Health inspection·February 8, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record identified Resident #143 was admitted on [DATE]. The record included the diagnoses of moderate dementia in other diseases classified elsewhere with mood disturbance, uncomplicated alcohol abuse, unspecified persistent mood (affective) disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. A review of Resident #143's Preadmission Screening and Resident Review (PASRR), completed by an acute facility on 1/30/23, did not identify the residents' diagnoses of substance abuse, depressive disorder, psychotic disorder and/or anxiety disorder. The document identified that the findings were based on Documented History and did not indicate findings from behavioral observations and/or medications. The PASRR indicated the resident may be admitted to the facility as a Level II evaluation was not required. Review of the acute facility's History and Physical (H&P) identified that a Care Coordination note, dated 1/31/23 at 1:01 p.m., indicated Resident #143 was also currently in Mitts and roll belt , must be 24 hours (hrs) before patient (pt) can discharge (dc) without having restraints on. The acute facility's H&P identified Resident #143 had a past medical history that included dementia, alcohol abuse, anxiety, and insomnia. The inpatient medications that Resident #143 was ordered included 0.5 milligrams (mg) of Lorazepam three times daily, Quetiapine 100 mg at bedtime, Divalproex Sodium Delayed Release 125 mg three times a day, mirtazapine 15 mg at bedtime, and trazodone 50 mg at bedtime. The Order Summary Report, as of 2/7/23 at 11:31 a.m., included the following medications: - Divalproex Sodium Delayed Release 125 mg three times a day for mood disorder, started 2/4/23; - Lorazepam 0.5 mg three times a day for anxiety, hold for lethargy or sedation, started 2/4/23; - Mirtazapine 15 mg at bedtime for depression, started 2/4/23; - Quetiapine Fumarate 50 mg at bedtime for psychosis, started 2/4/23; - Thiamine 100 mg daily for alcohol abuse, started 2/4/23; - Trazodone 50 mg at bedtime for depression/insomnia, started 2/4/23. Resident #143's care plan identified the following focuses: - is on antipsychotic therapy related to (r/t) psychosis, initiated 2/4/23. - uses psychotropic medications r/t behavior management, initiated 2/4/23. - uses antidepressant medication r/t depression. (resident) also has insomnia and mood disorder, initiated 2/4/23. - uses anti-anxiety medication r/t Anxiety disorder. (resident) has a history of alcohol abuse, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 2 of 23 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 02/08/2023 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 0644 initiated 2/4/23. Level of Harm - Minimal harm or potential for actual harm - has dementia with psychosis, failure to thrive. (resident) is confused and mental function varies. At risk for further cognitive loss related to progressive disease process, initiated 2/4/23 and revised 2/7/23. Residents Affected - Some - at risk for falls and for fall related injury secondary to C-Diff, pancolitis, diarrhea. Also has dementia with confusion and forgetfulness, failure to thrive (FTT), severe malnutrition, hypertension (HTN), alcohol abuse, dysphagia, mood disorder, psychosis, depression, and anxiety. Requires extensive assistance with needs and mobility, incontinent of bowel and bladder on admission, initiated 2/4/23. - has behaviors r/t dementia, wanders out of room despite being reminded currently on isolation, frequently undresses self, and easily redirected. An interview was conducted on 2/7/23 at 10:46 a.m. with the Social Service Director (SSD). The SSD reviewed Resident #143's PASRR and confirmed the document should been changed to include psychiatric diagnoses. 3. A review of Resident #78's medical record showed a new diagnosis of Schizophrenia, unspecified and Schizophreniform Disorder dated 12/02/22. A physician order dated 01/25/23 stated, Quetiapine Fumarate Tablet 25 Mg- give 3 tablets by mouth daily for Schizophrenia. The Quarterly Minimum Data Set (MDS) dated [DATE] showed a diagnosis of Schizophrenia under section I of the MDS with an antipsychotic given all seven (7) days during the look back period. A Preadmission Screening and Resident Review (PASARR) dated 10/14/22 was available. No additional PASARR was available after the new diagnosis of Schizophrenia. During an interview on 02/07/23 at 10:45 a.m., Staff B, SSD stated,I didn't know I needed to re-do a PASARR with a new psych diagnosis. 4. Resident #65 was admitted into the facility on [DATE] with admitting diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #65's Preadmission Screening and Resident Review (PASARR) dated 12/29/22 revealed no qualifying mental health diagnosis and that no PASARR Level II was required. Section I of the 5 Day Minimum Data Set (MDS) revealed the resident had the following active diagnoses: non-Alzheimer's dementia, depression, and psychotic disorder. A review of the medical record revealed the resident was not assessed for a PASARR Level II. On 02/07/23 at 10:56 a.m., the Social Services Director (SSD) confirmed the Level I PASARR was inaccurate and should be redone. Based on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for two (Residents #3 and #78); and 2.) ensure the accuracy of a PASARR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 3 of 23 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 02/08/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Level I for two (Residents #65 and #143) admitted with mental health diagnoses of four residents sampled for PASARR. Findings included: 1. Review of the Face Sheet for Resident #3 revealed admission to the facility on [DATE], with diagnoses that included cirrhosis, benign prostate hypertrophy and hepatitis. Further review revealed additional diagnoses identified after admission to the facility; they included: -schizophrenia, diagnosed 06/09/2015 -major depressive disorder (MDD), diagnosed 07/01/2020 -dementia, diagnosed 10/01/2022 Review of a Psychiatric Note dated 01/06/2023 revealed psychiatric diagnoses and history that included dementia, schizophrenia, MDD and dysphagia. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed in Section I diagnoses that included non-Alzheimer's dementia, depression, and schizophrenia. Section N of the MDS revealed antipsychotic medications had been administered to the resident during the past seven days. Review of the current Care Plan for Resident #3 revealed focus areas that included: -history of being resistive to care/treatment r/t [related to] hx [history] of anxiety, dementia, mood d/o [disorder] and schizophrenia at times. -history of behavioral problems r/t cognitive loss/dementia, depression, mood d/o, med [medication] use, disorganized schizophrenia. -[Resident] has impaired cognitive function or impaired thought process r/t dementia, depression, and mental illness. -on antipsychotic therapy r/t schizophrenia, mood disorder. -[Resident] has a mood problem r/t hx of anxiety, dementia with behavioral disturbances, disorganized schizophrenia, and unspecified mood disorder. Further review of the documents section of the clinical record revealed a PASARR Level I completed 04/10/2013 with history of mental illness checked 'no', and history of mental retardation checked 'no.' No additional PASARR assessments (Level I nor Level II) were evident in the clinical record. During an interview with Staff A, Assistant Director of Nursing (ADON) on 02/06/2023 at 4:13 p.m., she stated it was the responsibility of the Social Services department to ensure PASARRs were complete. On 02/07/2023 at 10:54 a.m., an interview was conducted with Staff B, Social Services Director (SSD) and the Nursing Home Administrator (NHA). The SSD stated she reviewed PASARRs that were completed prior to admission for accuracy and said she did not complete a new PASARR when a resident had a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 4 of 23 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 02/08/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm psychiatric or mental health diagnosis after admission. The SSD reviewed the clinical record for Residents #3 and #78 and confirmed both residents had a new psychiatric diagnoses identified since admission to the facility and completion of the last PASARR Level I. The SSD also reviewed the clinical record for Residents #65 and #143 and confirmed both residents were admitted to the facility with a psychiatric diagnosis that was not reflected on their pre-admission Level I PASARR. Residents Affected - Some Review of a facility-provided policy titled Role of Admissions and Social Services in PASRR dated 4/1/2022 revealed: Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs a by coordinating with the appropriate State-designated authority. IV 2. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II Resident Review upon a significant change in status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 5 of 23 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 02/08/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to follow the baseline care plan related to the use of oxygen for one (Resident #242) of thirty-five sampled residents. Findings included: On 02/05/23 at 10:00 a.m., Resident #242 was observed sitting on the side of the bed. An oxygen concentrator was next to the bed with oxygen tubing sitting on the top of the concentrator. The machine was not on. The resident was not using the oxygen at this time. On 02/06/23 at 10:14 a.m., the resident was sitting next to the bed. The oxygen concentrator was next to the bed, but the machine was not on. The resident was not using the oxygen at this time. On 02/07/23 at 10:19 a.m., Resident #242 was observed in her room sitting next to the bed. The oxygen concentrator was next to the bed, but the machine was not on. She was not using the oxygen at this time. She reported she did not know the last time she used the oxygen. She stated, I can't keep up with it. A review of the admission Record revealed Resident #242 was admitted into the facility with a diagnosis that included but was not limited to Chronic Obstructive Pulmonary Disease (COPD). Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired cognition. Section O Special Treatments, Procedures, and Programs indicated the resident used oxygen therapy. A review of the Order Summary Report with active orders as of 02/08/23 revealed the following order: 2 liters of oxygen via nasal cannula continuously for COPD every shift. The base line care plan initiated on 02/01/2023 related to oxygen included but was not limited to the following intervention: Oxygen at 2 liters per minute continuously via nasal cannula. On 02/07/23 at 10:20 a.m., Staff G, Licensed Practical Nurse (LPN), reported Resident #242 used oxygen sometimes. She stated she had not seen her use it this morning. Staff G pulled up the orders for the resident and stated she had an order for oxygen, and it should be continuous. Staff G, LPN, stated the resident had therapy this morning so that was probably why she did not have it on. She had it on before therapy. Staff G, LPN, stated she should have it on and she would put it on her now. Staff G was observed placing the oxygen on the resident. On 02/07/23 at 11:05 a.m., the Director of Nursing (DON) reported the resident had an order for oxygen, but she was noncompliant and was care planned for being noncompliant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 6 of 23 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 02/08/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 02/07/23 at 11:35 a.m., the MDS Coordinator