. the left bed rail was locked in an upright position, indicating a ½ rail position. The right bed rail was locked in an upright position, indicating a ¼ rail position. 5. 5/25/2021 at 11:40 a.m., and 12:20 p.m. the left bed rail was locked in an upright position, indicating a ¼ position. The right bed rail was locked in an upright position, indicating a ¼ position. 6. 5/26/2021 at 7:20 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. 7. 5/26/2021 at 8:30 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 17 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8. 5/26/2021 at 10:00 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. (Photographic Evidence was Obtained) Resident #57 was not noted with any behaviors of trying to get up and out from bed. On 5/25/2021 at 8:36 a.m. an interview and observation with Resident #57's assigned aide, Staff A, Certified Nursing Assistant (CNA) was conducted. Staff A was observed to go in the room and check on him. Staff A was observed to come back out from the room about two minutes later and she explained that they are to keep them (bed rails) up when in bed. She did not know why the bed rails were used and only knew the bed rails should be up. She did not know if the ¼ rails should be up or the ½ rails should be up when Resident #57 was in bed. She did confirm that both ½ bed rails were up and locked while Resident #57 was in bed at this time. On 5/26/2021 at 8:15 a.m. two CNAs, Staff B, and Staff C were interviewed. Staff C and Staff B confirmed Resident #57's bed rails were up and locked into position. They confirmed one was at the ½ rail position, and the other was at the ¼ rail position. Staff C revealed she does not have Resident #57 on her normal assignment and did not lock the bed rails in position. Staff B revealed Resident #57 is normally on her assignment and she was assigned to care for him today. Staff B confirmed that both bed rails were up but did not know exactly why. She stated, They told me to put them up, so I do. She was not able to explain who they were. On 5/26/2021 at 8:42 a.m. an interview with Staff D, Licensed Practical Nurse (LPN), who was an Agency nurse confirmed she does not know the residents and whether they should have bed rails in position or not. Review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include but not limited to: dementia with behavioral disturbance, schizoaffective disorder, bi-polar type, anxiety, major depression, and pseudobulbar affect. Review of the medical record contained an Incapacity Statement signed and dated by the physician on 10/27. The year was not readable. However, the Incapacity Statement was dated in the electronic record on 3/20/2020. Review of the current Minimum Data Set (MDS) Medicare 5-day assessment, dated 5/3/2021 revealed, a Brief Mental Interview Status (BIMS) with no score. However, it coded Resident #57 with short term/long term memory loss, with severely impaired decision making skills; Mood - Yes to little interest, Yes to trouble sleeping, Yes, Restless 2 - 6 days, Yes short tempered/easily annoyed; Behaviors - Verbal behaviors exhibited 1- 3 days, to include screaming and disruptive sounds daily; Activities of Daily Living ADL Extensive to Total dependence with all ADLs; B&B (bowel & bladder) - Not on Toileting program, Always incontinent of bladder, Always incontinent of bowels; Bed Rails - NOT USED. It was determined through observations and review of the medical record that Resident #57 does not ambulate and move on his own. He requires two person assist for transfers and positioning. Review of the MDS assessment significant change, dated 4/26/2021, revealed a Bed Rails - NOT USED. Review of the MDS assessment Quarterly, dated 2/3/2021, revealed Bed Rails - NOT USED. Review of the nurse progress notes dated from 5/26/2020 through to current 5/25/2021, did not indicate any notes related to use of bed/side rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 18 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current care plans with a next review date of 8/2/2021 did not indicate any problem area or interventions to any problem areas with utilization of Bed Rails or Bed Enablers. On 5/26/2021 at 12:09 p.m. The MDS/Care Plan Coordinator was interviewed related to Resident #57's bed rail use, and not identified anywhere in the record. The Care Plan Coordinator revealed the resident along with no other residents in the building are using bed rails as restraints, and that the rails are supposed to be used as enablers. She did confirm that there are so many types of bed rails in the building and some of them may work as ½ rails. She confirmed that Resident #57's rails can be adjusted to ¼ rails and did not know why staff had those specific rails positioned in a manner that displayed ½ rails on each side. She also confirmed that Resident #57 was and has been extensive assist with two person assist with bed mobility. She also revealed that Resident #57 cannot reposition himself and even if the rails were in a ¼ position, he still would not be able to use them as an enablers. The Care Plan Coordinator also confirmed that per review of the electronic medical record, there were no assessments, no orders, no care plans for the use of either bed rails or bed enablers. She also indicated that the facility was supposed to be going to bed rail/enablers free sometime in near the future. The Care Plan Coordinator, through review of Resident #57's medical record, confirmed there were no consents, assessments, orders, or care plans related to use of bed rails, or bed enablers. A review of the policy and procedure titled, Side Rail/Bed Rail, with an effective review date of 4/19/2018, revealed: Policy: The center, will attempt alternative interventions, and document in the medical record, prior to use of side rail/bed rail. The Policy further revealed, Side rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. The procedure section of the policy revealed the following: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/ or resident representative. 