Inspection·March 2, 2023

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/27/23 at 3:19 PM, an interview was conducted with Staff B, RN, who has worked with the facility since December 2022. She stated that normally she does not work on the med cart, but noticed one day last week there were no insulin pen needles, and at that time she called pharmacy to order insulin pen needles. The pharmacy never sent any of the insulin needle pens. On 02/28/23 at 8:58 AM, an interview was conducted with Staff C, RN, who stated she has been working with the facility since November 2022, and they have not run out of needles for the insulin pens. The pen needles for the insulin pens are ordered through central supply. If the facility does not have any, they send someone to a local pharmacy to purchase additional insulin pen needles. On 02/28/23 at 9:20 AM, an interview was conducted with Staff D, LPN, (Licensed Practical Nurse), who stated she has worked at the facility about 1.5 years. She stated she uses insulin pen needles with insulin pens and sometimes they run low, but she just calls the pharmacy and they send more. On 02/28/23 at 10:06 AM, an interview was conducted with Staff B, RN, who stated they now have the insulin pen needles for the insulin pens which had arrived at the facility on 02/27/23 at about 8:00 PM. She stated she discovered she needed to fill out a special request form for the pharmacy to send the insulin pen needles. On 02/28/23 at 1:35 PM, an interview was conducted with the facility's Pharmacist who stated she has been working with the facility since December 2015. When asked about insulin pens and drawing up insulin with an insulin syringe, she stated that per the document located on the website, consumermedssafety.org, it is not recommended to withdraw the insulin from the insulin pen with an insulin syringe because it may lead to inaccurate dosing the next time a pen needle is used with the insulin pen that was previously punctured with the insulin syringe. She stated she would have to look up information by each manufacturer for each specific type of insulin pen the facility uses to get their specifications and/or recommendations for each specific type of insulin pen. On 02/28/23 at 2:45 PM, an interview was conducted with the facility's Pharmacist who confirmed the insulin pens that the facility uses, have no recommendations or specifics to use an insulin syringe to draw up the insulin if there is no insulin pen needle available. She stated in drawing up insulin with a syringe from the insulin pen may lead to inaccurate dosing with future use of the inulin pen using a pen needle if the insulin pen is not properly primed. On 03/01/23 at 8:20 AM, an interview was conducted with the Director Of Nursing (DON), who stated that it is best practice to administer insulin pens with a pen needle attached. On 03/01/23 at 8:35 AM, an interview was conducted with Staff A RN/Wound Care Nurse. He was asked to demonstrate and describe how he would prime the insulin pen. He described the steps to include after placing the needle onto the insulin pen, he would hold the insulin pen with the needle facing downward, and depress the injection button, and would know the insulin pen was primed when he saw a drop of insulin come out of the needle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 2 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observations, records review, and interviews, the facility failed to provide feeding assistance to 1 of 1 sampled resident (Resident #63) during dining, as ordered and required by the resident. Residents Affected - Few The findings included: Review of the clinical record documented Resident #63's diagnoses included Cardiovascular Aneurysm with Hemiparesis, Diabetes Mellitus, Psychosis, Dementia, and Anxiety Disorder. Review of the Annual Minimum Data Set (MDS) section C, dated 12/18/22, documented Resident #63 obtained a score of 11 of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #63 had cognitive deficits. Section G of the form, titled, Functioning Status, documented the resident required supervision for eating and one-person physical assist. Review of the Care Plan (CP), dated 09/15/22 and updated 12/16/22, revealed Resident #63 was at risk for an alteration in: nutrition and/or hydration related to her receiving therapeutic & mechanically altered diet, having poor dentition, requiring staff assistance at meals, and having visual impairment. On 02/27/23 at 1:24 PM, Resident #63 was observed in her room attempting to eat her meal. The resident was observed haphazardly trying to locate the items on her plate with her hands. Further observation noted that Resident #63 was blind. On 02/27/23 at 1:26 PM, Staff F, Certified Nursing Assistant (CNA), entered Resident #63's room and removed the food tray from the resident's table. It was noted that Resident #63 did not eat the food at all. Staff F said the resident told her that she did not like the food. On 02/27/23 at 1:27 PM, an attempt made to communicate with Resident #63 was unsuccessful. Resident #63 did not answer any of the questions she was asked. Resident #63's