Health inspection·May 8, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 5/7/25 at 2:39 p.m. with Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member said residents needed to assessed for side/bed rails by therapy. Staff D, LPN reported Resident #58 had a history quarter rails, was able to hold onto bed rail to assist with repositioning, was not able to pull self-up in the bed with the rails, and when staff rolled the resident over, the resident was able to hold on to bedrail to hold self the on side during care. Staff D, LPN reviewed the resident's record and stated for the side rails intervention on 3/13/25, therapy went through the facility and did evaluations to determine if the rails were helping with mobility or keeping independence. Staff D stated therapy discontinued the intervention. An interview was conducted on 5/7/25 at 2:50 p.m. with the Director of Rehabilitation (DOR). The DOR stated the resident was assessed for bed mobility, rolling and repositioning. The DOR stated they looked at different devices such as trapezes and said, If we fail at other interventions, we look into bedrails. The staff member reported therapy went through the facility and audited for other devices to decrease the use of bed rails for safety. The DOR stated they assess if a resident was able to transition to trapeze and bigger beds, and if a resident wanted side rails, therapy would pick them up. He stated if a resident wanted side rails to feel safe, they would try other devices first. The DOR stated Resident #58 was picked up by therapy from 2/26 to 3/26/25 and was working on rolling, bed mobility and that the resident was maximum assist and was not using side rails for bed mobility. The DOR defined bed mobility as grabbing the bar (rail) and rolling. He reported the resident was a substantial to max assist with rolling right to left and could grip and hold the rail but did not know for how long. Review of Resident #58s Physical Therapy Evaluation and Plan of Treatment revealed a certification period of 2/26 to 4/9/25. The resident's baseline on 2/26/25 for rolling towards both sides safely without use of side rails with assist of 1 caregiver to improve functional mobility revealed the resident required a maximum assist to roll towards right side and moderate assist to roll towards left side with use of side rail. The goals for patient and caregiver was to Improve bed mobility/positioning without use of side rails with a fair potential for achieving rehab goals. The reason for referral/current illness revealed the resident was referred to skilled therapy services to address bed mobility/positioning without use of side rails. The assessment summary showed the reason for therapy showed the resident was currently positioned in standard bed with an air mattress. Patient refused to trial trapeze bar to assist with bed mobility. A change in the assessment, dated 2/26/25 at 2:18 p.m. revealed the Patient refused to trial trapeze bar to assist with bed mobility. A treatment encounter note, dated 3/13/25 (the day side rails were discontinued), showed Patient stated she was afraid to perform rolling in bed due side rails being removed. Patient was encouraged and reassured (pronoun) is safe. Certified Nursing Assistant (CNA) educated on performing patient care with another person to assist with bed mobility has patient is a max assist (A) with mobility. A follow up interview was conducted on 5/7/25 at 4:48 p.m. with the DOR who reported visiting the resident and Resident #58 did voice fear. The DOR said, it's back referring to the siderails. Review of the policy, procedure, and information, effective 4/1/23, showed to promote independence and well-being and as well as to not restrict freedom of movement. The facility recognizes that every resident deserves a safe as well as comfortable sleeping environment period to assure safety and optimum bed mobility. This facility will utilize an appropriate resident specific/ centered approach determining the use of side rails/ bed rails. 1. If a side rail does not restrict freedom of what's going on movement or normal access to one's body, it is not considered a restraint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 2 of 30 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 05/08/2025 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Side rails used for completely immobile residents are not considered restraints and may therefore be used if they provide access to bed controls/call bell. 4. Physical or occupational therapist to assess bed mobility and all residents within 72 hours of admission. If therapist determines that one or two half rails enhance bed mobility and/ or facilitate independent transfers from bed. These rails will be care-planned for resident use. 8. All side rails and use whether or not they are restraints must be carefully assessed for risk of entrapment. The maintenance department upon placement of the side rails will complete a bed system audit to ensure proper placement of the side rails. 9. The maintenance department will also complete a bed system audit anytime you've [NAME] is added or removed from a bed and whenever a mattress has changed, or bolster/ wedge is added or removed. They will be informed of these changes via the maintenance communication log book on each unit, which is checked daily by the maintenance staff. 2. During an interview on 05/05/2025 at 10:11 a.m., Resident #93 stated he was waiting to hear back from the facility about being transferred to another facility so that he can be closer to his family. During an interview on 05/06/2025 at 11:47 a.m., Resident #93's family member and Power of Attorney (POA) stated he had been trying to move Resident #93 to a facility closer to him. The POA said, I live 2 hours away and it is hard for me to be able to see him. He stated he had spoken with the facility and never heard back on what they could do to move Resident #93 to another facility closer to family. Review of Resident #93's admission record revealed an admission date of 11/26/2024 with an initial admission date of 06/28/2024. Resident #93 was admitted to the facility with diagnosis to include Cerebral Infarction Due To Thrombosis Of Bilateral Cerebellar Arteries, Unspecified Cirrhosis Of Liver, Unspecified Severe Protein-Calorie Malnutrition, Muscle Weakness (Generalized), Hypothyroidism, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region. Review of Resident #93's Care Plan dated 11/26/2024 revealed [NAME] is currently in long term care but plans to discharge to an Assisted Living Facility (ALF) when his nephew can find one close to his home. Review of Resident #93's social services quarterly progress note dated 3/4/2025 showed the resident was alert and oriented and able to make his needs known. He does have episodes of confusion and forgetfulness at times, and his mental function varies. He is here for long-term care and plans to discharge to an ALF (Assisted Living Facility) closer to family. During an interview on 05/05/2025 at 2:00 p.m., the Social Services Director (SSD) stated Resident #93's family has been expressing desire to get him to a facility closer to them. The SSD said, I do not know where the family lives. The resident has not mentioned wanting to go to another facility. I didn't know it was mentioned on his care plan. Who would add that to the care plan? During an interview on 05/08/2025 at 2:43 p.m., the Nursing Home Administrator (NHA) stated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 3 of 30 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 05/08/2025 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hard finding facilities for residents who are on Medicaid. The NHA asked, Why would the family want to remove a resident from a facility that knows the resident to another facility who will have to get to know the resident all over. It is confusing for the residents when they move facilities. Our residents are like our family. Review of the Resident Handbook revealed, you can discharge from our facility and receive care elsewhere. You have the right to refuse any care or services at our facility. You also have the right to receive care elsewhere. On 05/08/2025 at 5:16 p.m. a policy for discharge preferences was requested. The facility did not have related policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 4 of 30 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 05/08/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Residents Affected - Some Review of Resident #68's Level I PASARR dated 3/19/25, showed the resident had diagnoses of anxiety disorder, bipolar disorder, depressive disorder, and mood disorder. The level I PASARR showed the resident did not have validating documentation to support dementia or a related neurocognitive disorder. The review showed Resident #68 