Inspection·March 7, 2024

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the admission Minimum Data Set (MDS) Section A showed Resident # 368 was admitted on [DATE] with diagnoses, to include but not limited to, nontraumatic intracerebral hemorrhage, intraventricular, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, single episode, Review of the Care Plan, revised on 06/21/2023 and canceled on 06/21/2023, showed Resident # 368 was admitted to short-term placement with plans to transition to long term care. Review of the care plan interventions, revised on 06/21/2023, and canceled on 06/21/0223, showed the discharge plan was discussed with resident/ responsible party and Resident # 368 planned to discharge back to the community. Review of a Heath Status Note, dated 06/19/2022, showed the family requested Resident #368 be discharged to [Facility Name] on 06/20/2023. The note revealed the resident was accepted for admission. Review of a Nursing Home Transfer and Discharge Notice, dated 06/20/2023, showed Resident #368 was discharged to the facility per family request. Review of a Discharge Planning Summary, dated 06/20/2023, showed Resident #368 was transferred to the facility with all her belongings on 6/20/2023. During an interview on 03/06/2024 at 12:17 PM., with Resident #368's representative, she said the resident discharged from the facility in June and was owed a refund from the facility. She stated she spoke with the last Business Office Manager in November 2023 and was told the refund would be sent, but she had not received the money. She stated she tried to reach back out to the Business Office Manager to follow-up with her about the refund, but she had not received a response from her or anyone at the facility regarding the matter. An interview was conducted on 03/06/2024 at 9:34 AM., with the Business Office Manager. She said Resident #368 was admitted to the facility on [DATE] and discharged on 6/20/2023. She was skilled under Medicare from 7/27/22 to 7/31/22 and then she was skilled under Managed Care from 81/22 to 8/14/22. She stated Resident #368 had another payor change on 8/15/2022 to Medicaid long term care until she discharged from the facility on 6/20/2023. She stated Resident #368 was not private pay at any time during her stay and she had a financial responsibility of $745 dollars according to her Medicaid; part was covered by her Social Security. She said the resident's family was responsible for handing her finances. She stated there was a refund on her account for $301.40 which goes to the family, and $458.00 goes back to Medicaid for a total refund on her account of $ 759.43. She stated, I have only been here for three months since I started at the facility, I have been working on all the refunds. There are over 20 refunds that I have been working on since I started in this position. I have a back log that I am working on, and my goal was to make sure the request for refunds were all completed by the 21st of February and sent to corporate so that the refunds can get sent out. She stated the facility process was the resident or their representative should have their refund within thirty days of discharging from the facility. She stated the back log goes from 2022, to 2023. She stated, I identified this problem when I first started at the facility three months ago. Review of the Facility policy titled, Resident Rights Attachment 3, undated, showed the following: A) Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and service inside and outside the facility, including those specified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 2 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0582 in this section. Level of Harm - Minimal harm or potential for actual harm (18) The facility must inform each resident before, ort at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. Residents Affected - Some ( iv) the facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 3 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #135's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her admission medical diagnoses include post-traumatic stress disorder (PTSD), major depressive disorder, and generalized anxiety disorder. Residents Affected - Some Review of Resident #135's 5-day Minimum Data Set (MDS), dated , 2/16/24, Section I, Active Diagnoses revealed Psychiatric/Mood Disorder Post Traumatic Stress Disorder (PTSD): No An interview was conducted on 03/07/24 at 10:35 AM with Staff A, MDS Registered Nurse (RN). She said, I put in the medical diagnoses when they [residents] are admitted or when residents are given a new diagnosis, and they pull over automatically in the MDS. The nurse who completes the MDS checks to ensure the diagnoses are correct. They will also look on the physician notes and add new diagnoses as well. Staff A, MDS, RN reviewed Resident #135's PTSD diagnoses and confirmed Resident #135 had the diagnoses since her admission. She reviewed the Medicare 5-day MDS, dated [DATE], Section I, and confirmed the resident was not identified on the MDS to have PTSD and she should have been. Based on interviews and record reviews, the facility failed to ensure accuracy of comprehensive assessments for three (#135 and #83) of fifty two sampled residents. Findings included: A review of Resident #83's medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses of cerebral atherosclerosis, dysphagia following cerebral infarction, and dementia. A review of Resident #83's physician's orders revealed an order, dated 10/3/2023, for hospice services for end of life care related to a diagnosis of cerebral atherosclerosis. A review of Resident #83's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/28/2024, revealed under Section O - Special Treatments, Procedures, and Programs, Resident #83 was not receiving hospice services during her time as a resident of the facility. An interview was conducted on 3/7/2024 at 10:34 AM with Staff A, MDS Registered Nurse (RN). Staff A, MDS RN stated Resident #83 was receiving hospice services, which should be reflected on the resident's MDS assessment. Staff A, MDS RN reviewed Resident #83 quarterly MDS assessment with an ARD of 2/28/2024 and stated the assessment did not reflect Resident #83 was receiving hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 4 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I upon admission for three residents (#43, #128, and # 98) of seven residents sampled for PASRR Level 1. Findings Included: Review of the admission Record, dated 03/06/2024, showed Resident #43 was admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, moderate, dementia in other disease classified elsewhere, moderate, with mood disturbance. Review of Resident #43's PASARR, dated 09/14/2022, revealed no qualifying mental health diagnosis and no PASARR Level II was required. Review of an admission Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. An interview was conducted on 03/07/2024 at 2:00 PM., with the Director of Nursing (DON). She said their process is when a resident is admitted to the facility, she reviews the PASRR Level I to make sure they are accurate. She stated if she reviews an inaccurate PASARR they reach out to the hospital to have them correct it. She stated Resident #43's PASRR Level I should have been redone to reflect the resident had major depressive disorder and dementia. She stated, Resident # 43's PASRR is not accurate. Review of the medical record showed Resident #128 was admitted on [DATE] with diagnoses that included dementia in other disease classified elsewhere, unspecified severity with mood disturbance, Bipolar disorder, major depressive disorder, and Schizophrenia. The medical record revealed Resident #128 was not assessed for a Level I Preadmission Screening and Resident Review (PASRR) at, or prior to admission on [DATE]. Review Of Resident #128 medical record revealed a Level I PASRR completed on 2/24/2023 Part A. showed a Schizophrenia diagnosis checked and in Section IV PASRR Screen Completion a Level II PASRR evaluation not required. Review of medical record for Resident #128 revealed a new diagnosis of Bipolar disorder on 2/27/2023, major depressive disorder on 6/29/2023, generalize anxiety disorder on 6/29/2023, and a PASRR Level II was not completed. Review of the PASRR Level I completed on 8/18/2023 Part A showed Depressive Disorder and Schizophrenia box checked. Anxiety and Bipolar diagnoses boxes were unchecked. On 3/7/2024 at 12:50 PM an interview was conducted with the Director of Nursing (DON). She stated the PASRR's are received upon admission and reviewed to ensure clinical accuracy. She said, if the PASRR is inaccurate, they reach back out to hospital to correct the information. She said, if the hospital does not correct the screening then she (DON) will correct it by completing a new Level I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 5 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm PASRR. She stated when a new diagnosis is added to the medical record the expectation is to complete a new PASRR with the new diagnosis. She stated she will complete an updated PASRR when informed by doctor or staff that a resident acquires a new diagnosis. The DON stated Resident #128 should have had a Level I PASRR completed prior to, or at admission and an updated Level I PASRR should have been completed when new diagnoses were added to his medical record. Residents Affected - Some Review of the medical record showed Resident #98 was admitted on [DATE] with primary diagnosis of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Other diagnoses included schizoaffective disorder, major depressive disorder, pseudobulbar affect, and generalized anxiety disorder. Review of Resident #98's Level I PASRR completed on 3/22/2021 showed Section I: PASRR Screen Decision Making Part A with all listed diagnosis boxes unchecked. Section II: Other indications for PASRR Screen Decision-Making, Continued showed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator in accordance with 42 CFR 483.128(m)(2)(i) or 42 CFR 483.128(m)(2)(ii). No Level II PASRR was completed. Section IV: PASRR Screen Completion showed box was checked marked for No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #98 Level I PASRR completed on 1/23/2024 shows Section I: PASRR Screen Decision Making part A has diagnosis Anxiety Disorder and Depressive Disorder box marked with check mark. Schizophrenia box is unchecked. Other box is unchecked and line to right to specify other is left blank. Section II: Other indications for PASRR Screen Decision-Making, Continued showed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator in accordance with 42 CFR 483.128(m)(2)(i) or 42 CFR 483.128(m)(2)(ii). No Level II was completed. Section IV: PASRR Screen Completion showed box was checked marked No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. On 3/7/2024 at 12:50 the DON stated Resident #98 should have had a Level II PASRR completed on admission due to her primary diagnosis of dementia and should have had schizoaffective affective disorder and dementia diagnoses listed on the Level I PASRR completed on 1/24/2024. Review of the facility policy titled, admission Criteria, revised December 2016, showed the following: Policy: Our facility will admit only those residents who's medical and nursing care needs can be met. Policy Interpretation and Implementation: 7. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre- admission Screening and Resident Review program (PASRR) to the extent practicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 6 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0675 Honor each resident's preferences, choices, values and beliefs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to provide the Residents Affected - Few necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to outside provider appointments for 2 residents (#87 and #135) out of 2 sampled residents. Findings included: 1. Review of Resident #87's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included chronic obstructive pulmonary disease and vascular dementia. An interview was conducted on 03/04/24 at 11:11 AM with Resident #87 (Resident Council President) she said she has concerns related to appointments. She said her throat is sore and she is supposed to go see an Ear Nose Throat (ENT) Physician. She said the doctor thought she might've had a small airway and when she was sick and got intubated it might've caused some damage so the doctor wanted me to see an ENT and it's been two months. She said she still does not have an ENT appointment. Review of Resident #87's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating no cognitive impairment. Review of Resident #87's Advanced Practical Nurse Practitioner (ARNP) note date 3/5/24 revealed the following: Subjective .1/11/24 The patient is seen today to follow up on long-term care. The patient is sitting up in [sic] the side of the bed. The patient reports that her appetite is good. She reports that since she was intubated she has noticed that her vocal cords weren't as good. She reports that they've been like this for a while but she wants her singing voice back. We discussed for her to see an ENT [Ear Nose and Throat Physician] to assess her vocal cords and she reports that she was told about a Lidocine [sic] spray for her throat. We discussed that lidocaine spray could mask an issue. She reports that she doesn't want to see ENT at this time and wants to try Lidocaine spray first . 2/5/24 Patient seen for follow up on LTC [long term care] and per pt [patient] request. Reports she continues to have raspy voice/laryngitis and thinks should [sic] would like to see ENT now Review of Resident #87's physician orders revealed an order with a start date of 2/5/24 and no end date for ENT Consult Dx [diagnosis] Laryngitis. Review of Resident #87's medical record did not reveal an ENT appointment was scheduled. An interview was conducted on 03/06/24 at 12:35 PM with Staff L, Licensed Practical Nurse (LPN) Unit Manager (UM). She said when the doctor first ordered the ENT consult, she personally gave it to the transporter to have the appointment scheduled. She said Resident #87's ARNP came yesterday (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 7 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (3/5/24) and asked about the consultation and the Transporter had not scheduled the appointment yet but she was working on it. She confirmed Resident #87 does not have an ENT appointment scheduled. An interview was conducted on 03/06/24 at 02:48 PM with Staff N, Transporter. She said last month the Unit Manager gave her the ENT consult and she faxed it over to the ENT office Maybe within four or five days after receiving the consult. She said Staff L, LPN, UM asked her about the ENT appointment yesterday (3/5/24), so she called the ENT doctor, and they did not receive the fax so I need to refax the consult. I have not done it yet because I do all the appointments and the transportation for the whole building. She said she tries to get appointments scheduled in between her transports. 2. Review of Resident #135's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted back to the facility on 2/13/24 from an acute care hospital. Her medical diagnoses included lymphedema, venous insufficiency, cellulitis of the left lower limb, chronic pain syndrome, and difficulty in walking. An interview was conducted on 03/04/24 at 11:23 AM with Resident #135. Upon entering the resident's room Resident #135 had her eyes closed and grimacing. She said she was in excruciating pain in her left leg. She pulled back the covers and her left leg was dark red and purple with dry flaky skin. She said she finally went to the hospital and they told her she had lymphedema in her legs. She said they recommended her to go to a lymphedema specialist, but she has not gone. She said she does not have an appointment that she knows of. She said the doctor told her, her legs Look angry so she ordered an antibiotic. Review of Resident #135's Minimum Data Set (MDS), Section C, Cognitive Patterns, dated 2/16/24 revealed a brief interview for mental status (BIMS) score of 13 out of 15 indicating the resident's cognition was intact. Review of Resident #135's hospital records dated 2/6/24 revealed the following: History of Present Illness [Resident #135] is admitted to the hospital with poss [possible] infection both lower legs. She is admitted from the nursing home where she resides currently. States that she has difficulty walking due to the pain in her legs and weakness . Assessment/Plan 1. Bilateral lower leg cellulitis Suspect that the erythema is a result of her lymphedema rather than infection. 