3. Obtain consent from the resident/ and or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and [NAME]. 6. Re-Evaluate the use of side rail/bed rail, quarterly, with a change of condition or as needed. 7. Follow the manufacturer's recommendation and specifications for installing and maintaining side rails/ bed rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 19 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure a repeated pharmacy recommendation was responded to within a timely manner for one resident (#56) of five residents reviewed for unnecessary medications. Findings included: The Policy and Procedure titled, Monthly Drug Regimen Review, effective 4/21/2017 and revised 10/10/2018, indicated that the procedure to ensure the requirement was met for monthly drug regimen review the Executive Director (ED)/Director of Nursing (DON) should implement the following processes which included: - Provide the consultant with responses (Consultant Report - Continuous Print) for consultant comments and recommendations from previous visits. - Discuss the recommendations not responded to and develop to plan for completing. - Download of Pharmacist Consultant Reports: -- Consultant Reports - 1 recommendation per page. ---- Non-Urgent: Report provided to the attending physician for timely response: ------ Day 1-14 provide recommendation(s) to physician(s) for review and response; ------ Day 15-21 the DON/designee will contact the physician(s) with nay outstanding recommendations if no response from physician, notify the Medical Director for further assistance. - If follow up for consultant pharmacist recommendations are not completed within the specified time frame this should be reported to the Medical Director for follow up with attending physician as indicated. An observation was made, on 5/26/21 at 5:45 p.m., of Resident #56 lying in bed and she stated that she was just tired. A review of the admission Record revealed that Resident #56 was admitted on [DATE] and readmitted on [DATE]. The admission Record included diagnoses not limited to unspecified bipolar disorder, unspecified insomnia, and moderate recurrent major depressive disorder. The Order Summary Report, as of 5/27/21, for Resident #56 included an order for Sertraline Hydrochloride (HCl) 25 milligram (mg) tablet orally once a day for depression. The order was dated 5/22/21 and to start on 5/23/21. An Order Recap Report, dated 9/1/20 - 5/21/21, indicated an order for Sertraline HCl 25 mg orally every day related to recurrent moderate Major Depressive Disorder. This order was dated 9/20/20 and discontinued on 5/21/21. A review of the Consultation Report, dated 4/9/21, indicated that Resident #56 had been receiving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 20 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Sertraline 25 mg daily for depression since 3/17/20 and asked the facility to please attempt a gradual dose reduction (GDR) to Sertraline 25 mg every other day x 30 days while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms. The report indicated this request was a repeated recommendation from 12/1/20 and 2/5/21 and instructed the facility to please respond promptly to assure facility compliance with Federal regulations. The report indicated that a verbal order was received by the Advanced Registered Nurse Practitioner (ARNP) on 5/25/21 to decline the recommendation as the resident was stable at that time. A review of the psychiatry notes indicated the following: - 12/9/20: Major depressive disorder recurrent mild - Continue dose of Sertraline 25 mg every bedtime (QHS). Consider increasing to help manage depression if patient agrees. - 2/1/21: Major depressive disorder recurrent mild - Continue Sertraline 25 mg QHS. Consider increasing to help manage depression if patient agrees. - 3/26/21: Major depressive disorder recurrent mild - Continue Sertraline 25 mg QHS. Consider increasing to help manage depression if patient agrees. - 4/21/21: Major depressive disorder recurrent mild - Continue Sertraline 25 mg QHS. The patient is stable. consider increasing to help manage depression if patient agrees. On 5/26/21 at 3:39 p.m., the Director of Nursing (DON) stated her expectation was that the physicians respond to pharmacy recommendations when they come in to sign paperwork, within two weeks. The DON reported that she could not answer why the 12/1/20 and 2/5/21 recommendations had not been signed. The DON acknowledged that the verbal order from the ARNP on 5/25/21 had not been received until after the team had requested the pharmacy recommendations for Resident #56. The DON stated she was unable to locate a signed copy of the either the 12/1/20 or 2/5/21 recommendations and did not know if the physician had seen them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 21 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 - Some 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 failed to maintain drugs and biologicals used in the facility in a safe, secure and orderly manner in three medication carts (Canterbury Hall, [NAME] Hall, and [NAME] Hall) of four medication carts. Findings included: On 5/27/21 at 2:26 p.m. an observation of the medication cart for the Canterbury Hall was conducted. Staff J, Licensed Practical Nurse (LPN) was present during the observation. In the third drawer of the cart a loose round yellow pill, one yellow oblong pill, four loose round white pills, and three oblong loose white pills were observed. In the second drawer three half white pills, and one oval white pill were observed loose. In the top drawer, an unopened multidose vial of Humalog was observed stored in a container with no date indicating when it was removed from the refrigerator. A Lantus Pen was observed stored in a bag, with no open or expiration date documented. An Insulin Aspart Prot-Asp pen was observed with no open or expiration date. Staff J, LPN stated that the cart should not be like this, and that the cart cleaning was usually done by the night shift. Staff J, LPN stated that she would need to dispose of the pens since it was not known when the pens were opened. On 5/27/21 at 2:40 p.m. an observation of the medication cart for the [NAME] Hall was conducted. Staff D, LPN was present during the observation. In the second drawer of the cart one loose round white pill, one and one half white loose oval pills, and one oblong loose white pill were observed. In the top drawer, a Lantus pen was observed stored in a bag with no date as to when it was removed from the refrigerator. Also, an Insulin Lispro Pen was observed stored in a bag, with no open or expiration date documented. A Lantus Solostar pen was observed stored in a bag with no open or expiration date on the pen or bag. An open multidose vial, stored in a container was observed, with no date on the container or the vial. An open vial of Humalog was observed stored in a plastic bag with a handwritten illegible name and date on the bag. In addition, no resident identifying information, date opened or expiration date was observed on the vial. Staff D, LPN stated that she did not know who cleaned the medication carts. Staff D confirmed that the writing on the bag was illegible, but that she believed that the Humalog in the bag with the illegible name and date must belong to (Resident #38). She also stated that she would need to dispose of the pens since it was not known when the pens were opened. On 5/27/21 at 2:55 p.m. an observation of the medication cart for the [NAME] Hall was conducted. Staff K, Registered Nurse (RN) was present during the observation. In the top drawer, a Lantus Solostar pen was observed stored in a bag that was dated with the open date and the expiration date, but the pen was not dated. An Insulin Lispro pen was observed stored in a bag with an expiration date of 5/17/21, with no open or expiration date written on the pen. A Levemir Flex Touch pen was observed stored in a bag, with a pharmacy label, but no open or expiration date on the bag or the pen. Also, two Levemir pens were observed stored in a bag with the resident's name handwritten name on it. One pen was dated but the other had no date. An interview was conducted with Staff K, RN. Staff K, did not answer questions, but did state that she would dispose of the pens. On 5/27/21 at 3:00 p.m. an interview was conducted with the Staff L, RN/Unit Manager related to the observations. He was shown the photographs of the loose pills and the insulins with no expiration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 22 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 dates. He stated he that this should not be this way. Level of Harm - Minimal harm or potential for actual harm 05/27/21 at 3:49 p.m., an interview was conducted with the Consultant Pharmacist. She stated that the expectation was that the medication cart drawers are cleaned routinely, and that an open date is written on insulins when they are removed from the fridge, and it is useful to also have the expiration date on the insulins. Residents Affected - Some A review of the facility policy titled, Medication and Medication Supply Storage and Disposal, effective date 11/30/2014 revealed: Policy: Central storage of medications is required for prescription, prescribed over the counter medications and CAM(Complementary and Alternative Medicine). Will be kept in a locked area, in their original labeled container and may not be removed more than 2 hours prior to the scheduled administration. Meds (medications) will be kept in the medication cart that locks and the keys are only accessible to the licensed personnel distributing medications. Only current medication for individuals living in the residence will be kept in the residence. Procedure: 6. Medications will be stored in an organized manner under proper conditions and in accordance with manufacturer's instructions. 