had no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASARR evaluation was not submitted for consideration. Review of Resident #68s admission Record revealed the resident was admitted on [DATE] and 9/2/24. The record included the following diagnoses with onset dates: moderate recurrent major depressive disorder (onset 6/14/24), other bipolar disorder (onset 9/2/24), generalized anxiety disorder (onset 9/2/24), and mood disorder due to known physiological condition with depressive features (onset 6/14/24). Review of Resident #68s quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident received antianxiety and antidepressant medications. Review of Resident #68s psychology providers note, dated 4/28/25 revealed the resident was being seen to follow up after a recent medication change. The note showed the patient had been recently depressed wth some changes in mood but had been under treatment for infections. The resident presented with no change from baseline. Resident is still not at our treatment goals and is being treated for some mood disorders. The assessment showed the resident was not currently responding to therapy and medication combination and the resident's diagnoses of anxiety, depression, and bipolar disorders were unstable. The diagnoses listed included dementia with behavioral disturbances and insomnia. The psychiatric medication instructed to continue Buspar and lorazepam was adjusted to 0.5 mg (milligram) three times a day, continue trazodone for major depressive disorder, discontinue Zonegran, taper Depakote for 7 days, and start Lithium 300 mg twice daily for mood instability. Review of the Psychotherapy note dated 5/7/25, revealed Resident #68 presents with depressed mood, sad affect, reporting interpersonal conflict, negative self-esteem, reduced self-confidence, (and) loss of interest and enjoyment. During an interview on 5/8/25 at 10:48 a.m. the Social Service Director (SSD) stated the resident would trigger for a Level II PASARR with a dementia diagnosis and bipolar diagnoses. Based on interview and record review the facility failed to submit Pre-admission Screening and Annual Resident Review (PASARR) Level II screenings for three (#42, #68, and #42) out of seven residents sampled. Findings Included: 1. Review of Resident #42's admission record revealed an admission date of 11/14/24 with diagnoses to include Major Depressive Disorder, Recurrent, Unspecified, Bipolar Disorder, Unspecified, Anxiety Disorder, and Unspecified, Post-Traumatic Stress Disorder (PTSD). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 5 of 30 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 05/08/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a level I PASARR for Resdient #42 dated 11/15/2024 revealed, Section IV. PASARR Screen Completion: No diagnosis or suspicion of Serious Mental illness or intellectual disability indicated. A level II PASRR evaluation was marked as not required. Review of Resident #42 's medical record revealed Resident #42 was not assessed for PASARR Level II and a recommendation was not submitted. 3. A review of Resident #2's admission record revealed an initial admission date of 4/9/13 and a re-admission date of 9/9/24 with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified mood affective disorder, and disorganized schizophrenia. A review of Resident #2's physician orders revealed orders for divalproex sodium capsule delayed release sprinkle 125 mg (milligrams) give 2 tablet by mouth three times a day related to unspecified mood affective disorder and Risperidone tablet 0.5 mg give 1 tablet by mouth one time a day related to disorganized Schizophrenia. A review of a quarterly note for Resident #2's progress notes, dated 3/14/25 revealed Resident #2 was alert with confusion and forgetfulness he is sometimes understood and sometimes understands staff to anticipate his needs his mental function varies. He has episodes of being verbally aggressive with staff, spitting, cursing and resisting and refusing treatment/care, Shaving, nailcare and medications at times. He hollers staff names for assistance rather than use his call light. He is followed by psych [psychiatry] for Mood disorder, Schizophrenia. we will continue to follow current plan of care. Review of a level I PASARR dated 1/19/2024 revealed the following was marked under section IV, PASARR screen completion: No diagnosis or suspicion of Serious Mental illness or Intellectual Disability indicated. The review showed a Level II PASARR evaluation was not required or submitted for consideration. On 5/8/25 at 10:26 a.m., an interview with the Social Services Director (SSD) was conducted. She said she reviews PASARRs for every resident that is admitted to the facility. She stated she makes sure the PASARR, diagnoses, and medications, All line up. The SSD said if a resident had any new medications then she made sure the new diagnosis was added. She stated, I make sure it's captured on the PASSAR. The SSD sttaed she and the interdisciplinary team (IDT) reviewed Minimum Data Set (MDS) assessments for accuracy. The SSD said she inputs the correct information on the level I PASSAR and depending on what is marked, they get an immediate response to submit for a level II PASARR. The SSD stated if a level II isn't triggered and she suspected the resident might need one submitted, she would email the vendor. A review of the facility's policy titled Social Services - PASARR, dated 4/1/22, revealed the following: Purpose: The facility shall 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 by coordinating with the appropriate, State-designated authority. Definitions: An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: (i) Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. This mental disorder is A) A schizophrenic, mood, paranoid, panic, or severe anxiety disorder, somatformdisorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; (B) Not a primary diagnosis of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 6 of 30 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 05/08/2025 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 0645 dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined in paragraph (b)(1)(i)(A) of this section. 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 7 of 30 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 05/08/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow treatment recommendations related to obtaining weights on a weekly basis for one (#93) out of four residents sampled for weight loss. Residents Affected - Few Findings Included: During an observation on 05/05/2025 at 10:11 a.m., Resident #93 was observed laying in bed noted to be thin in appearance. During an observation on 05/07/2025 at 12:10 p.m., Resident #93 was observed in his room with his bedside table in front of him with his lunch tray. On his tray was a plate with spaghetti, green vegetables, a dinner roll, pudding and a piece of pie. In a follow up interview on 12:43 p.m., Resident #93 stated he ate his dinner roll and something else but could not remember what it was. During an interview on 05/07/2025 at 1:41 p.m., Staff E, Certified Nursing Assistant (CNA) stated Resident #93 ate about 25% of his meal. He ate his roll and his pudding. Staff E stated his appetite varies, sometimes it is good and sometimes he does not eat much. Staff C stated they are expected to document meal intake. Review of Resident #93's admission Record revealed an admission date of 11/26/2024 with diagnoses of cerebral infarction due to thrombosis of bilateral cerebellar arteries, unspecified cirrhosis of liver, unspecified severe protein-calorie malnutrition, muscle weakness (generalized), hypothyroidism, unspecified, gastro-esophageal reflux disease without esophagitis, spondylosis without myelopathy or radiculopathy, cervical region. Review of Resident #93's weights revealed on 4/1/2025 he weighed 126.9 Lbs.