reported the greyed out area on the care plan was what the care plan read before she made changes and that was the baseline care plan. The care plan did not indicate the resident was noncompliant with the use of oxygen. On 02/07/23 at 11:39 a.m., the DON stated the expectation was that she should wear the oxygen with the exception of during smoking times. Event ID: Facility ID: 105482 If continuation sheet Page 7 of 23 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 02/08/2023 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 ensure two (#55 and #36) of two residents sampled for pressure ulcers received wound care per the physician orders. Residents Affected - Few Findings included: 1. An observation and interview was conducted, on 2/5/23 at 2:02 p.m., with Resident #55. The resident confirmed the presence of an infection to the right thigh. The resident reported that wound care was supposed to be every day but a couple of them forgot. The observation of the resident identified a double lumen peripherally inserted central catheter (PICC) located in the right upper extremity. The review of Resident #55's admission Record indicated the resident was admitted on [DATE] with diagnoses that included right femur acute hematogenous osteomyelitis. The admission Minimum Data Set (MDS), 1/24/23, identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition. The MDS revealed the resident had one stage IV pressure ulcer and required pressure ulcer/injury care. Review of the Order Summary Report, active as of 2/8/23, identified the following wound care orders: - Treatment as follows: Right hip. Cleanse with normal saline (n/s), pat dry. Apply calcium alginate and collagen. Cover with clean dry dressing as needed. This order was ordered on 1/19/23. - Treatment as follows: Right hip. Cleanse with normal saline (n/s), pat dry. Apply calcium alginate and collagen. Cover with clean dry dressing every day shift for stage 4 pressure ulcer. This order was ordered on 1/19/23. The February Treatment Administration Record (TAR) for Resident #55 identified that wound care for the stage 4 pressure ulcer was not completed as scheduled on 2/2 or 2/5/23. The TAR did not indicate that as needed wound care to the stage 4 pressure ulcer had been done. Review of Resident #55's care plan included a focus that identified the resident was admitted with right hip chronic stage 4 -recently debrided, right heel - dry not open, right foot - scab not open, 1/23/23 rash left back, and groin - fungal rash. The interventions instructed staff to Administer treatments as ordered and monitor for effectiveness. 2. An observation and interview was conducted at 2:35 p.m. on 2/5/23, with Resident #36. The resident stated that 99% of the time staff changed the dressing to the left foot and the right back side got changed daily and if staff did not come in, the resident let them know. Resident #36 reported a couple of times wound care did not get done and the facility wrote them up. A review of Resident #36's admission Record indicated the resident was originally admitted on [DATE]. The record included diagnoses not limited to Stage 4 pressure ulcer of sacral region, unspecified peripheral vascular disease, Type 2 diabetes mellitus without complications, and morbid (severe) obesity due to excess calories. The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #36 had an intact cognition as evidence by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. The MDS assessment indicated that the resident had 2 - stage 4 pressure ulcers, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 8 of 23 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 02/08/2023 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 Moisture Associated Skin Damage. Level of Harm - Minimal harm or potential for actual harm An observation was made on 2/7/23 at 12:44 p.m., of Resident #36's wound care with Staff Member D, Licensed Practical Nurse (LPN) and Staff Member F, Registered Nurse/Unit Manager (RN/UM). The left lateral foot was observed with black tissue and yellow tissue. As Staff D pulled the dressing off the area, it began to have bright red drainage. The heel wound was observed with a large amount of black tissue. The resident rolled onto left side and Staff D removed a saturated dressing from the sacral area. The disposable pad which the resident was lying on was saturated with a black-brown substance. The bilateral buttock area of the resident was a purplish-red color with a large sacral wound. Staff B applied a super absorbent silicone dressing to the left buttock, Staff F supplied another super absorbent silicone dressing, that was applied to the sacral area, and another foam dressing was removed from the residents closet and then applied to the sacral area. Residents Affected - Few A review of Resident #36's progress notes identified a note, dated 12/20/22 at 10:26 a.m., written by the Social Service Director (SSD). The note indicated the SSD had spoken to the resident and a family member and the resident stated the bandage needed to be changed. The family member pointed out the dressing was dated 12/17/22. The note indicated the nurse changed bandage right away. On 2/7/23 at 3:34 p.m., the SSD confirmed the family member had complained of wound care not being completed in December. She stated she had completed a grievance immediately and turned it into the Director of Nursing. The SSD reported the findings were that wound care had not been provided to Resident #36. On 2/7/23 at 3:47 p.m., the SSD reported a grievance had not been completed as the team decided it was a reportable incident. The Nursing Home Administrator stated, on 2/7/23 at 3:50 p.m., a family member of Resident #36 reported wound care had not been done and the resident had reported notifying the nurse on 12/18/22 but had not reported it to anyone on 12/19/22. The