8. The original container for the prescription medications must be labeled with a pharmacy label that includes the following: resident's name, name of the medication, date the prescription was issued, prescribed dosage, and instructions for administration, name, and title of the prescriber. CAM and OTC(over the counter) medications must be identified with the resident's name. Review of the pharmacy guidelines titled, Medication Storage Guidance, dated March 2020 Humalog multidose vial: Unopened store in refrigerator (36-46 degrees F [Fahrenheit]) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store in refrigerator for 28 days Opened store at room temperature for 28 days Lantus multi dose vial: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store in refrigerator for 28 days Opened store at room temperature for 28 days Lantus Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 23 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 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 Opened store at room temperature for 28 days Level of Harm - Minimal harm or potential for actual harm Insulin Aspart Pro-Asp Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 14 days Residents Affected - Some Opened store at room temperature for 14 days Insulin Lispro Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store at room temperature for 28 days Levemir Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 42 days Opened store at room temperature for 42 days FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 24 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to implement their quality assessment and assurance measures for corrective action related to deficient practice identified on the annual survey conducted on [DATE]. Findings of deficient practice were identified during the revisit survey for three (F695,

F700, and F761) of the seven citations reviewed for correction. Findings included: 1. A review of the facility plan of correction for the recertification survey ending [DATE] revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F695: The Director of Nursing or designee will perform weekly observational audits for 3 months to verify the facility staff are providing care for tracheostomy patients, following proper procedures and use of personal protective equipment during care and the care of equipment related to respiratory care. Immediate education if required. Audit results will be reviewed by the QA/QAPI (Quality Assurance/Quality Assurance Performance Improvement) committee monthly until such time substantial compliance has been achieved as determined by the committee. During the revisit conducted on [DATE] the facility was found to have failed to provide respiratory care in accordance with professional standards of practice for 1 (Resident #3) of 1 resident sampled for respiratory care related to storage of a nebulizer machine and Resident (#15) related to oxygen nasal cannula and oxygen tubing and the citation was not corrected. On [DATE] at 8:35 am during the initial tour staff member (F), Patient Care Assistant (PCA) was observed handing Resident #3 a nebulizer mask. The nebulizer machine was on, vapor could be seen coming from the front of the mask. Resident #3 held the mask up to her face. Staff member (F), PCA was interviewed at the doorway of the resident's room, and she confirmed that she was not a nurse, she was a PCA (patient care assistant). Staff member (A) R.N.(Registered Nurse) was observed four doors away from the resident at her medication cart. A second observation was conducted at 9:15 a.m., the resident had her oxygen on. She was asked if she usually self-administered her nebulizer treatment and stated that she does. She then opened her top drawer of her nightstand and her nebulizer face mask along with the tubing was laying on top of other articles unbagged. Photographic evidence was taken. At this time staff member (A) came to the resident's doorway and asked if she needed anything, the resident responded that she didn't. Staff member (A) was asked to verify if Resident #3 nebulizer mask was stored in a sanitary manner. She stated that the resident self-administers her treatment. Staff member (A) was asked if the resident was care planned to self-administer, she stated that she didn't know because she was an agency nurse. Staff member (A) was asked if the nebulizer was stored in the resident nightstand appropriately, she reported no, that it should have been cleaned and bagged. The resident was asked if her nebulizer was cleaned before placing it inside her nightstand, she reported that it had not been cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 25 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with the MDS (Minimum Data Set) coordinator regarding Resident #3's plan of care for nebulizer treatments. The MDS coordinator stated that the resident does not self-administer her own nebulizer treatment and a nurse is the only one who should administer the nebulizer treatments. Care Plan review revealed the following: Resident has oxygen therapy related to respiratory illness, COPD (Chronic Obstructive Pulmonary Disease), Lung Cancer. She is easily short of breath. She removes nebs (nebulizers) and oxygen herself. Revision of the plan of care [DATE] with an intervention as follows: [DATE]-Nebs added routinely-every 6 hours. Review of the resident's MAR (medication administration record)/TAR (treatment administration record) revealed: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3-minute inhale orally via nebulizer every 6 hours for SOB (shortness of breath) start date [DATE]. The MAR showed that the resident received a nebulizer treatment on [DATE] at 6:00 am. Review of the facility Policies and Procedures: Dated [DATE], revised [DATE] titled Nebulizer (small volume nebulizer) under the heading procedure showed: Perform hand hygiene Evaluate the resident. Establish