(pounds). On 3/21/2025 126.8 Lbs. On 3/14/2025 - 127.6 Lbs. on 2/11/2025 - 161.6 Lbs. On 1/8/2025 - 164.0 Lbs. On 12/04/2024 -142.6 Lbs. Review of Resident #93's standards of care progress note dated 4/4/25 revealed the resident is here long term. He is receiving a regular dysphagia advanced diet. His current weight is 126.9 Lbs.Registered Dietician (RD) spoke with him, and he agreed to try fortified food, which were added, he is stable x3 weeks. He is not currently on antibiotic therapy or dialysis services. A nutrition note for Resident #93 dated 4/1/25 revealed a weight warning: Value: 126.9 a -7.5% change [ 22.6% , 37.1 ] -10.0% change [ 11.0% , 15.7 ] and it is noted to continue on weekly weights A nutrition note for Resident #93 dated 3/25/25 revealed a weight warning: Triggered due to -5.0% change [Comparison Weight 2/11/2025, 161.6 Lbs., -21.0% , -34.0 Lbs. ]. Diet is Regular diet, Dysphagia Advanced texture, Regular/Thin Liquids consistency. with No: Rice. Right curved built-up utensils at meals. By mouth (PO) intake is 75%+ most meals. Body Mass Index (BMI) is underweight. Spoke with resident who was agreeable to trying out fortified foods for weight loss. RD follow up as needed. An IDT (Interdisciplinary note) dated 3/6/2025 showed a care plan meeting was held with resident at bedside- He continues to feed himself with right built-up utensil- dysphagia advanced diet- no issues or concerns. Weight 161.6 with a BMI of 23.2. No significant changes noted. Md (Medical Doctor). is in agreement with Plan of Care (POC). Floor staff updated on POC. No issues voiced. Will monitor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 8 of 30 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 05/08/2025 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 0692 and continue current POC (Plan of Care) Level of Harm - Minimal harm or potential for actual harm A nursing progress note dated 1/17/25 showed weight warning - Triggered due to +5.0% change [Comparison Weight 12/4/2024, 142.6 Lbs., +15.0% , +21.4 Lbs. ]. Resident had no nutritional concerns right now but requested more food and agreeable to fortified foods. Requesting reweigh to confirm weight gain, resident did not desire weekly weights. RD follow up as needed. Residents Affected - Few During an interview on 05/07/2025 10:33 a.m., Registered Dietician (RD) stated he first saw the resident in March 2025. He saw that he had dropped 30 Lbs. in a month and was not sure how. He stated he did a re-weight and confirmed. He puts Resident #93 on weekly weights and spoke with the resident about his diet who was agreeable to adding fortified foods. He stated he spoke to the nurses about their weight policy. He stated he was on his weekly weights, and noted the nurses had not weighed him for the 4th weight record. If he is missing a weight he follows up with the nurses but does not document. I am working on getting better at documenting. The RD confirmed Resident #93 should have a weekly weight effective March 2025. He confirmed there were only three entries since then. During an interview on 05/08/2025 at 10:01 a.m., Staff F, Registered Nurse (RN), stated they have 2 CNA's that do the weights. She stated if a resident needed to be weighed weekly, the Unit Manager would know and relays that to the CNA's. During an interview on 05/08/2025 at 10:03 a.m., Staff G., CNA stated 2 CNA's are assigned to obtain weights for the entire building. She stated they get a list of residents who needed to be weighed from the nurse. During an interview on 05/08/2025 at 10:09 a.m., Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM) stated the RD provides the list of residents that need to be weighed. During an interview on 05/08/2025 at 10:12 a.m., RD, stated 26-50% of a meal is less than half of the meal is consumed. He stated if the resident only ate a roll and a pudding, he would consider that 0-25% of the meal being consumed. During an interview on 05/08/2025 at 1:35 p.m., DON stated 2 CNA's are assigned to doing weights. They are given a list of residents that need to be weighed. She stated they had an issue with keeping up with obtaining weights for residents and they are working on ensuring residents are weighed per orders. Review of the facility's policy dated 02/21/2023 titled Nursing-Weights revealed, Purpose: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates that it is not possible or resident preferences indicate otherwise. Procedure: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility should utilize a systematic approach to optimize our residents nutritional status. This process includes: A. Identifying and assessing each resident's nutritional status and risk factors. B. Evaluating/analyzing the assessment information. C. Developing and consisting consistently implementing pertinent approaches. D. Monitoring the effectiveness of the interventions and revising them as necessary 4. Intervention should be identified, implemented, monitored and modified parentheses as appropriate parentheses, consistent with the residents assessed needs, choices, preferences, goals and current professional standards to maintain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 9 of 30 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 05/08/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete acceptable parameters of nutritional status. 5. Weight monitoring schedule should be developed upon admission for all residents: A. Weight should be recorded timely. Residents with weight loss monitor weight weekly or per physician order until stable then monthly 8. Documentation A. The physician, resident, or responsible party should be informed of a significant change in weight. B. The physician should be encouraged to document the diagnosis of clinical conditions that may be contributing to the weight loss. The registered dietitian or dietary manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. D. Observations pertinent to the residents weight status should be recorded in the medical record as appropriate. Event ID: Facility ID: 105482 If continuation sheet Page 10 of 30 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 05/08/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observations, record reviews, and interviews the facility failed to provide optimal nutrition for one (#78) of one resident sampled for enteral feeding. Residents Affected - Few Findings included: An observation was made on 5/5/25 at 11:25 a.m. of Resident #78 lying in bed, non-verbal, with a bottle of Nepro 1.8 enteral nutrition hanging from the bedside pole with pump. The pump and the tubing showed the resident was not receiving nutrition. The observation showed the 1000 milliliters (mls) bottle contained approximately 350 ml of tan-colored liquid, was dated 5/3/24 at 22:04 (10:04 p.m.), and showed the resident was to receive 60 milliliter/hour (ml/hr) (60mL/hr x 20 hours = 1200 mLs). The bottle label instructed Hang product up to 48 hours after initial connection when clean technique and only one new feeding set are used. Otherwise, hang no longer than 24 hours. Review of Resident #78's physician orders revealed an order for Nepro at 60 ml/hr x 20 hours, down at 10:00 a.m. up at 2:00 p.m. to provide a total of 1200 ml's in a 24-hour period. Review of Resident #78's Nutrition Evaluation Initial, Annual and Significant Change, dated 3/18/25 showed the resident did have an oral diet order of puree texture with thin liquids and tube feedings of Nepro at 60 ml/hr x 20 hours (down at 10:00 a.m. and up at 2:00 p.m.) with 250 ml of water 5 times a day. The evaluation showed the resident received less than 25% of nutrition orally and 100% of total kilocalories (Kcal) via tube feedings in the 7 days prior to the evaluation. Review of Resident #78's late entry Nutrition Note showed- Monthly Enteral Note, created on 5/5/25, effective 4/29/25, showed the resident was ordered dysphagia puree texture, regular/thin liquids, small portions, and were for pleasure per Speech Language Pathologist (SLP). The note showed the resident's oral intake was usually 0-25% and the enteral order of 60 mls of Nepro for 20 hours provided 2160 kcal. Review of the observed nutrition bottle hanging on 5/5/25 at 11:25 a.m. showed the bottle was hung at 10:04 p.m. and according to physician orders when taken down 12 hours later at 10:00 a.m. on 5/4/25 the resident would have received 720 mls of nutrition leaving approximately 280 mls in the bottle. Review of Resident #78's care plan revealed the resident had a nutritional problem or potential nutritional problem. The interventions included instructions for nursing staff to provide tube feeding and water (H2O) flushes as ordered. An interview was conducted on 5/7/25 at 10:22 a.m. with the Registered Dietician (RD). The RD reported Resident #78 was on Nepro at full rate due to not being able to depend on the resident eating (orally). The resident received 2160 calories from Nepro at 60 ml/hr x 20 hours. The RD reviewed photograph of nutrition bottle observed hanging and stated if the bottle was of 300 mls the resident did not receive optimal nutrition on that day. During an interview on 5/8/25 at 11:27 a.m. the Director of Nursing stated liquid nutrition was good for 24 hours and wondered if Resident #78's observed liquid nutrition had been an incorrect date situation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 11 of 30 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 05/08/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy, procedures, and information - Nursing Enteral Tube Feeding via Continuous Pump, revised on 2/21/23 showed The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. The procedure for initiating the feeding instructed staff after attaching the