NHA stated the nurse who had worked on 12/18/22 had been contacted and it was confirmed that the wound care had been forgotten. The nurse who had worked on 12/19/22 reported the resident had refused three times due to not having a shower. The NHA stated there should be documentation regarding the resident refusing wound care and she did not know of the resident refusing treatments. A review of Resident #36's December Treatment Administration Record (TAR) identified the following: - Treatment as follows - cleanse left lateral foot ulcer with betadine, apply collagen and alginate, then cover with abdominal pad (ABD), and wrap with kerlix daily and as needed (prn) every day shift for arterial ulcer. This order started on 12/16/22 and was discontinued on 1/17/23. The TAR indicated that wound care was not provided on 12/18, 12/19, and 12/21/22. - Treatment as follows - left ischium. Cleanse with normal saline, pat dry, apply collagen, and cover with silicone dressing daily and prn every evening shift for left ischium pressure wound stage 4. This order was started on 12/7/22 and discontinued on 12/23/22. The TAR identified that wound care had not been provided on 12/18/22. - Treatment as follows: Clean the left inner buttock with normal saline (NS), pad dry, skin prep periwound, apply collagen, and cover with dry dressing daily and prn every day shift for trauma. This order was started on 12/8/22 and was discontinued on 12/23/22. The TAR indicated wound care was not provided on 12/18, 12/19, and 12/21/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 9 of 23 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 02/08/2023 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 - Treatment as follows: Cleanse left heel with NS, apply skin prep and ABD pad, then [NAME] with kerlix daily every day shift for trauma. This order was started on 12/16/22 and was discontinued on 12/23/22. The TAR identified that wound care was not provided on 12/18, 12/19, and 12/21/22. - Treatment as follows: Cleanse sacrum with Dakins, pat dry, apply silver alginate, with silver, then cover with foam dressing daily and prn, every day shift for Stage 4. This order started on 11/18/22 and was discontinued on 12/23/22. The TAR indicated that wound care had not been provided on 12/18 and 12/19, and 12/21/22. Review of the TAR for Resident #36 did not indicate staff had documented the resident had refused any treatments on 12/18, 12/19, and/or 12/21/22. Review of progress notes for Resident #36 for 12/19/22 and 2/20/22 did not indicate the resident had refused wound care, the notes did indicate that the residents' Mood status is pleasant and Behavioral problems are not noted. The review indicated that there was no progress note on 12/18/22. The care plan for Resident #36 included the focus that indicated the resident had multiple pressure ulcers/surgical/diabetic, vascular, (and) MASD wounds: sacrum stage 4 - admitted with, left ischium stage 4 - admitted with, left lateral plantar foot - arterial - 11/2/22 was diabetic, 8/11/22 bilateral buttock MASD, 11/9/22 - left inner buttock - trauma, 12/1/22 - left heel - trauma, (and) 1/17/23 - abdominal fold. The interventions indicated that on 12/21/22 the resident was seen by wound specialist and multiple treatments adjusted and instructed staff to Administer treatments as ordered and monitor for effectiveness. The Director of Nursing stated, on 2/8/23 at 9:28 a.m., wounds were done by the floor nurses and a wound Advanced Registered Nurse Practitioner (ARNP) came to the facility weekly. She acknowledged the facility did have a problem with one nurse not doing wound care for Resident #36 but was unaware that Resident #55 did not get wound care on 2/2 and 2/5/23. The DON reported the expectation was if a nurse was having an issue (regarding wound care) to reach out to the nursing management team and/or other floor nurses and if there was a reason wound care was not done, the expectation would be there was documentation as to the reason. The DON reviewed the record for Resident #55 and confirmed that there was no reason documented that wound care was not provided. The DON stated when Resident #36's wound care was not done the nurse was suspended and the facilty began its investigation, the nurse had reported going to the resident a few times and (the resident) was not ready, it was shift change, the nurse went to another unit and did not report to the oncoming nurse that it was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 10 of 23 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 02/08/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide pain management services per the physician orders. The facility provided pain medication outside the physician ordered parameters for two (Residents #46 and #30) of two residents reviewed for pain management. Residents Affected - Few Findings included: 1. During an interview on 02/05/23 at 10:25 a.m., Resident #46 stated the facility gave her medications for pain however the pain was always there even after medications were given. A review of Resident #46's medical record showed she had a diagnosis of Paraplegia, unspecified, pain in left leg and other muscle spasms. The care plan showed a focus of Chronic pain due to paraplegia, spinal cord injury and history of meningitis with an intervention to include an intervention to administer analgesia as per orders. A physician order dated 01/18/23 stated, Hydrocodone-Acetaminophen Tablet 5-325- Give tablet by mouth every 8 hours as needed for pain severe (7-10) not to exceed 3 grams. The Medication Administration Record (MAR) for January 2023 and February 2023 revealed the following dates that Hydrocodone was given outside the physician ordered parameters: 01/01/23- pain level was 6 with Hydrocodone administered 01/02/23- pain level was 5 with Hydrocodone administered 01/03/23- pain