answers were not coherent, due to possible serious mental illness and cognitive deficits. At 1:28 PM, Staff F said the resident liked sandwiches and she would have the kitchen staff prepare one for Resident #63. On 02/27/23 at 2:20 PM, the Food Service Manager (FSM) was interviewed and stated she did not know that Resident #63 did not eat her meal. She said that she would inquire about it. At 2:23 PM, the FSM stated that Resident #63 was blind and required setup to eat. She said Resident #63 could feed herself and that Resident#63 had asked for a grilled cheese sandwich, which would be prepared for her. On 03/01/23 at 12:33 PM, Resident #63 was observed in the dining room sitting at the table with another resident who was being fed by Staff H, CNA. Resident #63's had on her tray a cheese sandwich and a cup of apple juice. Resident #63 was overheard counting numbers and she was not eating. As this writer approached the Resident's table, Staff H spontaneously left the other resident whom he was feeding and walked over to Resident #63 and asked her, Do you want me to feed you. Resident #63 agreed. Staff F then asked another CNA (Staff G) to come and assist feed Resident #63. After unsuccessfully trying to feed Resident #63, Staff G concluded on 03/01/23 at 12:48 PM the resident did not want to eat the food. Staff G said they would give Resident #63 a peanut sandwich (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 3 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few instead. Staff G stated the resident did not feel well that morning and that might explain her lack of appetite for the food. On 03/02/23, review of the CNAs' documented completed tasks revealed Resident #63 received no assistance during dining on 02/27/23 and 02/28/23 during breakfast & lunch. The resident's dietary care plan, dated 12/30/22, clearly outlined that Resident #63 required one person physical assist during dining. The plan outlined the following: Provide diet as ordered. Offer and provide alternate as needed, honor food preferences. Encourage adequate intake at meals. Encourage adequate fluid intake. Give Supplements as ordered. Observe for signs and symptoms of chewing/swallowing difficulties and aspiration; notify physician if noted. Provide hands on assist with eating at meals and as needed. The support staff provided none of these services on 02/27/23 during lunch, and only attempted to assist the resident on 02/28/23 after observing the surveyor was concerned about the care being provided to Resident #63. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 4 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #20 had a Quarterly Minimum Data Set (MDS) assessment completed on 11/23/22. According to the MDS assessment the resident had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. The MDS assessment indicated that Resident #20 was a smoker. Resident #20 signed the new smoking agreement that indicated smoking materials would be held by the facility. The facility assessed Resident #20 to be a safe smoker at the time of the Quarterly MDS assessment of 11/23/22. Resident #20's care plan, with a review Start Date of 02/23/23, reflected the following Focus: [Resident #20] has been placed on supervised smoking due to the facility new policy and procedure for all residents. He has been evaluated and is able to smoke independently. The following Goal was placed on his Care Plan: Resident will adhere to the smoking policy daily thru the next review date. The following intervention was part of the Care Plan: Maintain smoking materials in designated area. On 02/28/23 at 11:54 AM, during the initial pool process, it was noted that Resident #20 was found outside on the smoking patio. Resident #20 agreed to be interviewed and upon returning to his room Resident #20 removed his package of cigarettes and a lighter from his pocket and placed both on top of his bedside table. When questioned about the facility allowing the residents keep their own cigarettes and lighters in their room, Resident #20 indicated that he was determined safe, so he was able to keep his supplies in his room. During an interview conducted on 03/01/23 at 10:15 AM with the Activities, the Activities Director was asked how the facility keeps the residents' smoking materials including cigarettes and lighters. The Activities Director stated the smoking items were kept in a lock box that is kept in the Social Services office during the day and in a locked closet when smoking hours have ended for the day. The Activities Director showed the locked box to the surveyor. Inside the locked box were packets of cigarettes that were labeled with residents' names and room numbers. The Activities Director explained that she or one her staff will check with the residents every week to see if they have received cigarettes from home or if the residents want the staff to buy more cigarettes. When asked if the locked box contained cigarettes and a lighter for Resident #20, she stated no. The Activities Director was surprised to learn that Resident #20 had his own cigarettes and lighter in his room. The surveyor went with the Activities Director when she went to Resident #20's room. Resident #20 surrendered his cigarette lighter but refused to surrender his cigarette. Resident #20 became offensive and told the Activities Director she could not have his cigarettes, accusing her of attempting to steal his property. The Activities Directory stated that she would need to update the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 5 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0689 care plan and document that the resident is non-complaint. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure smoking evaluations were completed and the care plan was updated related to smoking for 1 of 3 sampled residents reviewed for smoking / accidents (Resident #11), and failed to retain and store all smoking materials for 1 of 3 sampled residents reviewed for smoking / accidents (Resident #20). Residents Affected - Few The findings included: Review of the facility's policy, titled, Smoking Policy-Residents with a revised date of 10/05/22, included: The facility will establish and maintain a safe designated smoking area and safe smoking practices for the residents. Smoking is only allowed in the designated outdoor areas of the facility during designated times. Smoking is not allowed during inclement weather. Oxygen is not permitted within 50 feet from the designated smoking areas. The center will have safety equipment available in designated smoking areas including: a fire blanket, smoking aprons, a fire extinguisher, and non-combustible self-closing ashtrays. All smoking on premises is supervised and during established smoking times. Residents that wish to smoke will have an initial smoking assessment, quarterly with a change in condition, and as needed to determine if assistance and/or supervision is required for smoking. If a resident is identified during the smoking assessment by the interdisciplinary team to require assistance and supervision with smoking, the facility will include the appropriate information in the care plan. The facility will retain and store all smoking materials, including matches, lighters, cigarettes, cigars, and any other smoking implement for all residents who wish to smoke. All resident who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. 1. Record review for Resident #11 revealed the resident was originally admitted to the facility on [DATE] with readmissions in the past year on 05/16/22 and 11/09/22 with diagnoses that included: Type 2 Diabetes Mellitus and Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS), dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had an intact cognitive response. Review of Section G of the MDS, dated [DATE], revealed Resident #11 had a bed mobility self-performance of extensive assistance with support of two plus persons physical assist, transfer self-support of total dependence with support of two plus persons physical assist, dressing self-performance of extensive assistance with support of one-person physical assist, eating self-performance of independent with support of setup help only. Review of Section J of the MDS, dated [DATE], revealed Resident #11's current tobacco use was 'yes'. Review of Resident #11's care plan with a revised date of 11/16/22 and a focus on the resident that included 'desires to smoke'. The care plan included: Resident #11 had been assessed as able to smoke: independently. Resident / responsible party have been informed of the facility smoking policy. Resident has been placed on supervised smoking, due to the facility supervises smoking for all residents. Resident had been evaluated and able to smoke independently. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 6 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0689 Goals documented included: Level of Harm - Minimal harm or potential for actual harm Resident to be monitor by staff at designated time, while out smoking. Resident will demonstrate safe smoking practices thru the next review date. Residents Affected - Few Resident will adhere to the smoking policy daily thru the next review date. Interventions included: Resident may keep her own smoking materials. Accompany resident to designated smoking area as needed. Staff will provide assistance with lighting cigarette as needed and provide redirection if resident is observed in any unsafe smoking practices. To summarize, the smoking care plan for Resident #11 had a goal that included the resident will adhere to the smoking policy with an intervention that the resident may keep her own smoking materials. Review of the record documented a smoking evaluation that was completed on 03/30/22. There were no other smoking evaluations located in the record. During an interview conducted on 03/01/23 at 10:15 AM with the Director of Activities, when asked how they determine which residents are smokers, she said the residents are asked on admission, readmission, quarterly and as needed. She stated as soon as the facility is aware the resident is a smoker, they do a smoking evaluation / assessment and they are conducted on admission, readmission, quarterly and as needed. She stated the will also initiate a care plan