primed feeding pump set to enteral tube and unclamping tube, to hang feeding bag on to pole, connect the infusion pump, set rate, and press start for continuous feeding. The formula label staff would document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. (Photographic evidence was obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 12 of 30 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 05/08/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility did not ensure 1.) Continuous Positive Airway Pressure (CPAP) equipment and maintenance was provided for one resident (#12) out of one resident observed and 2.) Signage for oxygen use for five out of 17 rooms in one hallway ([NAME]) out of 4 hallways for four out of four days observed. Residents Affected - Some Findings included: 1.) On 5/05/2025 at 9:19 a.m., an observation and interview were conducted with Resident #12 in her room. Resident #12 was observed with a nasal cannula with settings at three liters per minute administered through an oxygen concentrator. Resident #12 stated she requires CPAP at night but stated her mask currently leaks. Resident #12 stated her mask was very old and in need of a replacement but the facility was unable to provide the mask she likes and one which fits her face. Resident #12 stated she has been in the facility for quite some time and an exchange of her CPAP machine occurred by the facility but obtaining a new mask has not occurred. Resident #12 stated someone came to her room several months ago with a new mask to try but she did not like the fit and requested a replacement for her current mask of which she has not received. Resident #12 stated she thinks the individual who came into her room was the representative for the CPAP machine. On 5/05/2025 at 9:26 a.m., an observation was made of Resident #12's CPAP mask in which there were two to three pieces of clear tape at the bottom of her mask. The resident stated she got the tape from one of the nurses and had placed the tape over the hole to try to minimize the air leak. Resident #12 stated she has had this mask for a long time. Resident #12 allowed the surveyor to look through her supplies for equipment for her CPAP. Upon observation, no extra masks, tubing or filters for her CPAP machine were seen. An observation was made of two commercial sealed cups of sterile water in which the resident stated the nurses will pour the water into her CPAP machine at night. A record review of Resident #12 admission Record showed an original admit date of 10/09/2020, a readmission date of 02/02/2023 with the following diagnoses to include but not limited to, Chronic Obstructive Pulmonary Disease, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Heart failure, Morbid obesity and Chronic rhinitis. A record review of Resident #12's Minimum Data Set (MDS), dated [DATE], Category C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. On 5/06/2025 at 1:51 p.m., an interview was conducted with Staff M, Licensed Practical Nurse (LPN). Staff M. LPN stated the nursing staff is responsible for respiratory equipment every week on Sunday night shift but as far as managing the CPAP machine and supplies the responsibility would be the Respiratory Therapist. On 5/06/2025 at 2:07 p.m., an interview was conducted with Staff N, LPN/Unit Manager (UM). Staff N, LPN/UM stated the nurses are responsible for supplying nasal cannulas, humidifiers, and nebulizers and these supplies are exchanged out weekly, every Sunday by the night shift nursing staff. On 5/06/2025 at 3:17 p.m., an interview was conducted with Staff O, Admissions Coordinator. Staff O stated he would order CPAP machine and supplies for all the new admissions requiring CPAP. Staff O (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 13 of 30 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 05/08/2025 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 Level of Harm - Minimal harm or potential for actual harm stated he knew of the Resident #12 requesting a new CPAP mask and stated he ordered a new mask several months ago as a trial. Staff O stated Staff P, Respiratory Director requested a new mask for Resident #12 and he simply went on the manufacturer's website to order a mask. Staff O stated he routinely does not order CPAP supplies for any of the long-term residents, only new admissions normally, unless a request is made. Residents Affected - Some On 5/06/2025 at 3:17 p.m., a telephone interview was conducted with Staff P, Respiratory Director. Staff P stated the facility was currently in the process of attempting to fill a vacancy for a respiratory therapist but in the interim of interviews, he was acting as the respiratory therapist for this facility and three other facilities in the area. Staff P stated he is accessible 24/7 for any concerns. Staff P stated he knew of the situation for Resident #12 and stated the mask could possibly be overnighted tonight. Staff P stated he will reach out to the Nursing Home Administrator who has access to a credit card to order the needed CPAP supplies. Staff O stated he will be at the facility this week to maintenance her CPAP machine and fit with a new mask. On 5/06/2025 at 4:02 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the nursing staff are responsible for respiratory supplies and changing the equipment every Sunday during the night shift and as needed. The DON stated respiratory therapy are not in the building but are available by phone for emergency situations. The DON stated currently there are four residents with either CPAP or BiPAP (Bilevel Positive Airway Pressure). The DON stated respiratory therapy will manage these residents' supplies and maintenance. The DON could not state how often respiratory therapy would manage these residents. The DON stated the nursing staff should document the resident's CPAP settings in the medical record on a daily basis. The DON stated a mask was provided for Resident #12 in February. The DON stated she has reached out to Staff O, Admissions Coordinator, to order a mask for her. The DON stated a mask arrived but it was not the same mask the resident currently had. The DON stated the resident told me she was fine with the mask she currently had. The DON stated she placed a note in her medical record on 02/25/2025. On 5/06/2025 at 3:40 a.m., Staff O shared a text message from Staff P of two CPAP masks. The image to the left was the image of the mask he stated he purchased for the resident of which she did not like the fit in comparison to the image on the right which was her current mask. The text was dated 01/31/2025. A record review of Resident #12's medical record progress notes showed a progress note from respiratory therapy dated 02/12/2024: visited with patient, on three liters per minute without SOB( shortness of breath). Changed filter out to CPAP. Patient currently using CPAP-patient compliant. Patient doing well at this time . No further progress note entries were observed. On 5/07/2025 at 8:48 a.m., an interview was conducted with Resident #12 who stated the nursing staff came in last night and cleaned out the filter to my concentrator and CPAP machine. Resident #12 stated she did not know there was a filter in her concentrator and could not recall the last time her concentrator had been cleaned. On 5/07/2025 at 11:55 a.m., an interview was conducted with Staff O, Admissions Coordinator. Staff O stated he would order supplies for CPAP upon admission but as far as long- term residents he does not order supplies unless specifically requested. Staff O reviewed his emails and demonstrated his order placed for Resident 12's CPAP mask but could not find any email order receipts for CPAP tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 14 of 30 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 05/08/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/07/2025 at 11:43 a.m., an interview was conducted with Staff Q, central supply in the main central supply room. Staff Q stated she does not have supplies for CPAP and does not order supplies. Staff Q stated the NHA or Staff O in admissions will order CPAP supplies. On 05/07/25 12:29 p.m., an interview was conducted with the NHA. The NHA stated respiratory therapy would be managing Resident #12's CPAP and the maintenance. The NHA stated she was aware the regional respiratory came in to see the resident a few months ago to assist with finding a mask but the resident was not willing to try a new mask. The NHA stated she was not responsible for ordering supplies but confirmed she ordered a new mask from [on-line shopping network] last night for Resident #12. A record review of Resident #12's current physician orders showed the following: - Clean mask daily every day shift for hygiene - Clean the unit and filter of CPAP machine weekly every night shift every Sunday for