baseline respiratory rate, pulse, oxygen saturation and breath sounds. Administer treatment until medication is depleted Disassemble device and rinse the mouthpiece with water and air dry Place entire unit in bag to be maintained in residents' room A review of Resident #15's Medical Record revealed that Resident #15 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, heart failure, and shortness of breath. A review of Resident #15's Physician's orders revealed an order, dated [DATE], for oxygen as needed at 2 liters per minute via nasal cannula for shortness of breath and chronic respiratory failure. Resident #15's Physician's Orders also revealed an order, dated [DATE], for changing oxygen tubing, mask, and/or nasal cannula as needed for hygiene. A review of Resident #15's Care Plan revealed a problem, last revised on [DATE], that Resident #15 had potential for shortness of breath related to having a history of dyspnea and respiratory failure. Interventions included oxygen at 2 liters per minute as needed for shortness of breath and to use universal precautions as appropriate. An observation was conducted on [DATE] at 12:53 PM of Resident #15 resting in bed. An oxygen concentrator was observed next to Resident #15's bed. A plastic bag with an oxygen nasal cannula and oxygen tubing were observed hanging from the oxygen concentrator and sitting on the floor. The nasal cannula inside of the plastic bag was observed to be dated [DATE] and the plastic bag that the nasal cannula was inside was dated [DATE]. An interview was conducted following the observation with Staff B, Registered Nurse (RN) Unit Manager. Staff B, RN stated that residents with oxygen had their tubing, nasal cannulas, and storage bags changed out on a weekly basis. Staff B, RN observed that Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 26 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm #15's storage bag was dated on [DATE] and said that the storage bag should have been changed out when the nasal cannula was changed out [DATE]. Staff B, RN stated that storing the newly changed nasal cannula in the old bag would contaminate the nasal cannula. Staff B, RN also stated that the storage bag should not be touching the floor in the resident's room and should be stored in a way so that it was not touching the floor. Staff B, RN removed the storage bag and nasal cannula from Resident #15's room. Residents Affected - Some An interview was conducted on [DATE] at 01:21 PM with Staff G, RN, Assistant Director of Nursing (ADON). Staff G, RN stated that oxygen tubing and storage bags that the tubing was kept in were changed out on a weekly basis. Residents should have orders in their medical record for the changing out of oxygen tubing and other respiratory equipment if they use it. Staff G, RN stated that Resident #15's storage bag should have been changed at the same time that her nasal cannula was because the nasal cannula would become contaminated once it was stored in the old storage bag. An interview was conducted on [DATE] at 04:46 PM with the facility's Director of Nursing (DON). The DON stated that there was an issue previously that nursing staff were not properly changing out or dating respiratory equipment as it should be. Nursing staff were supposed to change out storage bags, nebulizer set ups and oxygen tubing on a weekly basis. The DON stated that she would not expect to see a newly changed nasal cannula stored inside of an older bag and that the bag should be changed at the same time. A review of the facility policy titled Equipment Change Schedule, effective date of [DATE] and revised date of [DATE], revealed the following: - Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. - Procedure: Nebulizer set-up once, every seven days along with equipment bag labeled with name, date, and room number. 2. A review of the facility plan of correction for the recertification survey ending [DATE] revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F700: Conduct audits of newly admitted and current residents utilizing assistive devices/side rails to ensure appropriate use. Any resident identified to not require side rails will have them removed. Facility policy regarding side rail use was reviewed by the Interdisciplinary Team and deemed appropriate. Immediate In-service provided to all interdisciplinary staff and nursing staff on assessments for bed rails/enablers to include policy and procedure by ADON/staff development nurse Assessment of all residents with side rails/enablers for continued use. Facility audit completed for all residents for side rails/enablers. Interdisciplinary Team (IDT) completed therapy referral as indicated for all other residents that could benefit from enablers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 27 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Side rails assessments completed for all residents Level of Harm - Minimal harm or potential for actual harm The Director of Nursing or designee will perform weekly audits for 5 residents for 3 months to verify the facility staff is assessing for interventions and the use of any problem areas to include the use of bedrails/enablers. Immediate education if required. Audit results will be reviewed by the QA/QAPI committee monthly until such time substantial compliance has been achieved as determined by the committee. Residents Affected - Some During the revisit conducted on [DATE] the facility was found to have