for smoking upon determining that the resident is a smoker, and the smoking care plan is updated at least quarterly. When asked if the residents who smoke hold their smoking materials, she stated 'no, the facility holds all smoking materials including cigarettes and lighters'. She stated occasionally a resident will have smoking materials brought in by a family member and the residents are aware that the smoking materials are to be tuned in to any activity staff member or their nurse to be safely stored by the activities department. All of the resident who smoke have signed that they have read or been reads and understand the smoking policy and procedure and will follow it for the safety of all the residents and staff at the facility. When asked if Resident #11 was a smoker, she replied yes, she has been for years. When asked about the smoking evaluations from admission, readmission and quarterly, she stated they are in the electronic medical record for the resident. She then verified on her computer that the resident only had 1 smoking evaluation performed and it was dated 03/30/22. She then stated that there should be many more smoking evaluations for Resident #11. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 7 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure medications were attended and secured related to 1 of 1 sampled resident (Resident #15), failed to secure medications at the bedside for 1 of 1 sampled resident (Resident #42), failed to lock an unattended medication cart, and failed to secure medications being returned to the pharmacy. The findings included: Review of the facility's policy, titled, Storage of Medications with a revised date of November 2020, included: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Unlocked medications carts are not left unattended. 1. During record review for Resident #15, it was revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia and Cochlear Implant Status. Review of Section C of the Minimum Data Set (MDS) for Resident #15, dated 12/19/22, revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. During an observation of medication (med) pass conducted on 02/27/23 at 1:11 PM with Staff A, RN (Registered Nurse) / Wound Care Nurse on the Division-2 med cart for Resident #15, the nurse brought a glass of water and Percocet 5/325mg 1 tab into the resident's room. The resident stated she cannot take the medication with water, water is too thin and needs something thicker to drink. Staff A left the medication with the resident, who was holding the pill in her hand while he went behind the privacy curtain and dumped out the water in the bathroom then proceeded to the medication cart in the hallway, out of view of the resident to obtain some thickened liquid. Staff A brought the thickened liquid back to the resident in her room so she could take the Percocet that she still had in her hand. During an interview 2/27/23 at 1:13 PM with Staff A when asked why he left the medication unattended with the resident, he stated he only came to the medication cart in the hallway for a moment and the resident is alert and oriented so it was okay to leave the medication with the resident. 2. Observation was conducted on 03/01/23 at 10:50 AM of wound care performed by Staff A, RN (Registered Nurse)/Wound Care Nurse, with assistance by Staff B RN for Resident #42. Both nurses washed their hands. The nurse gathered supplies, proceeded to the room, introduced himself to the resident, brought the supplies including the Dakin's' 0.5% solution, collagen powder and Calcium Alginate AG and placed them on the over bed table next to the resident. The privacy curtains were pulled around the resident leaving about an 8 inch gap in the privacy curtains (the privacy curtains were blocking the view of the medications on the over bed table from the resident's bathroom area). Both staff members proceeded to the residents bathroom to wash their hands, leaving the medications next to the resident unsupervised and out of both staff members' sight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 8 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 During an interview conducted on 03/01/23 at 11:15 AM with both Staff A and Staff B, they were asked why when they both went to wash their hands, they both left the medications for the wound care on the overbed table next to Resident #42 unattended and out of their sight, Staff A stated he thought she could see the medications and Staff B said the resident would not be able to grab the medications. 