2. She would benefit from a lymphedema clinic evaluation upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 8 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0675 discharge . Level of Harm - Minimal harm or potential for actual harm Review of Resident #135's medical record did not reveal a consultation to a lymphedema clinic or lymphedema specialist. Residents Affected - Few Review of Resident #135's physician SOAP Note dated 2/14/24 revealed .follow up BLE [bilateral lower extremity] cellulitis, and other related chronic conditions .Patient seen at bedside sitting up in bed. Patient is alert and oriented and able to make her needs known. BLE swollen +3. Patient currently in bed with BLE elevated. No skin weeping noted. Ace bandage on BLE. Patient encouraged to keep her legs elevated while in bed. An interview was conducted on 03/06/24 at 12:40 PM with Staff L, LPN Unit Manager. She said, Resident #135 does not have an appointment to see a lymphedema specialist or an appointment to go to a lymphedema clinic. She was not aware she needed the services. She said they used to wrap her legs, but Resident #135 would refuse it and then she would get cellulitis, so we stopped doing the wraps. An interview was conducted on 03/06/24 at 02:48 PM with Staff N, Transporter she said Resident #135 came to her yesterday and told her she was supposed to see a lymphedema therapist so I need to look at her hospital records and her chart because that was the first time, I have been informed about her needing an appointment for her lymphedema. Staff N, Transporter confirmed Resident #135's legs were swollen. An interview was conducted with the Director of Nursing (DON) on 3/7/24 at 9:38 AM. She said, I know we don't have a lymphedema specialist at the facility. She said she does not know off the top of her head anything about Resident #135 needing to see a lymphedema specialist. She said when a resident comes from the hospital, Admissions uploads the discharge medication list and the nurses call the physical and ensure those medications are still appropriate to keep ordered. When the resident arrives, they come with hospital paperwork and the medications are reconciled again to ensure no changes were made and the next morning at morning meeting the clinical team reviews all hospital documents and orders to ensure appointments are made and orders are in place. An interview was conducted on 3/7/24 at 9:38 AM with the DON she said once a consult is ordered or recommended the scheduler should be working on it immediately. If there are concerns with getting the appointment that should be communicated to the Unit Manager, the DON, and the family. Review of the facility's Transportation Standard Procedure undated, revealed the following: .Community Resident Physician/Provider Visits .Ordered appointments related to the residents stay can be accommodated through the following methods: scheduled with specialty providers credentialed with the facility who make in-house visits, telehealth via video call, in-house driver to add to schedule, and if there is no in-house can transport will be coordinated with the designated facility vendor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 9 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #366's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis to include orthopedic aftercare following surgical amputation. Review of the resident's Brief Interview For Mental Status (BIMS) score dated 8/5/23 revealed a score of 15, indicating cognitively intact. Residents Affected - Few Review of a Summary of Skilled Services note, dated 8/5/2023 at 9:37 PM, revealed Resident is alert-oriented able to make needs know, tolerated meds well. No signs or symptoms of distress, IV-line patent no signs of infiltration. Complaint of SOB [shortness of breath], will continue to monitor. Review of a Medication Administration note, dated 8/6/2023 at 11:37 AM, revealed medication held resident dizzy NP [Nurse Practitioner] aware Review of a Nursing note dated 8/7/2023 at 6:01 AM revealed This writer went to flush resident's right arm line. This writer observed line detached from resident's right arm. When asked what happened, the resident said, I pulled it out. oncoming nurse notified. Review of the SBAR [Situation Background Assessment and Recommendation] Summary for Providers dated 8/7/2023 at 8:14 AM revealed: Pulse Oximetry Oxygen Saturation of 94% while receiving oxygen via nasal cannula Altered level of consciousness Needs more assistance with ADLs (activities of daily living), general weakness, decreased mobility. Personality change. that the resident had a change in condition related to an altered mental status. Continued review of Nursing observations, evaluation, and recommendations are: AMS [Altered Mental Status] not at base line with conversation. Primary Care Physician responded with Recommendations: family request resident be transferred to [name of hospital] ER [Emergency Room] for evaluation and treatment. Resident surgeon works out of [name of hospital]. NP say AMA [Against Medical Advice] due to resident using non emergency to be transported to hospital. Review of the nursing note dated 8/7/2023 at 12:50 PM revealed that the resident was transported by a transport service to an emergency room for evaluation and treatment. Review of Resident #366's physician's order dated 8/7/2023 revealed Ok to send resident to ER via non emergent per family request. Review of Resident #366's hospital record revealed a History and Physical dated 8/7/23 documenting: History of Present Illness . Patient presented back to the emergency room today brought by family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 10 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm for altered mental status, weak, not eating or drinking well, no fever or chills. Blood pressure 161/91, respiratory rate up to 28, heart rate up to 110, white count 30.55 (Reference Range: 4.40-10.50), Neutrophils Absolute 25.91 (Reference Range 1.50-7.50), Glucose 287. Active problems: Community acquired bacterial pneumonia Residents Affected - Few Plan: Sepsis secondary to right lung pneumonia. Patient is tachypnea, tachycardia, with leukocytosis and identified focus of infection. The resident remained in the hospital until 8/21/2023. Interview on 03/07/2024 at 1:53 PM with the Director of Nursing (DON) revealed the resident was transferred out of the facility for a change in condition per the SBAR. She reported she was not in the facility at the time of the transfer, but per the SBAR the change of condition was due to the resident not being at baseline for conversations. She reviewed the resident's progress notes and reported that she was unsure if the resident was assessed for dizziness on 8/6/23 and for pulling out her PICC line on 8/7/23. Based on observations, interviews, and record review, the facility failed to provide treatment and care to meet the needs of residents by 1.) failing to ensure alterations in skin were identified and treated for one resident (#316) of two residents sampled for skin conditions, and 2.) failed to ensure residents were assessed for a change in condition for one (#366) of five residents sampled for discharges. Findings included: A review of Resident #316's medical record revealed Resident #316 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnosis of sepsis, urinary tract infection, and Diabetes Mellitus. An observation was conducted on 3/5/2024 at 9:09 AM of Resident #316 in the resident's room. Resident #316 was observed resting in bed and dressed in a hospital gown. Resident #316 was observed to have several red colored abrasions on the upper right side of his chest. The skin surrounding the abrasions was observed slightly red in color. A review of Resident #316's physician's orders did not reveal treatment orders related to the abrasions on Resident #316's chest. A review of Resident #316's progress notes did not reveal documentation related to the abrasions on Resident #316's chest. A review of Resident #316's weekly skin check, dated 2/28/2024, did not reveal documentation related to the abrasions on Resident #316's chest. An interview was conducted on 3/6/2024 with Staff B, Licensed Practical Nurse (LPN) and Unit Manager (UM), Resident #316's assigned nurse. Staff B, LPN UM stated she was not aware Resident #316 had abrasions on his chest and the skin condition was not reported to her. Staff B, LPN UM observed the abrasions to Resident #316's upper right chest and stated the condition should have been reported to her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 11 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 3/6/2024 at Staff C, Certified Nursing Assistant (CNA), Resident #316's assigned CNA. Staff C, CNA stated if a new skin condition is identified on a resident, the condition is reported to the nurse. Staff C, CNA also stated she had not observed Resident #316's skin during care recently and she was not aware Resident #316 had abrasions on his upper right chest. An interview was conducted on 3/7/2024 at 2:12 PM with the facility's Director of Nursing (DON). The DON stated CNA staff should be observing resident's skin for any skin alterations while assisting resident's with care and should notify the nurse if any new skin alterations are identified. The DON also stated when the nurse is notified of a skin alteration, the nurse should assess the resident to determine if the alteration is new or previously identified. The nurse should also complete an incident report, skin assessment, and pain evaluation in the resident's record and notify the resident's physician for any required treatment orders. A review of the facility policy titled Standards and Guidelines: Prevention of Skin Impairments/Pressure Injury, last revised in January 2024, revealed under the section titled Monitoring/Documenting, staff are to evaluate, report, and document potential changes in skin, notify the physician and the resident/resident representative of changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 12 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure physician orders were obtained related to care and services for catheters, and catheters were appropriately covered for 1 (#218) of 3 residents sampled for catheters. Findings included: Review of Resident #218's record revealed he was admitted to the facility on [DATE], with diagnosis that included stage 5 chronic kidney disease, polycystic kidney, and malignant neoplasm of prostate. Observations of Resident #218 on 03/04/24 at 10:48 AM from the hallway revealed a catheter bag hanging on the side of the bed, with urine visible and no privacy bag noted. Review of the residents record revealed there were no current orders for a catheter or for catheter care. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the month of March 2024 revealed there was no documentation indicating monitoring or provision of care to the residents catheter. Review of the resident care plan revealed there was no care plan in place that would address the presence and care of a catheter. Interview on 03/06/24 at 11:05 AM with Staff G, Licensed Practical Nurse (LPN) revealed she was assigned to Resident #218 and she was aware of the presence of a catheter. She reported the Certified Nursing Assistant (CNA) provides catheter care based on the facility policy. She reported there should be a physician order in place for the use and care of the catheter. Interview on 03/06/24 at 11:10 AM with Staff I, Registered Nurse (RN), Unit Manager revealed catheter bags should be covered, orders should be in place, and the facility policy is the admitting nurse should put in the orders, and on the next business day nursing management works on orders and medications are reviewed. Interview with the Director of Nursing (DON) on 03/07/24 at 10:28 AM revealed there should have been a leaf on the catheter bag to cover it. She reported if the staff see the catheter bag exposed they should fix it or change bag to the appropriate bag that allows the catheter bag to be covered. The DON reported Resident #218 was admitted from the hospital with an uncovered catheter bag, which should have been changed. Review of the facility policy titled Catheter Care-Quality of Care dated 10/2020, with a revised date of 01/2024 revealed the following: 3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is kept at an appropriate level to promote urine flow, and dignity is maintained. Catheter coverings are not required when drainage bags are out of sight from the public or per the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 13 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0690 preference. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 14 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0694 Provide for the safe, appropriate administration of IV fluids 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 observation, record review and interview the facility failed to ensure care and services related to Intravenous (IV) fluids were provided for a one resident (#68) out of 1 of four residents with IV access in the facility. Residents Affected - Few Findings included: Observations on 03/04/24 at 10:20 AM of Resident #68 revealed the resident sitting up in his bed. An empty Intravenous (IV) bag was noted hanging at his bed side, but not connected to the peripheral line. During an attempt to interview the resident at this time, the resident was unable to verbalize why or how long he has had the peripheral line. Observations on 03/04/24 at 03:48 PM of Resident #68 revealed the resident seated in his wheelchair next to his bed. The empty IV bag was noted to be hanging at the bed side, but not connected to the peripheral line. Continued observations of Resident #68 at this time revealed the peripheral line inserted into the residents right hand and the dressing noted to be soiled, lifting and with no date. Review of Resident #68's record revealed he was re-admitted to the facility on [DATE], with diagnosis that included: Sepsis, and cellulitis of left lower limb. The resident had a Brief interview For Mental Status dated 1/29/24 with a score of 13 (Cognitively intact). Review of the resident's record revealed a physician order dated 3/2/2024 for Insert Peripheral. May use 1% Lidocaine for insertion. Review of the IV access vendor documentation revealed the vendor inserted a peripheral line for IV fluids in the residents right hand. Interview on 03/04/24 at 03:54 PM with Staff J, Licensed Practical Nurse (LPN) revealed the resident was on IV for fluids due to dehydration. She reported the IV team placed the IV, but that she did not see orders for care of the IV line. Interview on 03/04/24 at 04:06 PM with Staff I, Registered Nurse (RN), Unit Manager. revealed right now is the first time he was aware the resident had a IV line. He reported the IV team should have dated the dressing for the IV line, and that if there was no date the nurses should have followed up and ensured that care was provided. Interview on 03/07/24 on 09:28 AM with the Director of Nursing (DON) revealed if the peripheral line dressing is not dated or soiled, staff are to remove the dressing, re-apply the dressing and then date it. She reported the peripheral line is monitored every shift. The DON reported she was unsure as to why the staff did not notice the soiled, undated dressing. The DON reported the role of Unit Manager is to oversee the staff of the unit, review admissions and do meet and greet with new residents as well as review the physician orders for the newly admitted residents. She reported new admissions are reviewed as part of clinical meetings which is done every day. Review of the facility policy titled Peripheral IV Dressing Changes dated 05/2019 and a revised date of 11/2023 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 15 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0694 Level of Harm - Minimal harm or potential for actual harm -Standard: This purpose of this procedure is to minimize catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. -Procedure: 1. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5 to 7 days. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 16 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 reviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice by failing to ensure respiratory equipment was stored in a sanitary manner for two (#218 and #103) of two residents sampled for respiratory care. Residents Affected - Few Findings included: Observations of Resident #218 on 03/04/24 at 10:48 AM revealed a CPAP (continuous positive air pressure) machine on the resident's nightstand. Closer observations at this time revealed the CPAP mask laying unbagged face down on the nightstand. Observations on 03/05/24 at 11:45 AM revealed the resident's CPAP mask laying unbagged, face down on the residents nightstand. Review of Resident #218's record revealed he was admitted to the facility on [DATE]. The record revealed there was no current order for the use of the CPAP, no current order for the care of the CPAP and no care plan in place for the use, monitoring and care of the CPAP. Review of the history and physical dated 3/1/24 revealed the plan it indicated CPAP nightly Review of the progress note dated 3/1/24 revealed per resident wife, resident is to wear BPAPP (sic) machine to bed at night Interview on 03/06/24 at 11:05 AM with Staff G, Licensed Practical Nurse (LPN) revealed that she was assigned to the resident. She reported the residents CPAP goes on at nighttime. She reported there should have been a physician order in place for the use of the CPAP and that it should be bagged when not in use. Interview on 03/06/24 at 11:10 AM with Staff I, Registered Nurse (RN), Unit Manager revealed that CPAP masks should be bagged when not in use, orders should be in place, and the facility policy is that the admitting nurse should put in the orders, and on next business day nursing management works on orders and that medications are reviewed. Interview with the Director of Nursing (DON) on 03/06/24 at 11:26 AM revealed when staff take off the CPAP mask they are to place it in a bag. She reported it should not be left on the nightstand uncovered. She reported the expectation is the nurse is supposed to notify the physician of the CPAP and put the order into the electronic system. She reported admission charts are normally reviewed by the admitting nurse to ensure orders are in. She reported the supervisory nurses would review the orders and chart on the next business day. Review of the facility policy titled CPAP/BIPAP usage dated 04/2020, with a revised date of 01/2023 revealed the following: -Under procedure: 2. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, BIPAP, and EPAP) for the machine. -Under general guidelines for cleaning 4. Storage: Store mask and tubing in a hygienic manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 17 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 - Few A review of Resident #103's medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and chronic obstructive pulmonary disease. A review of Resident #103's physician's orders revealed an order, dated 10/25/2023, for oxygen at 2 liters per minute (LPM) via nasal cannula, as needed for shortness of breath per resident preference. Resident #103's physician's orders also revealed an order to change oxygen tubing/mask/bag weekly and as needed. An observation was conducted on 3/5/2024 at 10:00 AM in Resident #103's room. Resident #103 was observed resting in bed with an oxygen nasal cannula in place. Resident #103 stated she would usually wear her oxygen at night, but not during the daytime. An observation of Resident #103's oxygen tubing revealed the oxygen tubing was dated 2/24/2024. An observation was conducted on 3/6/2024 at 11:38 AM in Resident #103's room. Resident #103 was at an outside appointment at the time of the observation and was not in the room. Resident #103's oxygen tubing and nasal cannula was observed coiled on top of her oxygen concentrator on top of a white plastic bag. The oxygen tubing was dated 3/6/2024. An interview was conducted on 3/7/2024 at 2:06 PM with the facility's Director of Nursing (DON). The DON stated resident respiratory equipment should be stored inside of a bag, labeled with the resident's name and the date the bag was replaced. The DON also stated oxygen tubing and storage bags should be changed out weekly and per the physician's orders. A review of the facility policy titled Standards and Guidelines: Oxygen Administration, last revised in December of 2023 revealed under the section titled General Guidelines, staff are to store oxygen tubing in a hygienic manner (i.e. labeling bag with date tubing was changed). Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 18 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure physician ordered pain medication was prescribed for one resident (#72) out of three residents sampled. Findings Included: During an observation on 03/05/24 at 11:59 AM., Resident # 72 was observed in the hallway, fully dressed, propelling in her wheelchair towards Staff M, Licensed Practical Nurse (LPN). Resident #72 said she was in a lot of pain since last night and she has not received any of her pain medicine. She said that she has been waiting for her pain medication all night and the nurse told her that they did not have her medication. Resident # 72 was presented with signs of distress on her face. During an observation on 03/06/2024 at 2:00 PM., Resident was observed laying down in her bed with her feet placed on her wheelchair. She said she finally received her pain medication yesterday after having to ask for it multiple times. She said the nurses told her she was not able to receive her pain medication because they did not have it. She said this is not the first time this has happened to her. Review of admission Record showed Resident #72 was admitted on [DATE] with diagnoses to include but not limited to unspecified diastolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, lack of coordination, chronic tension-type headache, intractable, other chronic pain. Review of an Order Summary Report dated 03/06/2024 showed an active order, start date 5/24/2024, for Oxycodone- Acetaminophen Tablet 5-325 MG (milligram) give 1 tablet by mouth every 6 hours for non-acute pain. Review of care plan, dated 03/27/2023, showed Resident #72 was at risk for pain related to tension headaches, right breast cancer, constipation, chronic pain, backs/knees, as well as age related aches and pain. Review of the care plan interventions, dated 03/27/2023, showed administer analgesia medication as per orders, observe for and report to Nurse any resident complaints of pain, request for pain treatment and non-verbal signs and symptoms of pain. Medication Administration Records were requested to show the days and times Resident #72 did not receive her medication but was not provided for review. During an interview on 03/05/2024 at 12:00 PM., with Staff M, Licensed Practical Nurse (LPN), he said he was able to obtain the script from the resident's doctor, it took an hour to get it and they are waiting for pharmacy so they can get an authorization to pull her pain medication to administer it. He stated the resident's scheduled pain medication has been out since yesterday and the resident was scheduled to get it every 6 hours. During an interview on 03/06/2024 at 12:47 PM., with Staff B, Unit Manager. She said Resident #72 is on pain medication because of low back pain. She has been receiving pain medication since she was admitted to the facility. She gets Oxycodone and Tylenol mix every 6 hours since May 24 of 2023. She gets a Diclofenac sodium one percent for pain in her left knee. She said the Nurse Practitioner (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 19 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wrote a script for 7 days for the resident pain medication Oxycodone and it ran out over the weekend on Sunday evening. They called the on-call doctor to send the script to the pharmacy. The Pharmacy said they did not receive the script or a call from the doctor. Staff B said on Monday when she got to the facility, she called the on-call provider number to have them call in the script for the resident to receive her pain medication. She said when the on-call doctors did not call her back immediately, she went to the Director of Nursing to follow-up and call the doctor. Staff B said she called the pharmacy to make sure they received the scripts so that they can pull the medication to administer it to the resident. The pharmacy told her she has to wait ten to 15 minutes then she was able to go in to request the medication. Resident #72 was supposed to get her pain medication every 6 hours. The last time she received her pain medication was on 3/3/24 at 5:37 pm on Sunday. She did not receive it again until 03/4/24 at 1:10 pm because we did not have a script for her medication. Resident #72 went 20 hours without her pain medication. She said that she was not made aware until Monday about the resident medication. The process is the nurse on the floor should have made sure that the resident scripts were filled on Friday. Standard practice is on Friday the nurse is supposed to go through what scripts need to be filled with the Nurse Practitioner or the doctor to make sure that scripts are filled for the weekend. She said she does not know why this process was not followed out. During an interview on 03/07/2024 at 10:00 AM., with the Director of Nursing. She said the facility process is if the nurses on the floor passing medication see that a resident doesn't have a medication available, they are supposed to notify the physician, family and call the pharmacy for a refill. We do have an in-house medication bank that does have some medication available. Narcotics are the only medication that the nurses would not be able to pull from the medication bank because they would have to reach out to the provider for a new script. The nurse should have called the physician to get a new script and notify the family to ensure Resident #72 had her pain medication. She stated the process was not followed for Resident #72's medications. The facility did not have a policy to provide for this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 20 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 review, the facility failed to maintain a medication error rate of less than 5%. A total of 25 medication administration opportunities were observed with 3 medication errors for two (#84 and #61) of three residents sampled for medication administration, which resulted in a medication administration error rate of 12%. Residents Affected - Few Findings included: A review of Resident #84's medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus and hypertension. A review of Resident #84's physician's orders revealed the following orders: - An order, dated 2/9/2023 for Aspirin 325 milligrams (mg) by mouth (PO) one time a day. - An order, dated 2/9/2023 for Citalopram Hydrobromide 20 mg PO one time a day. - An order, dated 6/22/2023 for Divalproex Sodium 125 mg PO every morning and at bedtime. - An order, dated 2/13/2023 for Cholecalciferol 1000 units PO one time a day. - An order, dated 1/18/2024 for Insulin Glargine 100 units/milliliter (ml) via pen-injector, inject 26 units subcutaneously one time a day. - An order, dated 2/9/2023 for Lisinopril 10 mg PO one time a day. - An order, dated 3/3/2024 for Gemfibrozil 600 mg PO two times a day. - An order, dated 7/31/2023 for Fish Oil 1000 mg PO one time a day. An observation of medication administration was conducted on 3/6/2024 at 8:30 AM with Staff D, Registered Nurse (RN) on the 100 unit of the facility. Staff D, RN prepared the following medications for administration to Resident #84: - Aspirin 325 mg PO, one tablet. - Citalopram