failed to ensure an assessment for bed rails/enablers was conducted and failed to have a consent for the use of bed rails/enablers for one resident (#1) of seven sampled residents and the citation was not corrected. A medical record review was conducted for Resident #1 who was admitted to the facility on [DATE]. Resident is alert and oriented with confusion and forgetfulness but able to make his needs known. Review of the Minimum Data Set, dated [DATE], showed a BIMS (Brief Interview of Mental Status) score of 13, signifying that the resident was cognitively intact. The MDS also showed he had impaired cognition function or impaired thought process related to his diagnosis of Dementia with Behavioral disturbances. Resident #1 was observed with 1/4 bedrails on each side of the bed in the raised position at 8:45 a.m. A second observation was made at 1:15 p.m., the bedrail remained in the raised position. The Resident reported that his rails were always raised. Staff member (B) R.N. was asked to confirm if the resident's side rails were in the raised position. He confirmed that they were and that he was in a specialized bed (Bariatric) which comes with attached rails and if removed there would be a large gap between the mattress of approximately 2 or more inches. Review of the resident's record revealed a Side Rail Evaluation dated [DATE] included, weakness, balance deficit, pain, unable to support trunk in upright position, alert, Recommendations: he has been evaluated by therapy an does not require any side rails or bars. He has no type of device on his bed, be is bedbound by choice - total care. An interview was conducted with the Director of Nursing at 1:22 p.m. She reviewed the side rail evaluation that was conducted on [DATE] and said that a new side rail evaluation should have been completed. Care Plan Review revealed: Resident has ADL (Activities of Daily Living) self-care performance deficit related to weakness with impaired balance and mobility and requires extensive assistance of 1-2 staff with his needs and mobility. Intervention dated [DATE] showed: Side Rails: ¼ side rails used to assist with bed mobility and repositioning. P.O. dated [DATE] Bilateral side rails on bed for bed mobility. Minimum Data Set, dated [DATE] Section P indicates under bed rails (O)- not in use. At 2:30 P.M. an interview with the Minimum Data Set (MDS) Coordinator reports that the bed rail is not a restraint. She was asked if therapy or any IDT (inter disciplinary team) member had evaluated the resident prior to the use of the side rails for risk of entrapment. She confirmed there was no evaluation after the [DATE] side rail assessment. There should have been one completed. The MDS coordinator also confirmed that no consent from the resident was conducted for the use of bed rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 28 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the policy and procedure titled, Side Rail/Bed Rail, with an effective review date of [DATE], revealed: Policy: The center, will attempt alternative interventions, and document in the medical record, prior to use of side rail/bed rail. The Policy further revealed, Side rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. The procedure section of the policy revealed the following: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/ or resident representative. 3. Obtain consent from the resident/ and or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and [NAME]. 6. Re-Evaluate the use of side rail/bed rail, quarterly, with a change of condition or as needed. 7. Follow the manufacturer's recommendation and specifications for installing and maintaining side rails/ bed rails. 3. A review of the facility plan of correction for the recertification survey ending [DATE] revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F761: Review the facility policy regarding medication carts/storage by the Interdisciplinary Team. In-service immediately provided to nurses on appropriate storage and maintaining of drugs and biologicals by ADON (Assistant Director of Nurses)/Staff development nurse. Audit of medication carts. The Director of Nursing or designee will perform weekly audits for 3 months to verify storage and labeling of medication and biologicals. Immediate education if required. Audit results will be reviewed by the QA/QAPI committee monthly until such time substantial compliance has been achieved as determined by the committee. During the revisit conducted on [DATE] the facility was found to have failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards in 3 of 3 medication carts observed and the citation was not corrected. A medication cart inspection was completed on [DATE] at 03:20 PM with Staff C, Registered Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 29 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 (RN). Level of Harm - Minimal harm or potential for actual harm A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. Staff C, RN stated that the container of blood glucose test strips should have a date labeled on them to indicate when they were opened. Residents Affected - Some A manufacturer's box for a Breo Ellipta inhaler and doses were observed in the medication cart. The box had an affixed white label that read Discard after 42 days. The label also had a section which indicated the expiration date, with a hand written date of [DATE] on the provided line. Staff C, RN stated that the medication