3. During an observation conducted on 02/27/23 at 11:18 AM of the Division-2 Nursing Station with open access by residents and no staff member present at nursing station, there was a cart full of 6 bags for pharmacy. One (1) of the 6 bags was labeled pharmacy returns and was open with numerous medication blister packs inside, and numerous residents sitting in the hall around the corner from the Division 2 Nursing Station. Photographic Evidence Obtained. During an interview conducted on 02/27/23 at 11:29 AM with the Regional Administrator, she verified that the Division-2 nursing station is accessible to residents and there were unsecured medications in bag labeled pharmacy returns in a cart in the Division-2 Nursing Station. She stated they should be in a more secure location and asked a staff member to put the medications in the locked medication room. An interview was conducted on 02/27/23 at 11:35 AM with the Director of Nursing (DON), who stated she put the medications to be returned to the pharmacy behind the Division-2 nursing station on 02/27/23 at 7:30 AM and told Staff A, RN, who was at the Division-2 med cart at that time, that she was leaving the medications to be picked up from pharmacy. 4. During a record review of Resident #30 electronic medical record revealed the resident was admitted to the facility on [DATE] with a most recent readmission on [DATE], with diagnoses that included Metabolic Encephalopathy, Type 2 Diabetes mellitus with Diabetic Peripheral Angiopathy without Gangrene, and Unspecified Dementia. Review of Section C of the Minimum Data Set (MDS) for Resident #30, dated 12/31/22, documented that Resident #30 had a BIMS score of 15, indicating the resident was cognitively intact. Record review of Resident #34 electronic medical record revealed that the resident was admitted to the facility on [DATE] with a most recent readmission on [DATE], diagnoses that included Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene and Schizoaffective Disorder Depressive Type. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #34 had a BIMS score of 15, indicating the resident was cognitively intact. During an observation of med pass conducted on 2/27/23 at 11:07 AM with Staff A, the nurse was observed leaving his Division-2 medication cart unlocked and unattended, to go to a treatment cart approximately 50 feet away from the unlocked and unattended medication cart to obtain a cleaning wipe for a glucometer. Resident #30 was sitting in his wheelchair the entire time next to the medication cart was unlocked and unattended. Also, Resident #34 came into the hallway and stopped at the unlocked and unattended medication cart on 02/27/23 at 11:08 AM. During an interview conducted on 02/27/23 at 11:09 AM with Staff A, he acknowledged he left med cart unlocked and unattended and said he only left for a moment and should not have done that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 9 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the approved menu and failed to periodically update the menu for 6 of 52 sampled residents on a Regular Diet (sampled Residents #30, #29, #276, #72, #71, #32); 5 of 14 sampled residents on a Mechanical Soft Diet (sampled Residents #15, #4, #64, #42, #63); 1 of 4 sampled residents on a Pureed Diet (sampled Resident #9); and 1 of 4 sampled residents on a Renal Diet (sampled Resident #9). The findings included: 1. During review of the Approved Menu for the lunch meal of 02/27/23, the following was noted: *3-ounce portion of Honey Glazed Ham to be served to Regular Diet *3-ounce portion of Beef Steak to be served as alternate entree for Regular Diets *Seasoned Roasted Potatoes - to be served to Regular diets. Further review noted no documentation that the mashed potatoes were documented to be served to Mechanical Soft Diets, Purred Diets. Observation of the lunch tray line in the Main Kitchen on 02/27/23 at 11:30 AM, accompanied with the Certified Dietary Manager (CDM) noted the following: At the request of the surveyor, a random portion of the entrees of the Glazed Ham and Beef Steak were weighed on the facility's commercial portion scale. The weights were recorded as follows: Glazed Ham = 2.4 ounces Beef Steak = 2.2 ounces. An interview with the CDM at the time of the observation noted that she was unaware that the portion size of the Glazed Ham and Beef Steak were insufficient and did not meet the documented portion size to be served as per the approved menu. Interview with the Dietitian and CDM at the time of the meal observation noted that the Instant Mashed Potatoes were being served to Pureed Diets and Mechanical Soft Diet. It was discussed that since the Regular Diets received fresh/frozen Roasted Potatoes that the Mechanical Soft and Purred Diets should have been prepared using the same potatoes to ensure that all residents were receiving fresh foods. 2. Review of the approved menu for the lunch meal of 03/02/23 noted the following: *Breaded Fish (Alternate Entree) - no portion size indicated *Breaded Pork - no portion size documented to be served to Renal Diets. *Pureed Garlic French Bread - 4-ounce portion to be served to pureed diets. *1 each Garlic Toast to be served to Mechanical Soft Diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 10 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0803 *1 Each Pound Cake serving to be served to Regular and Therapeutic Diets. Level of Harm - Minimal harm or potential for actual harm *Spaghetti & Meatballs - no portion size documented to be served to Regular Diets and Mechanical Soft Diets. Residents Affected - Some Observation of the tray line assembly in the main kitchen on 03/01/23 at 11:30 AM, accompanied with the Consultant Dietitian and CDM noted the