Hydrobromide 20 mg PO, one tablet. - Divalproex Sodium 125 mg PO, one tablet. - Cholecalciferol 1000 units PO, one tablet. - Insulin Glargine 100 units/ml pen-injector - Lisinopril 10 mg PO, one tablet. - Gemfibrozil 600 mg PO, one tablet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 21 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 - Fish oil 1000 mg PO, one capsule. Level of Harm - Minimal harm or potential for actual harm Staff D, RN removed the PO medications from the medication cart and placed them inside of a medication cup. Staff D, RN removed Resident #84's Insulin Glargine pen injector and applied a needle to the tip of the pen. Staff D, RN dialed the pen's dosage selector to 26 units, gathered an alcohol preparation pad and PO medications for the resident, and entered the resident's room. Staff D, RN administered the PO medications to Resident #84 before performing hand hygiene and donning clean gloves. Staff D, RN administered Resident #84's insulin into the resident's lower left quadrant. Staff D, RN did not prime the insulin pen injector needle before administering the insulin to Resident #84. Staff D, RN performed hand hygiene and exited Resident #84's room. An interview was conducted following the observation with Staff D, RN. Staff D, RN stated she did not prime the insulin pen injector needle prior to administering insulin to Resident #84 because she didn't think it needed to be primed and the top of the insulin injector pen did not have any air bubbles in it. Staff D, RN was not able to state why the insulin pen injector needle needed to be primed prior to administration of the insulin. Residents Affected - Few A review of Resident #61's medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur and diabetes mellitus. A review of Resident #61's physician's orders revealed the following orders: - An order, dated 12/21/2023 for Loratadine 10 mg PO one time a day. - An order, dated 10/9/2023 for Vitamin C 500 mg PO one time a day. - An order, dated 11/15/2023 for Aspirin 81 mg PO one time a day. - An order, dated 7/21/2023 for Doxazosin Mesylate 2 mg PO one time a day. - An order, dated 5/22/2023 for Duloxetine Hydrochloride (HCl) 60 mg PO one time a day. - An order, dated 5/1/2023 for Humulin 70/30 (Insulin Neutral Protamine [NAME] (NPH) Isophane & Regular insulin), 100 units/ml via pen-injector, inject 30 units subcutaneously one time a day. - An order, dated 8/8/2023 for Senna 8.6 mg PO one time a day. - An order, dated 4/28/2023 for Hydralazine HCl 50 mg PO two times a day. - An order, dated 10/8/2023 for artificial tears solution 0.2-0.2-1 % (Glycerin-Hypromellose-Polyethylene Glycol 400) 2 drops in each eye three times a day. - An order, dated 6/1/2023 for Ferrous Sulfate 325 mg PO three times a day. An observation of medication administration was conducted on 3/6/2024 at 8:50 AM with Staff B, Licensed Practical Nurse (LPN) and Unit Manager (UM). Staff B, LPN UM prepared the following medications for administration to Resident #61: - Loratadine 10 mg one tablet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 22 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 - Vitamin C 500 mg one tablet. Level of Harm - Minimal harm or potential for actual harm - Aspirin 81 mg one tablet. - Doxazosin Mesylate 2 mg one tablet. Residents Affected - Few - Duloxetine HCl one tablet. - Humulin 70/30 pen-injector. - Senna 8.6 mg one tablet - Hydralazine HCl 50 mg one tablet - Artificial tears solution bottle. - Ferrous Sulfate 325 mg one tablet. Staff B, LPN UM removed the PO medications from the medication cart and placed them inside of a medication cup. Staff B, LPN UM gathered Resident #61's Humulin 70/30 pen injector, artificial tears solution bottle, an alcohol preparation pad, and PO medications for the resident, and entered the resident's room. Staff B, LPN UM administered the PO medications to Resident #61 before performing hand hygiene and donning clean gloves. Staff B, LPN UM applied a needle to the tip of Resident #61's Humulin 70/30 pen injector and dialed the pen's dosage selector to 30 units. Staff B, LPN UM administered Resident #61's insulin into the resident's left upper arm. Staff D, RN did not prime the insulin pen injector needle and did not mix the Humulin 70/30 solution before administering the insulin to Resident #61. Staff D, RN performed hand hygiene and donned clean gloves. Staff B, LPN UM administered artificial tears solution to Resident #61 before performing hand hygiene and exiting the room. An interview was conducted following the observation with Staff B, LPN UM. Staff B, LPN UM stated the Humulin 70/30 solution in the pen injector did not need to be mixed because it already came premixed in the pen injector. Staff B, LPN UM then stated, it probably does but she was not certain at the time it was administered to Resident #61. Staff B, LPN UM also stated the pen injector needle did not require priming before administering insulin. An interview was conducted on 3/7/2024 at 2:16 PM with the facility's Director of Nursing (DON). The DON stated when administering insulin via insulin injector pen, nursing staff must verify the dose they are administering, ensure they are administering the correct type of insulin, and ensure the pen injector needle is primed prior to administering the insulin. The DON also stated to prime the pen injector needle, nursing staff must apply the needle to the tip of the pen injector and inject a small amount of insulin into the needle to remove the air from the needle. The DON stated if the resident has an order for Humulin 70/30 insulin, staff must mix the insulin suspension by rolling the injector pen in their hands prior to administering the insulin. The DON also stated if staff do not prime the insulin pen injector needle or mix 70/30 insulin prior to administration, the resident may not receive an accurate dose. The DON stated she was not certain the nursing staff had specific education related to the use of insulin injector pens. A review of the facility policy titled Standards and Guidelines: Medication Administration, last revised in January 2024, revealed under the section titled Procedure, insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 23 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 insulin pen, the nurse verifies that the correct pen is used for that resident. The nurse follows manufacturer guidelines related to insulin pens. Review of the manufacturer's instructions for the Humulin 70/30 pen injector revealed the following under the section titled preparing your pen: Residents Affected - Few - Step 1: Pull the pen cap straight off. Do not remove the pen label. Wipe the rubber seal with an alcohol swab. Do not attach the needle before mixing. - Step 2: Gently roll the pen between your hands 10 times. - Step 3: Move the pen up and down (invert) 10 times. Mixing by rolling and inverting the pen is important to make sure you get the right dose. - Step 4: Check the liquid in the Pen. Humulin 70/30 should look white and cloudy after mixing. Do not use if it looks clear or has any lumps or particles in it. - Step 5: Select a new needle. Pull off the paper tab from the outer needle shield. - Step 6: Push the capped needle straight onto the pen and twist the needle on until it is tight. - Step 7: Pull off the outer needle shield. Do not throw it away. Pull off the inner needle shield and throw it away. The manufacturer's instructions for the Humulin 70/30 pen injector also revealed the following under the section titled priming your pen: - Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. - Step 8: To prime your pen, turn the dose knob to select 2 units. - Step 9: Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. - Step 10: Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 8 to 10, no more than 4 times. If you still do not see insulin, change the needle and repeat priming steps 8 to 10. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 24 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and review of facility policy, the facility failed to ensure proper storage, labeling, and security of medications and biologicals in one of four treatment carts in the facility, three of seven medication carts in the facility, and two of three medication rooms in the facility. Findings included: An observation was conducted on 3/6/2024 at 8:22 AM in the 100 unit of the facility. A medication cart was observed in the unit hallway with a medication cup containing crushed medications on top of it. A resident was observed in a wheelchair next to the medication cart. No staff were observed at the medication cart at the time of the observation. Staff D, Registered Nurse (RN) was observed approaching a treatment cart down the hallway from the medication cart and gathering treatment supplies. Staff D, RN approached the medication cart and an interview was conducted. Staff D, RN stated the crushed medications in the medication cup were for the resident observed near the medication cart. Staff D, RN also stated while preparing the medications, she noticed the resident had a skin tear and went to the treatment cart to gather supplies to care for the wound. Staff D, RN addressed the crushed medications should not have been left on top of the medication cart unattended. Staff D, RN gathered the medications and treatment supplies before assisting the resident to their room. An observation was conducted on 3/6/2024 at 8:26 AM of the treatment cart in the 100 unit hallway. The treatment cart was observed to be unlocked. No staff were observed in the unit hallway at the time of the observation. An inspection was conducted of the treatment cart without staff present. During the inspection, Staff L, Licensed Practical Nurse (LPN) and Unit Manager (UM) approached the treatment cart and requested to lock the treatment cart once the inspection was completed. After the inspection of the treatment cart, Staff L, LPN UM locked the treatment cart and an interview was conducted. Staff L, LPN UM stated the treatment cart should not have been left unlocked. An inspection of a medication cart on the 200 unit was conducted on 3/6/2024 at 2:09 PM with Staff E, LPN. A plastic bag containing five $1 bills was observed inside of the narcotics drawer of the medication cart, with hand written text $5 found in 232a closet with a hand written date of 1/12/24. The narcotics drawer also contained five computer mice were also observed inside of the narcotics drawer in the medication cart. Staff E, LPN was not able to state why the plastic bag of money was stored inside of the medication cart and was not able to state who the money belonged to. Staff, LPN stated the computer mice were used for the laptop on the medication cart but was not able to state why there were so many or why they were stored inside of the narcotics drawer. Following the inspection of the medication cart, an inspection of a medication storage room on the 200 unit was conducted with Staff E, LPN. During the inspection, the top shelf of a medication cabinet was observed to have several open medication boxes spread out on the shelf in an unorganized manner. The medications were difficulty to observe from the ground level. Staff E, LPN stated she was not aware any medications were stored on the shelf and was not able to state what medications were contained on the shelf. An inspection of a medication cart on the 300 unit was conducted on 3/6/2024 at 3:47 PM with Staff F, LPN. An unpowered, black colored cell phone was observed inside of the narcotics drawer of the medication cart. Staff F, LPN was not able to state who the cell phone belonged to or how long the cell phone was inside of the medication cart. Following the inspection of the medication cart, an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 25 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inspection of a medication storage room on the 300 unit was conducted with Staff F, LPN. During the inspection, a large box containing several bottles of opened medications and several bags of opened medications was observed in a storage cabinet. Several more bags containing medications were observed deep in the storage cabinet. Some of the medications were observed to be labeled with resident names. Staff F, LPN was not able to state why the medications were stored in the large box or who the medications belonged to. An inspection of a medication cart on the 100 unit was conducted on 3/6/2024 at 4:16 PM with Staff D, RN. An undated and opened novolog pen injector was observed inside of a bag in the medication cart. The pink colored Date Opened sticker was observed blank. Staff D, RN was not able to state when the pen injector was opened and stated the pen injector should have a date labeled when it was opened. An interview was conducted on 3/7/2024 at 2:27 PM with the facility's Director of Nursing (DON). The DON stated she would not expect nursing staff to leave medications unattended and would expect medications be administered after they are dispensed. The DON also stated medication carts and treatment cart should be kept locked and secure at all times unless there is a nurse present at the cart. The DON stated the medication cart should not have any treatment supplies or personal items inside of it unless it is being stored securely off hours until it can be given to the Unit Manager. The DON was not able to state why there were several bags of personal medications stored inside of the medication room but assumed they must have been resident's personal medications. The DON stated resident's personal medications should be given back to the resident after discharge or to the resident's family. The DON also stated she would expect staff to ensure insulin pens were dated upon opening. A review of the facility policy titled Standards and Guidelines: Medication Storage and Labeling, last revised in January 2024, revealed under the section titled Standard drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include appropriate accessory and cautionary instructions, and the expiration date when applicable. The policy also revealed the following under the section titled Procedure: - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 26 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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** Based on observations, interviews, and record reviews, the facility failed to maintain an accurate medical record by documenting treatments, which were not completed, for one (#103) of fifty two sampled residents. Findings included: A review of Resident #103's medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and chronic obstructive pulmonary disease. A review of Resident #103's physician's orders revealed an order, dated 10/25/2023, for oxygen at 2 liters per minute (LPM) via nasal cannula, as needed for shortness of breath per resident preference. Resident #103's physician's orders also revealed an order to change oxygen tubing/mask/bag weekly and as needed. An observation was conducted on 3/5/2024 at 10:00 AM in Resident #103's room. Resident #103 was observed resting in bed with an oxygen nasal cannula in place. Resident #103 stated she would usually wear her oxygen at night, but not during the daytime. An observation of Resident #103's oxygen tubing revealed the oxygen tubing was dated 2/24/2024. A review of Resident #103's treatment administration record (TAR) for February of 2024 revealed documentation of Resident #103's oxygen tubing and nasal cannula being changed on 2/26/2024. A review of Resident #103's TAR for March of 2024 revealed documentation of Resident #103's oxygen tubing and nasal cannula being changed on 3/4/2024. An interview was conducted on 3/7/2024 at 2:06 PM with the facility's Director of Nursing (DON). The DON stated resident respiratory equipment should be stored inside of a bag, labeled with the resident's name and the date the bag was replaced. The DON also stated oxygen tubing and storage bags should be changed out weekly and per the physician's orders. The DON stated usually the Central Supply personnel would change the oxygen tubing and nasal cannulas weekly, but the nursing staff should double check to ensure the respiratory equipment was changed before documenting in the TAR and nursing staff should not document the changing of the respiratory equipment if it was not completed. A review of the facility policy titled Standards and Guidelines: Oxygen Administration, last revised in December of 2023 revealed under the section titled General Guidelines, oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physician's orders and/or facility protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 27 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and review of facility policy, the facility failed to maintain an effective infection control and prevention program by 1.) failing to ensure hand hygiene was performed during medication administration and 2.) failing to ensure medications were dispensed in a sanitary manner for one (#84) of three residents observed during medication administration. Residents Affected - Few Findings included: An observation of medication administration was conducted on 3/6/2024 at 8:30 AM with Staff D, Registered Nurse (RN) on the 100 unit of the facility. Prior to the observation, Staff D, RN was observed at a treatment cart near the end of the hallway after assisting a resident. Staff D, RN was not observed performing hand hygiene after handling items in the treatment cart or prior to the observation of medication administration. Staff D, RN reached into her pocket, removed the medication cart keys, and opened the medication cart before preparing the following medications for administration to Resident #84: - Aspirin 325 mg PO, one tablet. - Citalopram Hydrobromide 20 mg PO, one tablet. - Divalproex sodium 125 mg PO, one