level was 3 with Hydrocodone administered 01/06/23- pain level was 0 with Hydrocodone administered 01/19/23- pain level was 6 with Hydrocodone administered 01/24/23- pain level was 6 with Hydrocodone administered 01/28/23- pain level was 6 with Hydrocodone administered 01/31/23- pain level was 3 with Hydrocodone administered 02/04/23- pain level was 6 with Hydrocodone administered 02/05/23- pain level was 6 with Hydrocodone administered During an interview on 02/06/23 at 2:25 p.m., the Director of Nursing (DON) confirmed the pain medication was given outside the parameters of the physician order. DON stated the Hydrocodone was not administered per physician order and outside the pain scale parameters. A review of the facility's policy and procedure titled, Administering Medications with no date stated, Medications are administered in accordance with prescriber orders, including any required time frame. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 11 of 23 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 02/08/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #30 reported, on 2/5/23 at 10:40 a.m., pain in left hip, left knee, upper shin, and left ankle that comes and goes. The resident reported a pain level of 9. Staff N, Licensed Practical Nurse (LPN), reported, at 10:43 a.m. on 2/5/23, the resident had previously been medicated for pain. The resident reported Tylenol was not working and Percocet did not work at times. On 2/5/23 at 12:15 p.m., Resident #30 was observed sloped to the right while sitting in a wheelchair, Staff I, Certified Nursing Assistant (CNA), called the resident's name numerous times and Staff N asked for the resident to be put back in bed due to pain. A review of Resident #30's admission Record indicated the resident was admitted on [DATE] with diagnoses that included non-displaced comminuted fracture of shaft of left femur subsequent encounter for closed fracture with routine healing, displaced fracture of lesser tuberosity of left humerus subsequent encounter for fracture with routine healing, repeated falls, and polyneuropathy in diseases classified elsewhere. The Order Summary Report, active as of 2/8/23, included the following physician orders: - Acetaminophen 325 milligram (mg) - Give 2 tablets by mouth every 4 hours as needed for pain, ordered 1/14/23. - Oxycodone-Acetaminophen 5-325 mg - Give 1 tablet by mouth every 4 hours as needed for pain, pain scale 4-6, ordered to start on 1/14/23. - Oxycodone-Acetaminophen 5-325 mg - Give 2 tablet by mouth every 4 hours as needed for pain, pain scale 7-10, ordered to start on 1/14/23. Review of Resident #30's February Medication Administration Record (MAR) identified that 2 tablets of Acetaminophen had not been administered. The MAR indicated staff administered 2 tablets of 5-325 mg Oxycodone-Acetaminophen on 2/1 at 7:47 p.m. for a pain level of 5, on 2/3 at 10:02 a.m. for a pain level of 3, at 5:00 p.m. for a pain level of 5, and on 2/6 at 1:32 a.m. for a pain level of 4. The care plan for Resident #30 indicated the resident had the potential for pain related to (r/t) a fall at home resulting in a left femur fracture with nailing on 12/13/22 and a left humerus fracture without surgical intervention. The interventions indicated that staff were to administer pain med as per orders. The Admission/5-day Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating a moderate loss of cognition. The MDS indicated a pain assessment interview was conducted with the resident who reported occasional pain with the worst pain level of 4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 12 of 23 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 02/08/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and three errors were identified for two (Residents #71 and #53) of five residents observed. These errors constituted a 11.11% medication error rate. Residents Affected - Few Findings included: 1. Staff D, Licensed Practical Nurse (LPN) obtained, at 8:45 a.m. on 2/7/23, a blood pressure of 147/83 and a pulse of 70 from Resident #71. On 2/7/23 at 8:50 a.m., Staff D dispensed the following medications for Resident #71: -- Carbamazepine Extended Release 100 milligram (mg) - 6 tablets -- Amlodipine 5 mg tablet -- Aspirin 81 mg Enteric Coated tablet -- Calcium Carbonate 500 mg chewable tablet - Vitamin D3 5000 unit tablet -- Citalopram 10 mg tablet -- Lisinopril 10 mg tablet -- Memantine 10 mg tablet -- Daily Vitamin with multimineral tablet -- Pregabalin 50 mg capsule The staff member confirmed 15 tablets/capsules prior to entering Resident #71's room. An interview, on 2/7/23 at 9:14 a.m., after the administration and upon returning to the medication cart, Staff D confirmed dispensing one Vitamin D3 tablet not the two that was ordered. The staff member confirmed the amount of tablets/capsules would have been 16 if two Vitamin D3 tablets had been dispensed. Review of the Order Summary Report, active as of 2/8/23, for Resident #71 included a physician order: - Cholecalciferol tablet 5000 unit - Give 2 tablets by mouth one time a day for Vitamin D deficiency. 2. On 2/7/23 at 9:17 a.