hygiene - Clean tubing weekly CPAP every night shift every Sunday for hygiene - Device and settings CPAP AUTO 4 to 20 centimeters of water evening and night shift - Empty water chamber and air dry every AM every day shift - Fill water chamber with distilled water every evening shift - Replace tubing and mask every three months every night shift every three months starting on the 28th for one day for hygiene - Respiratory therapy to evaluate. On 5/08/2025 at 9:58 a.m., an interview was conducted with Staff P, Respirator Director. Staff P stated Resident #12 was fitted today for her CPAP machine and she chose the medium size which was what she currently had. Staff P stated he will put on his calendar to see the resident once a month for her CPAP maintenance and supplies. Staff P stated an Inservice may be in order to the nursing staff for cleaning the CPAP machine, tubing and mask. On 5/08/2025 at 12:46 p.m., an interview was conducted with Staff N, LPN/UM. Staff N stated she was not familiar with how to set up a CPAP machine but would defer to her DON. On 5/08/2025 at 12:48 p.m., an interview was conducted with Staff D, LPN/UM. Staff D stated new admissions will normally come with a CPAP machine and pre-set for settings but if they received a new CPAP machine, she would not know how to set it up and would defer to the DON or the respiratory therapist. On 5/08/2025 at 1:29 p.m., an interview was conducted with the DON. The DON stated she knows how to set up CPAP settings once ordered from the physician. The DON stated she recognized an opportunity for education on CPAP management including setting up the parameters as well as cleaning the tubing, mask and filters was needed. 2.) An observation was made in [NAME] hallway of five rooms out of 17 rooms of residents utilizing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 15 of 30 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 05/08/2025 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 oxygen therapy for four days out of four days during survey without oxygen signage posted. Level of Harm - Minimal harm or potential for actual harm On 5/06/2025 at 1:51 p.m., an interview was conducted with Staff M, LPN who confirmed the residents in her assignment were currently receiving oxygen. Staff M stated rooms 201, 210, 214, 215 and 216 had residents with orders for oxygen and were currently on oxygen. An observation was made of no signage outside those room to indicate oxygen was in use. Residents Affected - Some On 5/08/2025 at 3:53 p.m., an interview was conducted with the DON related to oxygen signage. The DON walked to the front of the building entrance to demonstrate a small sign stating, Oxygen in Use. The DON reviewed the facility's policy on oxygen use and stated there should be signs in front of each residents' room requiring oxygen. A review of the facility's policy and procedures titled, Nursing- CPAP/BiPAP Support effective date 04/01/2022 showed the following purpose statement: 1.To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2.To improve arterial oxygenation (PAO2) in residents with respiratory insufficiency, obstructive sleep apnea., or restrictive /obstructive lung disease 3.To promote resident comfort and safety. Preparation: 1.Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. 2.Equipment and supplies: 1.NO SMOKING sign for the resident's room. 2.General Guidelines for Cleaning: 1.General guidelines for cleaning specific cleaning instructions are obtained from the manufacturer supplier of the CPAP device 4.Machine cleaning : wipe machine with warm soapy water and rinse at least once a week and as needed 5.Humidifier (if used): a.Use clean, distilled water only in the humidifier chamber b.Clean humidifier weekly and air dry c.To disinfect, place vinegar water solution 1:3 and clean humidifier. Soak for 30 minutes and rinse thoroughly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 16 of 30 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 05/08/2025 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 6.Filter cleaning: Level of Harm - Minimal harm or potential for actual harm a.Rinse washable filter under warm water once a week to remove dust and debris Replace this filter at least once a year. Residents Affected - Some b.Replace disposable filters monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 17 of 30 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 05/08/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility did not ensure there was documented communication of coordination of care with the dialysis center for one (#81) of one resident reviewed. Residents Affected - Few Findings included: A review of Resident #81's admission record revealed an initial admission date of 7/23/24 and a re-admission date of 1/24/25. Further review of the admission record revealed diagnoses to include type 2 diabetes with diabetic polyneuropathy, end stage renal disease, and dependence on renal dialysis. A review of Resident #81's physician orders revealed the following to include: - hemodialysis [dialysis center name and address] chair time 0615 Monday, Wednesday, Friday (M/W/F) every night shift, with a start date of 1/27/25. A review of Resident #81's progress notes from 4/8/25 to 5/8/25 revealed no documentation related to communication with the dialysis center. A nurse's progress note on 5/2/25 revealed the following, [Name of dialysis center] Dialysis [telephone #]. A review of Resident #81's electronic medical record revealed dialysis communication notes dated 3/19/25 4/30/25 with no documentation from the dialysis center to the facility. A review of Resident #81's dialysis binder, that goes with the resident from the facility to the dialysis center, revealed communication notes dated 5/3/25 and 5/5/25. The documentation revealed no communication to and from the dialysis center. On 5/6/25 at 2:28 p.m. an interview was conducted with Staff R, Registered Nurse (RN). She confirmed Resident #81 is one of her assigned residents. She said nurses are expected to check the resident's vitals before and after going to dialysis. She said they also check the access site. Staff R, RN said she documents this information in the resident's electronic health record and on the dialysis communication form. She stated, The dialysis center doesn't always fill out the middle part and I don't know why. She said Resident #81 has been okay but has needed some extra dialysis sessions on Saturdays. On 5/6/25 at 2:58 p.m., an interview was conducted with Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM). She stated, The dialysis center sends over a mass amount of notes about once a month. She said the dialysis center does not fill out the middle part of the communication form. On 5/7/25 at 10:05 a.m., an interview was conducted with Staff D, LPN/UM. She said the dialysis center is good at communicating over the phone if a resident is staying later for treatment or if there's concerns about lab results. She said they are not good about filling out the middle part of the dialysis communication form. Staff D, LPN/UM said staff should be documenting in the residents' progress notes if they communicate with dialysis over the phone. She said the dialysis center sends their notes to the facility every few weeks. On 5/7/25 at 10:18 a.m., an interview was conducted with the Registered Dietitian (RD). He said he emails or calls the dietitian at the dialysis center every month, or more often as concerns appear. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 18 of 30 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 05/08/2025 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few He stated, It's really hard to get notes from [dialysis center name] and [dialysis center name]. He confirmed Resident #81 goes to the dialysis center as scheduled and that it is hard to retrieve notes from the center. The RD said he had to reach out to request notes. On 5/7/25 at 10:56 a.m. a follow-up interview was conducted with the RD who stated the dialysis center Resident #81 goes to, Got hacked about a month ago, and there is a back log of notes. On 5/7/25 at 1:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). She said the facility received Resident #81's dialysis treatment notes today, dated 4/2/25 to 4/30/25. She said the dialysis center's system was hacked and they are delayed in sending notes. On 5/7/25 at 5:10 p.m., an interview was conducted with the Director of Nursing (DON). She said if the area on the communication form for the dialysis center is not filled out, staff should be sending it back. The DON said if the communication form from the dialysis center is not filled out, they try to call. She said if something happens while the resident is at dialysis, the center will notify the facility. The DON stated nursing staff are expected