tablet. - Cholecalciferol 1000 units PO, one tablet. - Insulin Glargine 100 units/ml pen-injector - Lisinopril 10 mg PO, one tablet. - Gemfibrozil 600 mg PO, one tablet. - Fish oil 1000 mg PO, one capsule. During the observation, Staff D, RN was observed removing Resident #84's Citalopram, Divalproex sodium, Lisinopril, and Gemfibrozil tablets from a blister pack and into her ungloved hand before placing the medication into a medication cup. Staff D, RN removed the remainder of Resident #84's medications from the manufacturer's container, into the lid of the container, and into the same medication cup. Staff D, RN removed Resident #84's Insulin Glargine pen injector and applied a needle to the tip of the pen. Staff D, RN dialed the pen's dosage selector to 26 units, gathered an alcohol preparation pad and PO medications for the resident, and entered the resident's room. Staff D, RN administered the PO medications to Resident #84 before performing hand hygiene and donning clean gloves. Staff D, RN administered Resident #84's insulin into the resident's lower left quadrant. Staff D, RN performed hand hygiene and exited Resident #84's room. An interview was conducted following the observation with Staff D, RN. Staff D, RN stated she normally removed the medications from the medication blister packs and into her hand due to having pain in her thumbs. Staff D, RN addressed she did not perform hand hygiene after handling items in the treatment cart and stated she did not touch anything dirty inside of the treatment cart. An interview was conducted on 3/7/2024 at 2:16 PM with the facility's Director of Nursing (DON). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 28 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated she would expect nursing staff to perform hand hygiene before handling medications, after passing medications, and before and after donning gloves. The DON also stated she would not expect nursing staff to dispense medications by placing the medications into their hand and the medication should be dispensed directly into the medication cup from it's container. A review of the facility policy titled Standards and Guidelines: Medication Administration, last revised in January 2024, revealed under the section titled Procedure, staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolations precautions, etc.) for the administration of medications, as applicable. A review of the facility policy titled Standards and Guidelines: Hand Hygiene Infection Control, last revised in June 2023, revealed under the section titled Procedure the facility acknowledges the CDC (Centers for Disease Control and Prevention) guidelines to improve adherence to hand hygiene in health care settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in health care settings to promote resident safety. The policy gives examples of situations that require hand hygiene such as before and after medication administration and after handling soiled equipment or utensils. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 29 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide a safe and home like environment for one resident (#154) out of 19 residents sampled. Finding Include During an observation on 03/04/2024 at 10:00 AM., Resident #154 was observed laying down in bed with an extension cord in her bed. She said that she uses the cord so that all her electronics can be plugged in to a location that she can reach. She said she has had her extension cord for a while, and she always places it in her bed. She said no one has told her that she the cord is a safety hazard and that she cannot have the cord in her room. During an observation on 03/05/2024 at 2:00 PM., Resident was observed laying down in bed with her call light in reach. Resident extension cord was observed on top of her dresser. She said staff moved her cord so that she can have a bed bath, but staff will put it back in her bed later today. During an interview on 03/06/24 at 04:01 PM with the Maintenance Supervisor. He said residents are not supposed to have extension cords in their rooms unless it has been approved by the facility. The resident in room [ROOM NUMBER] is the only one the facility has given approval to have an extension cord in their rooms. We conducted monthly room audits to ensure the safety of our residents and to make sure they do not have inappropriate items in their rooms like extension cords. We did not approval for Resident #154 to have an extension cord and the fan she has in her room. These items should have been identified during the mangers weekly audits and reported to keep our residents safe. During an interview on 03/06/2024 at 4:01 PM., with the Nursing Home Administrator, NHA. He said managers conduct weekly audits in the building to ensure that things are working properly inside residents' rooms. Resident #154 should not have an extension cord in her room and it should not be in bed with her. He said I will get my staff to do a whole house audit to see if there are any more rooms with extension cords that have not been approved by the facility because extension cords are not allowed in residents rooms without approval. This should have been identified when the managers conducted their last room audit. Photographic Evidence Obtained The facility did not have an environmental policy to provide related to extension cord for this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 30 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program, so the facility was free of pests when one resident (#90) was observed with black ants crawling on him while in bed out of 52 residents sampled. Residents Affected - Few Findings included: Review of Resident #90's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses of Alzheimer's Disease, muscle weakness, lack of coordination, Type 2 diabetes with foot ulcer, and acquired absence of left great toe. An observation was conducted on 03/05/24 at 2:05 PM. Resident #90 was observed to be lying in bed. Resident #90 was observed to have one small black ant crawling on his sheet over his lap. Staff O, Human Resources (HR) came into the room and pinched the small black ant located on the resident's bedsheet which was laying over his lap. She also confirmed there was another small black ant crawling on his bed next to his shoulder. She stated she was going to get maintenance and walked out. Resident #90 was then observed to have a small black ant crawling on his upper arm and onto his shirt. The resident said there were 2 or 3 ants in his bed. An observation of Resident #90's room was conducted at this time and there was an observation of Resident #90's corner baseboard located next to the air conditioner wall unit and across from his bed was not adhered to the wall. On 03/05/24 at 02:08 PM Staff L, Licensed Practical Nurse (LPN), Unit Manager (UM) was observed talking to Staff O, HR. Staff L, LPN, UM was made aware there was another small black ant crawling on Resident #90's arm and shirt. Staff L, LPN, UM said she is going to have a staff member get him up out of bed and have the room sprayed. On 03/05/24 at 2:10 PM a Certified Nursing Assistant was observed to be in Resident #90's room getting him out of bed. An interview was conducted on 03/06/24 at 11:44 AM with the Director of Nursing (DON) she confirmed ants should not be crawling on residents. Review of the facility's Pest Sightings Log from September 2023 through March 2024 revealed there were six other ant sightings in the facility and 3 of the six sightings were on Resident #90's hallway. For all six documented sightings except for one, the Pest Sighting Log revealed under the Corrective Action(s) Taken (Describe) revealed illegible writing. For all documented sightings from 2/16/24 through 3/5/24, documented under Corrective Action(s) Taken (Describe) revealed the word Treated with an arrow pointed down to the sighting on 3/5/24. An observation was conducted in Resident #90's room on 3/7/24 at 1:56 PM. The baseboard located across from Resident #90's bed and next to the air conditioner wall unit was not adhered to the wall. [Picture evidence obtained] Review of the facility's Pest Control policy revised on 1/2022 revealed the following: Policy: Pest Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105620 If continuation sheet Page 31 of 32 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 105620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete It is the policy of the facility to maintain an effective pest control program through a licensed pest control company and staff education. Procedure: .Maintenance is to do a full audit of resident rooms and document any areas that pests may come into the building or any areas that pests may breed (moist dark areas). They will then address these areas and close any opening or eliminate any areas that may encourage breeding . Event ID: Facility ID: 105620 If continuation sheet Page 32 of 32