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #53. The staff member dispensed the following medications: - Acetaminophen 325 mg - 2 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 13 of 23 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 02/08/2023 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 0759 - Aspirin 81 mg chewable tablet Level of Harm - Minimal harm or potential for actual harm - Sodium Chloride 1 gram - 2 tablets - Metoprolol Succinate 50 mg Extended Release (ER) tablet Residents Affected - Few - Losartan Potassium 50 mg - 2 tablets - Namenda 10 mg tablets Staff Member E confirmed dispensing 9 tablets. The staff member entered the residents' room and administered the medications. Review of Resident #53's Order Summary Report identified the following orders: - Losartan Potassium 50 mg - Give 2 tablet by mouth one time a day for hypertension (HTN). Hold for systolic blood pressure (SBP) <120. - Metoprolol Succinate ER 24 hour 50 mg - Give 1 tablet by mouth one time a day for HTN. Hold for SBP < 120 and /or pulse <60. The review of Resident #53's February Medication Administration Record (MAR) identified that on 2/7/23 Staff E documented NA for the required blood pressure prior to the administration of Losartan and NA for the required blood pressure and pulse for the administration of Metoprolol. On 2/7/23 at approximately 9:50 a.m., Staff E reported, without consulting paperwork and hesitation, that Resident #53's blood pressure was 122/76 and pulse 78. The staff member reported the blood pressure and pulse were obtained at 7:15 a.m. this morning and they had not been documented anywhere but she remembered them. A review of Resident #53's Weights and Vital Summary indicated that Staff E documented at 9:53 a.m. on 2/8/23 a blood pressure of 122/68. The Director of Nursing stated, on 2/8/23 at 9:28 a.m., reported knowledge of the Resident #71's missed Vitamin D during the task of medication administration. She stated her expectation was to follow physician orders and to document (blood pressure and pulse) at the time of administration. The facility policy - Administering Medications, undated, identified that Medications are administered in a safe and timely manner, and as prescribed. The Interpretation and Implementation indicated the following: - Medications are administered in accordance with prescriber orders, including any required time frame. - The following information is checked/verified for each resident prior to administering medications: -- a. Allergies to medications; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 14 of 23 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 02/08/2023 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 0759 -- a. Vital signs, if necessary Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 15 of 23 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 02/08/2023 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 - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure insulins were removed after expiration date, medications were stored per route and not in same compartment with non-medications in one ([NAME]) of two sampled medication carts, failed to ensure one (Canterbury) of two sampled medication carts were locked while unsupervised, and failed to ensure one ([NAME]/[NAME]) of two medication rooms did not contain expired medications. Findings included: On 2/6/23 at 12:00 p.m., an observation of the [NAME] medication cart was conducted with Staff G, Licensed Practical Nurse (LPN). The observation identified a clear bag containing an Insulin Lispro injection KwikPen. The bag indicated the pen was opened on 1/3/23 and expired on 2/1/23. A pharmacy bag contained 2 vials of Insulin Lispro. The bag identified that the vials were opened on 1/2/23, one of vials was labeled with 1/5. The website, https://www.humalog.com/u100, identified that Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. In the bottom drawer of the medication cart was a compartment that contained an opened bottle of a drug disposal solution, an opened bottle of the medication Valproic Acid, and a box of Lidocaine topical patches. Photographic evidence was obtained. On 2/8/23 at 9:28 a.m., the Director of Nursing stated that external (medications) should be separate from internal (medications). On 2/7/23 at 7:49 a.m., an observation was made of the Canterbury medication cart located in the hallway between rooms [ROOM NUMBERS]. The observation indicated the cart was unlocked and two staff members were at the opposite end of the hallway. The Director of Nursing arrived to the area and confirmed the cart was unlocked and should be locked. Staff D, Licensed Practical Nurse (LPN) came out of room [ROOM NUMBER], at 7:50 a.m. on 2/7/23, and confirmed that the cart was unlocked, I'm so mad at myself. On 2/8/23 at 9:15 a.m., an observation was made of the [NAME]/[NAME] medication room with Staff F, Registered Nurse/Unit Manager (RN/UM). On the top shelf of an upper cabinet was a box of Acetaminophen 650 milligram (mg) suppositories which was opened on 12/27/20 and expired 12/2022. The staff member confirmed findings. Photographic evidence was obtained. The policy - 5.0 Medication Storage, undated, indicated that Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida (FL) Department of Health guidelines. The procedure indicated the following: - A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. - B. Medications for external use will be stored separately from medications for internal use. Ophthalmic, otic and nasal products will be stored separately from other medications for internal use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 16 of 23 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 02/08/2023 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 - C. Medications will be stored in an orderly, organized manner in a clean area. Level of Harm - Minimal harm or potential for actual harm - F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 17 of 23 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 02/08/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and photogenic evidence, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items and did not ensure the dishwasher temperature log was up to date. The failed practice had the potential to effect more than a limited number of Residents. Findings included: 1. An observation on 02/05/23 at 9:15 a.m., during the initial tour of the kitchen, showed the walk in refrigerator contained food items that were not labeled or dated. The following items were noted with photogenic evidence obtained: A bag of lettuce was not labeled or dated A container of white substance was not labeled or dated A container of chopped meat was not labeled or dated. During an interview 02/05/23 at 9:17 a.m., Staff J, [NAME] confirmed the bag of lettuce should have been labeled and dated. Staff J confirmed the container of white substance that was identified as cottage cheese was not labeled or dated and should have been. Staff J also confirmed the chopped meat identified as chopped chicken should have been labeled and dated. Staff J stated all food should be labeled and dated. 