to, Document what the facility tells them. She said she started a performance improvement plan (PIP) and audits, in April 2025, to review the dialysis communication forms in morning meetings and determine how they can better monitor the residents. The DON said the PIP and audits were brought to Quality Assurance and Performance Improvement (QAPI). The facility did not have a policy related to communication with dialysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 19 of 30 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 05/08/2025 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, interviews, and record review, the facility failed to execute physician orders as recommended by the Consulting Pharmacist for two residents (#68 and #81) out of five residents sampled for unnecessary medications. Findings included: 1) Review of Resident #68's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses of not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, moderate recurrent major depressive disorder, other bipolar disorder, generalized anxiety disorder, other seizures, gastro-esophageal reflux disease without Esophagitis, and abdominal distension (gaseous). Review of Resident #68's record showed the resident was on Hospital Paid Leave on 3/23/25, returning to the facility on 3/25/25. On 5/5/25 at 11:37 a.m. Resident #68 was observed sitting upright in bed, wearing a nasal cannula delivering 4 liters per minute (lpm) of oxygen. Review of Resident #68's Medication Regimen Recommendations made by the Consultant Pharmacist on 3/12/25 revealed the following: -Currently with active order for Ondansetron (Zofran) as needed (prn) which has not been used in over 30 days. Please evaluate current need and discontinue if appropriate. The physician response was Agree; Will do and signed by the provider on 3/25/25. -Currently receiving Divalproex (Depakote). Unable to locate recent serum level in chart. Recommended 2 weeks after start then every 6 months thereafter. Please consider ordering. The physician response was Agree; Will do and signed by the provider on 3/25/25. Review of Resident #68's April 2025 Medication Administration Record (MAR) showed an order for Ondansetron 4 milligram (mg) - Give one tablet by mouth every 4 hours prn for nausea and vomiting, started on 3/25/25 at 7:51 p.m. The MAR revealed the resident had received the medication fifteen times during the month of April. Review of Resident #68's laboratory results showed a Complete Blood Count (CBC with differential), Comprehensive Metabolic Panel (CMP), and a thyroid-stimulating hormone 3rd generation panel had been completed on 3/5/25. The results revealed the next testing the resident had was a stool culture on 4/30/25. The results did not show the resident had a Depakote level completed after 3/25/25 as ordered by the physician. During an interview on 5/8/25 at 1:41 p.m. the Director of Nursing (DON) reported not knowing why Resident #68's Zofran had not been discontinued, a new order for Zofran was ordered on 3/25/25, and the Depakote level was not ordered or obtained. She stated she searched the orders and results and was unable to locate either. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 20 of 30 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 05/08/2025 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 2) A review of Resident #81's admission record revealed an initial admission date of 7/23/24 and a re-admission date of 1/24/25. The admission record revealed diagnoses to include inflammatory polyneuropathy, unspecified, Type 2 Diabetes with diabetic polyneuropathy, End Stage Renal Disease, dependence on renal dialysis, major depressive disorder, recurrent, moderate, and mood disorder due to known physiological condition with mixed features. Residents Affected - Few A review of Resident #81's physician orders revealed the following: -Sertraline Hydrochloride (HCl) tablet 100 milligrams (mg) give 1 tablet by mouth one time a day for depression related to major depressive disorder, recurrent, moderate. - Oxycodone HCl oral tablet 10 mg (Oxycodone HCl) *controlled drug* give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. - Apixaban oral tablet 2.5 mg (Apixaban) give 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of right upper extremity. -Gabapentin capsule 300 mg give 1 capsule by mouth three times a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Humalog injection solution 100 unit/milliliters (ml) (insulin Lispro) inject subcutaneously three times a day for Diabetes Mellitus (DM). - Sevelamer Carbonate 800 mg tablet give 1 tablet by mouth before meals related to End Stage Renal Disease do not send, supplied by dialysis. - Tresiba subcutaneous solution 100 unit/ml (insulin Degludec) inject 27 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Biscolax suppository 10 mg (Bisacodyl) inset 1 suppository rectally every 24 hours as needed for constipation or no results from Milk of Magnesia (MOM). -Enulose solution 19 grams (gm)/ml (Lactulose) give 30 ml by mouth every 24 hours as needed for no bowel movement (BM) in 3 days for (x) 1 dose. If ineffective by next shift see as needed (prn) Bisacodyl dialysis resident only. -Miralax enema insert 1 applicator rectally as needed for constipation/no results from Bisacodyl suppository if no or poor results from Miralax enema, notify primary care provider (PCP). A review of Resident #81's medication regimen review (MRR) by the consultant pharmacist, dated 3/12/25, revealed the following recommendations: - Currently receiving Gabapentin in dose exceeding maximum recommended dose based on estimated creatinine clearance (CrCl) below 30 ml/minute (min). To decrease risk of central nervous system adverse effects including ataxia, dizziness, and drowsiness consider taper Gabapentin to 600 mg daily at bedtime, if appropriate. - Currently with an active order for Miralax enema which is not recommended for use in residents on dialysis. Please evaluate risk versus benefit of use and discontinue, if appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 21 of 30 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 05/08/2025 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 -The MRR revealed no response was marked for the Gabapentin recommendation, and Agree; Will do, was marked for the Miralax enema recommendation. There was no physician/prescriber signature observed on the MRR, dated 3/12/25. A review of Resident #18's Medication Administration Record (MAR) for March, April, and May 2025 revealed the following orders: - Gabapentin capsule 300 mg give 1 capsule by mouth three times a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy, with a start date of 2/26/25, was administered as ordered. - Miralax enema insert 1 applicator rectally as needed for constipation/no results from Bisacodyl suppository if no or poor results from Miralax enema, notify primary care provider (PCP), with a start date of 1/27/25, was not administered. On 5/8/25 at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). She said the facility does not have documentation the physician acknowledged the pharmacy recommendations made in March 2025. The DON confirmed the physician did not document whether they considered the pharmacy suggestions or their rationale for not agreeing with the recommendations. A review of the facility's policy titled Pharmacy Services - Drug Regimen Review, dated 4/1/22, revealed the following: . Procedure: 1. The drug regimen of each resident should be reviewed at least monthly by a licensed pharmacist and the pharmacist should report any irregularities to the attending physician, the facility's medical director and the director of nursing and these reports should be acted upon . 