appeared to be expired and stated that medications were disposed of if they were discovered to be expired. An inspection of the 2nd, 3rd, and 4th drawers of the medication cart revealed a total of 13 loose medications that were not stored inside of any type of container. Staff C, RN addressed that the medication cart should not contain any loose medications and that medications should be stored in the proper container. Staff C, RN stated that she would normally inspect her cart every shift for cleanliness of the medication cart and ensuring that medications had proper labeling. A medication cart inspection was completed on [DATE] at 03:37 PM with Staff D, Agency RN. An inspection of the 2nd drawer of the medication cart revealed a total of 12 loose medications that were not stored inside of any type of container. Staff D, RN addressed that the medication cart should not contain any loose medications and that medications should be stored in the proper container. Staff D, RN also stated that she would expect for the medication carts to be inspected by the nurses working the floor, but also stated that she did not routinely inspect the medication cart for cleanliness. Staff D, RN was not able to state whether the facility had a protocol in place related to inspection of the medications carts by the nursing staff. A medication cart inspection was completed on [DATE] at 03:50 PM with Staff E, Agency Licensed Practical Nurse (LPN). A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. Staff E, LPN stated that the container of blood glucose test strips should have a date labeled on them to indicate when they were opened. A medication bottle containing an open vial of Latanoprost 0.005% eye drops was observed in the medication cart. The medication bottle had an affixed yellow label with a section that read Date Opened:, which did not contain a labeled date. The yellow label also contained a section that read Discard after 42 days. Staff E, LPN stated that medications which contained a label from the pharmacy should be filled out properly to indicate the expiration date of the medication. Staff E, LPN was not able to state when the vial of Latanoprost 0.005% eye drops was opened. An inspection of the 2nd drawer of the medication cart revealed a total of 3 loose medications that were not stored inside of any type of container. Staff E, LPN addressed that the medication cart should not contain any loose medications and that medications should be stored in the proper container. Staff E, LPN also stated that it was her first time with the medication cart and that she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 30 of 31 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 105482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Breezy Hills Rehab and Care Center 5245 N Socrum Loop Rd Lakeland, FL 33809 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some inspect the medication cart for presence of loose medications or proper labeling of medications in the medication cart. A telephone interview was conducted on [DATE] at 04:28 PM with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that she conducted monthly visits to the facility and conducted spot checks of the medication carts. Nursing staff should be inspecting the medication carts for open dates of medications, expiration dates of medications, and cleanliness of the medication cart itself, which would include loose medications. The Consultant Pharmacist stated that she would recommend that the nursing staff inspect the medication carts at least once a week to correct any potential issues. Nursing staff were also provided with guides to help keep track of the expiration dates of certain medications. An interview was conducted on [DATE] at 04:46 PM with the facility's Director of Nursing (DON). The DON stated that nurses were expected to inspect the medication carts for proper dating of medications, ensuring medications were not expired, and cleanliness of the medication carts. The DON also stated that there was no interval in which nursing staff should be inspecting the medication carts for issues. A review of facility Pharmacy Guidelines: Common Medication Storage, dated [DATE], under General Guidance revealed the following guidelines: - Xalatan Ophthalmic Solution (latanoprost). Store in a refrigerator at 36 to 46 degrees Fahrenheit (F) until ready to use. Date when opened and discard after 6 weeks. Store at room temperature up to 77 degrees F after opening. - Breo Ellipta Inhalation Powder. Store in a dry place away from direct heat or sunlight at 68 degrees F to 77 degrees F with excursions from 59 degrees F to 86 degrees F permitted. Date when opening the foil tray and discard after 6 weeks or when the dose counter reads 0, which ever comes first. During an interview with the Nursing Home Administrator during the Quality Assurance interview on [DATE] she reported that assessments were completed, evaluations, education, and audits. She said that the Director of Nursing and the Assistant Director of Nursing were responsible for reviewing the audits that were completed by the nursing staff for the plan of correction. We have some work ahead of us, the leaders have been here less than 4 months. We will have other disciplines conduct audits sine they would be a set of fresh eyes. Will we continue to develop action plans especially regarding side-rails. Class III FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 31 of 31