2. An observation on 02/05/23 at 9:00 a.m., during the initial tour of the kitchen, showed a dish washer temperature log that was not completed for the evening of 02/04/23. Photogenic evidence was obtained. During an interview on 02/05/23 at 9:10 a.m., Staff J confirmed the dish washer log was not completed for the evening shift of 02/04/23 and should have been. An observation on 02/05/23 at 9:20 a.m., showed Staff K, [NAME] completing the dish washer temperature log for the 02/04/23 evening shift. In an immediate interview on 02/05/23 at 9:20 a.m., Staff K stated he should have completed the dishwasher temperature log last night. Staff K stated the dishwasher temperature log should have been completed on the evening shift but he forgot to complete it at that time. A review of the facility's policy titled, Food Storage: Cold Foods with revision date on 04/2018 stated, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 18 of 23 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 02/08/2023 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the arbitration agreement explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it and the agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility for three (Resident #205, Resident #55, and Resident #293) of the sampled three residents. Residents Affected - Many Findings included: Section G of the admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration, shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with the party to the extent that such affiliates joins in the arbitration, and judgement on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The form was signed by Resident #205 on 01/27/23. The form was signed by Resident #55 on 02/07/23. The form was signed by Resident #293 on 01/30/23 The arbitration agreement did not grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement. The arbitration agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. On 02/07/23 at 1:32 p.m., the Admissions Director reported she explained the arbitration agreement to the residents on their level. It was a small blurb in the Admissions Agreement. She explained to them that if there were any issues, they should try to resolve it with the facility first. She also lets the residents know that they could hire an attorney. The residents were signing and acknowledging that they understood the agreement. On 02/08/23 at 9:30 a.m., the Admissions Director stated she had concerns with the arbitration agreement also especially with the Jersey City, New Jersey part. The agreement did not include the residents could rescind the agreement and signing the agreement was voluntary. They were working with the legal team to change it. The legal team sent a new arbitration agreement that they were working on. They were just waiting for legal to approve it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 19 of 23 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 02/08/2023 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to ensure the arbitration agreement provided for the selection of a venue that was convenient to both parties for three (Resident #205, Resident #55, and Resident #293) of three sampled residents. Residents Affected - Many Findings included: Section G of the admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration, shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with the party to the extent that such affiliates joins in the arbitration, and judgement on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The form was signed by Resident #205 on 01/27/23. The form was signed by Resident #55 on 02/07/23. The form was signed by Resident #293 on 01/30/23. The arbitration agreement did not provide for the selection of a venue that was convenient to both parties. It indicated that the binding arbitration agreement shall be conducted in Jersey City, New Jersey. On 02/08/23 at 9:30 a.m., the Admissions Director stated she had concerns with the arbitration agreement also especially with the Jersey City, New Jersey part. They were working with the legal team to change it. The legal team sent a new arbitration agreement that they were working on. They were just waiting for legal to approve it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 20 of 23 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 02/08/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement an effective infection control program as evidence by not ensuring the appropriate hand hygiene was completed after delivering a meal tray to one (Resident #143) of one resident infected with Clostridioides Difficile (C Diff) on one of four units, failed to designate Contact precautions for one (Resident #55) of 35 sampled residents, and failed to ensure that non-dedicated equipment was cleaned in between two (Residents #7 and #145) of five residents observed during medication administration. Residents Affected - Some Findings included: 1. A review of the admission Record revealed Resident #143 was admitted on [DATE] with a primary diagnosis of Enterocolitis due to Clostridium Difficile not specified as recurrent. The Order Summary Report for the resident included a physician order, dated 2/3/23, for Isolation C Diff every shift for isolation and Isolation maintained for shift, activities, and