5. The attending physician shall document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 22 of 30 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 05/08/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to administer pain medication as ordered for one resident (#13) out of five residents sampled for pain management. Residents Affected - Few Findings Included: Review of Resident #13's admission record revealed an admission date of 04/03/2024. Resident #13 was admitted to the facility with diagnosis to include other sequelae following unspecified cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, need for assistance with personal care, muscle weakness (generalized), sedative, hypnotic or anxiolytic dependence, uncomplicated, anxiety disorder, unspecified, Opioid dependence, uncomplicated, major depressive disorder, recurrent, moderate. Review of Resident #13's annual Minimum Data Set (MDS), dated [DATE], revealed in Section NMedications: Anti-Depression, Hypnotic, Anticoagulant, Diuretic, Opioid, and Anticonvulsant. Review of Resident #13's orders revealed: -Norco Oral Tablet 10-325 MG (milligrams) (Hydrocodone Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Moderate/Severe pain -Start Date 02/17/2025. -Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for general discomfort 2 tabs=650 MG not to exceed 3 gm (grams) in 24 hours- Start Date 02/17/2025. Review of Resident #13's Medication Administration Record (MAR), dated February 2025 revealed: -Norco Oral Tablet 10/325 MG was dispensed for a pain level of 0 on 2/8/2025 and 2/23/2025 -for a pain level of 3 on 2/4/2025, and 2/12/2025 -for a pain level of 4 on 2/03/2025, 2/05/2025, 2/09/2025, 2/10/2025, 2/13/2025, 2/17/2025, 2/18/2025, 2/19/2025, 2/21/2025, 2/22/2025, and 2/27/2025. Review of Resident #13's Medication Administration Record (MAR), dated March 2025, revealed: -Norco Oral Tablet 10/325 MG was dispensed for a pain level of 0 on 3/2/2025 and 3/31/2025 -for a pain level of 2 on 03/20/2025 and 3/30/2025 -for a pain level of 3 on 3/4/2025, 3/8/2025, 3/17/2025, 3/22/2025, 3/25/2025, and 3/26/2025 -for a pain level of 4 on 3/3/2025, 3/5/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/18/2025, 3/19/2025, 3/23/2025, 3/24/2025, and 3/27/2025. Review of Resident #13's Medication Administration Record (MAR), dated April 2025, revealed: -Norco Oral Tablet 10/325 was dispensed for a pain level of 0 on 4/25/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 23 of 30 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 05/08/2025 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 0757 -for a pain level of 2 on 4/11/2025, 4/12/2025 4/27/2025 Level of Harm - Minimal harm or potential for actual harm -for a pain level of 3 on 4/4/2025 4/10/2025 4/15/2025, 4/20/2025, and 4/30/2025 Residents Affected - Few -for a pain level of 4 on 4/2/2025, 4/5/2025, 4/6/2025, 4/9,2025, 4/14/2025, 4/16/2025, 4/19/2025,4/21/2025, 4/23/2025, 4/24/2025, and 4/28/2025. During an interview on 05/05/2025 at 3:35 p.m., Staff Q, Licensed Practical Nurse (LPN) stated moderate/severe pain is a level of 5 or 6 and above. During an interview on 05/05/2025 at 3:36 p.m., Staff R, Registered Nurse (RN) stated moderate/severe pain would be a pain level of 6/7 or above. During an interview on 05/05/2025 at 3:48 p.m., the Director or Nursing (DON) stated moderated/severe pain would be at a level of 4-10. During a phone interview on 05/06/2025 at 4:40 p.m. the Physician stated a moderate/severe pain level would be 7-10. He stated if the order is scheduled, he would expect for the pain medication to be given as ordered even with a pain level of 0. He stated Resident #13's order is as needed and he would not expect pain medication to be given with a pain level of 0 or 2. He stated he would expect Tylenol to be given for a pain level in the lower range. The facility was asked to provide a policy for unnecessary medication and stated they did not have a policy for unnecessary medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 24 of 30 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 05/08/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and three errors were identified for one resident (#35) of five residents observed. These errors constituted a 10% medication error rate. Residents Affected - Few Findings included: On 5/6/25 at 9:40 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted for Resident #35. Staff H reported the resident's blood pressure of 135/80 and heart rate of 86 had been obtained approximately four minutes prior to the observation. The staff member dispensed the following medications: - Carvedilol 3.125 milligram (mg) tablet - Sevelamer 800 mg tablet - Hydralazine 50 mg tablet - Amlodipine 5 mg tablet - Folic acid 1000 microgram (mcg) over-the-counter (OTC) tablet - Aspirin low dose enteric-coated 81 mg OTC tablet (order: chewable 81 mg tablet) - acetaminophen 325 mg - 2 OTC tablets The staff member confirmed dispensing 8 tablets prior to entering the resident room. The resident was observed lying in bed and the oral medications were administered. Staff H returned to the medication cart and reported holding the resident's Midodrine due to the blood pressure was too high. Review of Resident #35's May Medication Administration Record (MAR) showed the following errors: -Aspirin 81 (mg) chewable - Give 1 tablet by mouth one time a day related to peripheral vascular disease unspecified. The observation showed the staff member administered an enteric-coated 81 mg tablet of Aspirin. -Midodrine 5 mg - Give 1 tablet by mouth one time a day every Tuesday (Tues), Thursday (Thu), and Saturday (Sat) for hypotension to give in AM (morning) before Dialysis. The order was started on 4/22/25 and did not include blood pressure parameters to hold the medication. -[NAME]-Vite (B complex/C/Folic Acid) - Give 1 tablet by mouth one time a day for nutrition. The staff member documented this medication had been administered, however, it was not observed. Review of Resident #35's Medication Admin Audit Report for the 7 a.m. - 3 p.m. shift on 5/6/25 showed Staff H had administered the following medications at 9:55 a.m.: Carvedilol, Sevelamer, Hydralazine, Amlodipine, Folic Acid, and Aspirin. The following medications were documented as given on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 25 of 30 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 05/08/2025 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 Level of Harm - Minimal harm or potential for actual harm 5/6/25 at 9:57 a.m.: Carvedilol, Sevelamer, Hydralazine, Amlodipine, Folic Acid, Aspirin, Acetaminophen and [NAME]-Vite (also administered at 9:57 a.m.). During an interview on 05/08/25 at 11:16 a.m. the Director of Nursing (DON) reviewed Resident #35's MAR. She confirmed the documentation from the nurse. Residents Affected - Few Review of the policy - Administering Medications, revised 2/21/23, showed the following: Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. 3. Medications are administered in accordance with prescriber orders, and current standards of practice. 6. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or suspected of being associated with adverse consequences, the person preparing or administering the medication should contact the prescriber, the resident's Attending Physician, or the facility's Medical Director to discuss the concerns. 20. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 26 of 30 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 05/08/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility did not follow professional standards for food service safety related to sanitary practices in one of one facility kitchens. Residents Affected - Many Findings included: On 5/5/25 at 9:35 a.m., an initial tour of the kitchen was conducted with the Dietary Manager. An observation of the low temperature dish machine was in use by Staff A, Dietary Aide. An observation of Staff A, Dietary Aide revealed she was wearing gloves and putting soiled items with food debris in the machine. She conducted the testing of the sanitizing solution using the same gloves she had on while putting soiled items to be washed. She used two testing strips and one of them fell in the water of the dish machine, while the other was placed on a clean insulated lid. Staff A, Dietary Aide was not observed removing the testing strip from the insulated lid and the lid was not put back to be cleaned. On 5/5/25 at 9:42 a.m., an observation of the reach-in cooler revealed a brown plastic bag on one of the racks labeled [staff member name]. Observations of the brown plastic bag revealed there were clear, plastic water bottles inside. Further observations of the reach-in cooler revealed a Styrofoam cup, with a lid, next to the plastic bag. The Dietary Manager confirmed it was a staff member's personal items and proceeded to remove them. On 5/5/25 at 10:02 a.m., an observation of the ice machine revealed the ice chute cover had streaks of black residue towards the top of it. Further observation of the ice chute cover revealed the bottom ledge had the same black residue across it. Observations of the inside of the ice scoop holder revealed build-up of a white substance, as well as light brown bio growth/residue. The Dietary Manager said she thinks the maintenance staff cleans the ice machine and is not sure if cleaning the inside falls under the kitchen responsibilities. She said she would confirm with the District Manager. On 5/7/25 at 11:17 a.m., a follow-up tour revealed Staff C, Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON) were observed in the kitchen with no hair restraints. On 5/7/25 at 4:17 p.m., an observation of Staff L, [NAME] completing the hot holding dinner temperatures revealed a stryofoam cup with a brown liquid, with no lid, was on the table next to the steam table. The cup contained a staff member's beverage. On 5/7/25 at 4:48 p.m., interviews were