services brought to room C Diff every shift for Isolation. On 2/5/23 at 12:53 p.m., Staff H, Certified Nursing Assistant (CNA), donned gown, gloves, and a face shield then entered Resident #143's room with a meal tray. The staff member removed gown and eye protection in the hallway outside of the residents' room and crossed the hall to utilize the wall dispenser of hand sanitizer in between rooms [ROOM NUMBERS]. The staff member stated that the hand sanitizer was sticky. Staff H asked Staff Member N, Licensed Practical Nurse (LPN) (as the LPN left room [ROOM NUMBER]) what Resident #143 was on precautions for and Staff N said for C Diff. Staff Member H stated the appropriate hand hygiene was to wash hands. Staff H traveled from outside of rooms [ROOM NUMBERS] to the nursing station at the other end of the hallway and was observed entering a room behind the desk. The Centers of Disease Control and Prevention (CDC) indicated at cdc.gov/cdiff, that washing with soap and water is the best way to prevent the spread from person to person. A CDC informational indicated that C. diff spreads when people touch surfaces that are contaminated with poop from an infected person or when people don't wash their hands with soap and water. The information identified that healthcare professionals can prevent C. diff by: wearing gloves and gowns when treating patients with C. diff and remembering that hand sanitizer doesn't kill C. diff. Review of the facility policy - Hand Hygiene, effective 9/5/2016 and revised 2/5/2021, indicated its purpose was To reduce the spread of germs in the healthcare setting. The process section of the policy identified Hands should be washed with soap and water when they are visibly soiled or before and after eating and with bathroom use. Use of soap and water to perform hand hygiene is recommended when caring for a resident(s) with known or suspected Clostridium difficile, when caring for a resident(s) with known or suspected infectious diarrhea or Norovirus outbreaks. 2. The admission Record for Resident #55 identified an admission date of 1/17/23. The record included diagnoses not limited to acute hematogenous osteomyelitis of right femur and unspecified paraplegia. An observation was conducted, on 2/5/23 at 2:02 p.m., of Resident #55. The resident reported a wound infection to the right thigh. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 21 of 23 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 02/08/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #55's Order Summary Report included a physician order, dated 1/23/23, that indicated Isolation type - Contact every shift for Methicillin-resistant Staphylococcus aureus (MRSA) until 2/19/23. The February Treatment Administration Record (TAR) for the resident identified that staff had documented every shift (minus day shift on 2/2/23) that the resident was on Contact isolation. An observation, on 2/6/23, of the door and area outside of Resident #55's room did not identify that the resident was on contact precautions. Photographic evidence was obtained. Staff O, Licensed Practical Nurse (LPN) confirmed, on 2/6/23 at 2:18 p.m., that Resident #55 was on contact isolation. The staff member confirmed there was no sign on the door or Personal Protective Equipment available outside of the room. Staff O reported just finding the order in the computer and that the resident was on isolation until the 19th. The Director of Nursing (DON) confirmed, on 2/6/23 at 2:24 p.m., that Resident #55 was on contact isolation due to wound until 2/19/23. The DON confirmed that the order did not indicate that contact isolation was for the wound and that it should identify where the MRSA was and that isolation was needed for wound care. An observation with the DON identified that there were no signs on the resident door indicating the necessity for contact precautions. The Centers of Disease Control and Prevention (CDC) guideline - Methicillin-resistant Staphylococcus aureus (MRSA), reviewed January 31, 2019, indicated that to prevent MRSA infections, healthcare personnel: Use Contact Precautions when caring for patients with MRSA (colonized, or carrying, and infected). The instructions indicated that Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. 3. On 2/7/23 at 7:58 a.m., an observation was made with Staff C, Registered Nurse (RN) of the administration of medication with Resident #7. Observed from the hallway of Staff C obtain vital signs with a wrist blood pressure cuff. The staff member returned to the medication cart, laid the cuff on top of the cart without cleaning it and reported vital signs of 115/70, pulse 75, temperature of 97.2, 97% oxygen saturation on room air, and 17 respirations. Staff C dispensed medications and administered the medications to the resident. Staff C moved the medication cart to in front of Resident #145's room. The staff member removed the wrist blood pressure cuff and pulse oximeter from top of the medication cart, that was previously used on Resident #7 and obtained vital signs from Resident #145. Staff C removed a canister of Microkill wipes from the medication cart and used a wipe to clean the oximeter then the wrist cuff. On 2/7/23 at 8:33 a.m., Staff C reported thinking that cleaning of the cuff and pulse oximeter was done after leaving Resident #7's room. The policy - Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy identified that a blood pressure cuff was considered a non-critical item and Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 22 of 23 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 02/08/2023 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 0880 The Director of Nursing stated, on 2/8/23 at 9:28 a.m., that staff were to clean reusable equipment in between residents with bleach wipes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 23 of 23