conducted with the dietary manager and District Manager. The Dietary Manager said personal items are supposed to be stored in the breakroom refrigerator, in her office, or there are lockers where staff can store their belongings. The Dietary Manager stated the ice machine gets a deep clean quarterly by the service provider. The District Manager said general maintenance of the ice machine, as well as cleaning, falls under the maintenance staff. He said he thinks the daily cleaning should be under the kitchen's responsibility, however, it could also be nursing or maintenance. He said they need to confirm if the ice machine falls under the responsibility of maintenance. Regarding the observation of the dish machine on 5/5/25, the Dietary Manager confirmed Staff A, Dietary Aide was handling soiled dishes, operating the dish machine, and transferring clean items without changing gloves. She said the testing strip that was observed in the water is, going to be flushed down and would not contaminate the water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 27 of 30 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 05/08/2025 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 On 5/8/25 at 1:19 p.m., a follow-up interview was conducted with the Dietary Manager and District Manager. They said the kitchen staff are responsible for cleaning the outside of the ice machine as well as the scoop and scoop holder. The District Manager said the maintenance staff is responsible for cleaning the ice chute cover. A review of the facility's policy titled Dish Machine Best Practices Guidelines, revealed the following, Placing a sanitization test strip directly on a plate that has just come out of the dish machine, which his considered a sanitized surface, could be viewed as a foreign object. Further review of the policy revealed the following: - Hygiene: The plate is intended to be clean and sanitized, and the test strip, even if used to check the sanitizer, could introduce contaminants back onto the plate if it isn't handled properly. - Unintentional handling: If the strip is left on the plate and is inadvertently moved or touched, it could contaminate other surfaces or food if not properly disposed of. - Proper Procedure: Sanitization test strips are usually designed to be dipped into the sanitizer solution or placed in contact with a surface being tested, such as a warewashing rack, but they shouldn't be left on clean, sanitized surfaces. - Best Practices: Proper Disposal After using the test strip, it should be properly disposed of, not left on a clean plate or surface. A review of the facility's policy titled Outside Food Storage Standard Operating Procedures, revealed the following, Storing food in Dietary coolers by employees, especially without proper labeling, date marking, or temperature control, is a violation of food safety regulations and can pose a risk to residents. Further review of the policy revealed the following, Proper Storage: Food brought into the facility should be stored in designated areas, such as personal refrigerators or community refrigerators, with appropriate labeling and temperature control. A review of the facility's policy titled Ice, revealed the following under policy statement, Ice will be prepared and distributed in a safe and sanitary manner. Further review of the policy under procedures revealed the following: - 3. The exterior of the ice machine will be cleaned weekly. - 4. Ice bins will be cleaned monthly and as needed. - 5. Ice scoops will be cleaned and stored in a separate container that limits expose to dust and moisture retention. (Photographic evidence obtained). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 28 of 30 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 05/08/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/5/25 at 11:49 a.m. Resident #68 was observed sitting upright in bed wearing a nasal cannula delivering 4 liters per minute (lpm) of oxygen. The resident stated there was a dressing on the right hip and something on left hip. The resident granted permission to view and photograph for evidence abdominal pad dressing on right hip, dated 5/3/25. The observation of left hip did not reveal any injury or dressing. Review of Resident #68's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, intra-abdominal and pelvic swelling mass and lump unspecified site, and other sites of candidiasis. Review of Resident #68's quarterly Minimum Data Set (MDS), target date 3/3/25, revealed the resident scored 15 of 15 for the Brief Interview of Mental Score (BIMS) indicating an intact cognition. A request was made for the facility to provide Resident #68's Non-pressure and Pressure Skin Reports. The facility provided one Non-pressure Wound Report, dated 4/29/25, revealing one left lower leg lymphedema, one left foot lymphedema wound, one right lower leg - lymphedema, and one right foot lymphedema. The skin report did not reveal a right hip wound. Review of the medical record revealed a Non-pressure Wound Report, dated 4/8/25 showing a right hip wound measuring 1.0-centimeter (cm) x 0.5 cm x 0.2 cm which was acquired on 3/4/25. Review of a Skin Evaluation, dated 4/9/25 revealed wounds to bilateral lower extremities, right hip, raised areas to trunk, bilateral buttocks, and thighs with a reddened coccyx. Review of Resident #68's May 2025 Treatment Administration Record (TAR), printed on 5/8/25 at 10:56 a.m. did not include treatment orders to place a dressing to the right hip of the resident. An interview was conducted on 5/8/25 at 11:45 a.m. with the Director of Nursing (DON). The DON reported knowing of the resident's right hip wound and thought it was there on the resident's admission. The DON reported Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM) said the wound was like a little blister in between (skin) folds, from the edema, clear liquid leaking out. The DON confirmed there should be documentation related to the right hip blister. A request was made for a policy regarding Skin Evaluations. The facility reported they did not have a policy related to Skin Evaluations. Photographic Evidence was Obtained. Based on observations, interviews and record review, the facility failed to ensure complete and accurate documentation was in the resident's medical record for two (#93 and #68) out of 23 residents sampled. Findings Included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 29 of 30 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 05/08/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm During an interview on 05/06/2025 at 11:47 a.m., Resident #93's Family Member and Power of Attorney (POA) stated he had received a call from the facility on Friday letting him know they were putting an order for Hospice for Resident #93. He stated he was told it was because Resident #93 had recently declined and there was a change in his appetite. The POA stated he tried calling back a few times to speak with someone in regard to the Hospice Order and had not received a call back. Residents Affected - Few Review of Resident #93's admission Record revealed an initial admission date of 06/28/2024 and a readmission admission date of 11/26/2024 . Resident #93 was admitted to the facility with diagnosis to include Cerebral Infarction Due To Thrombosis Of Bilateral Cerebellar Arteries, Unspecified Cirrhosis Of Liver, Unspecified Severe Protein-Calorie Malnutrition, Muscle Weakness (Generalized), Hypothyroidism, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region. Review of Resident #93 Orders revealed on 05/02/2025, Consult Hospice as per family and patient request Review of Resident #93's progress notes revealed there were no progress notes documenting Resident #93, family or POA elected Hospice care. During an interview on 05/05/2025 at 2:00 p.m., the Social Services Director (SSD) stated when residents or families request for a Hospice consult, she gives them brochures for all of the hospice companies they have information for. The SSD sends the referral once the family has chosen the hospice company. She stated Resident #93 asked the Advanced Registered Nurse Practitioner (ARNP) about going on hospice. The ARNP came and verbally told her that Resident #93 was requesting to go on Hospice. The SSD stated this conversation was not documented and there was no note. The SSD stated she had reached out to Resident #93's family in regards to the hospice order, but they are very hard to get a hold of and never returns her calls. She stated she did not document the phone calls attempts. During an interview on 05/08/2025 at 1:37 p.m., Director of Nursing (DON) stated anytime a conversation happens with a resident or family member it should be documented in the resident's chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105482 If continuation sheet Page 30 of 30