following: At the request of the surveyor, the entree as an average portion of the Breaded Pork Chop and and Breaded Fish Fillet, were weighed. The weights were recorded as follows: Breaded Pork Chop = 3 ounces Breaded Fish Fillet = 3 ounces. It was reviewed with the Dietitian and CDM that the menus are based on a 3-ounce portion entree and that the Pork and Fish were only providing a 2 once portion of protein. It was also reviewed that the 'Breaded' on the Fish and Pork was estimated at 2 ounces per entree portion. Observation of the lunch meal and interview with the CDM noted that the Garlic French Bread and Garlic Toast documented on the approved menu was not prepared or served to Pureed and Mechanical Soft Diet. diets. Review of the facility's 'Next Level approved Diet Manual' documented that the Renal diet may receive up to 3 servings of canned tomato sauce per week. Interview with the Dietitian and CDM noted that the meatballs could have been included on the Renal Diet. Residents with physician ordered renal diets were not receiving any canned tomato on the weeks approved menu. Interview with Resident #30 on 03/01/23, noted to be following a Renal Diet, stated his preference would be the meatballs in place of the Breaded Pork Chop. Observation and interview noted that Plain [NAME] Cake was being served to Regular and Therapeutic Diet residents. Interview conducted at the time of the observation with the CDM noted that Pound Cake was not included on the specific ordering purveyor catalog. The surveyor informed the CDM that cake was served as dessert for the lunch meal of 02/27/23. Interview with the Dietitian and CDM during the lunch meal observation noted the entree serving size for the Meatballs & Spaghetti failed to be documented on the approved menu. 3. Review of the Resident Diet Census for 02/27/23 noted the following: *52 Physician ordered Regular Diets: included sampled Residents #30, #29, #276, #72, #71, #32. *14 Physician ordered Mechanical Soft Diets: included Sampled Residents #15, #4, #64, #42, #63. *4 Physician ordered Puréed Diets: included Sampled Resident #9. *4 Physician ordered Renal Diets: included Sampled Resident #30. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 11 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide special eating equipment and utensils for 1 of 5 sampled residents reviewed for nutrition (Resident #32). Residents Affected - Few The findings included: During the review of the clinical record of Resident #32 on 02/27/23, the following was noted: Date of re-admission [DATE] Diagnoses included: Heart Failure, ASHD (Atherosclerotic Heart Disease), Vitamin Deficiency, Altered Mental Status, Contracture of Right Hand, and Dysphagia. The current physician orders included: 01/16/21: No Added Salt Diet 03/11/22: Built-Up Utensils with Meals 02/27/23: Divided Plate with Meals. Weight History: 02/8/23 = 158 pounds 01/5/23 = 161 pounds 12//9/22 =162 pounds Ht (height) = 72 inches BMI (body mass index) = 21.4 (Nutritional Risk). MDS: Dated 02/10/23 (Quarterly Assessment) documented: Sec C= BIMS (Brief Interview for Mental Status) =6 (severe cognitive impairment ) Sec D: Low Interest, feeling depressed, Sec G: Eat = Supervision with eating Sec K: No Swallow Issues, 72 inches / 158# (pounds), Unknown wt [weight] loss, Therapeutic Diet Sec M: Risk For Pressure Ulcer. Progress Note: dated 02/15/23: Quarterly review, resident would benefit from a slow weight gain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 12 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0810 toward a healthier BMI range. Level of Harm - Minimal harm or potential for actual harm Care plan, dated 02/10/23, documented the following: Risk For Alteration in Nutrition: Residents Affected - Few Provide adaptive equipment as ordered (Specifics for the Built-Up Utensils were not documented and the care plan was not updated to include the Divided Plate with all meals. Observation conducted on 02/28/23 at 8:00 AM noted the breakfast meal tray was delivered to the room of Resident #32. Review of tray card documented only: No Added Salt diet, and Built-Up Utensils (Fork, Knife, and Spoon). Continued observation noted that a Divided Plate was not provided and only a Built-Up fork and spoon was provided. A Built-Up knife was not provided. The resident was alert with some confusion and able to eat independently with set up and the Divvied Plate would help in continued independent eating. Resident #32 was noted to be able to use both hands when eating and could benefit with the use of a Built-Up Knife to cut entrée of Biscuits and Sausage Gravy. Photographic Evidence Obtained Observation of the lunch meal on 03/01/23 at 12:00 PM again noted a lunch meal tray was delivered to the room of Resident #32. Further observation noted the tray did not included a divided plate and a Built-Up Knife. The surveyor requested the Certified Dietary Manger to view the resident's lunch tray and confirmed the findings with the surveyor. Photographic evidence obtained. Observation conducted on 03/2/23 at 8:15 AM noted the resident's meal tray card did not document to include a Divided Plate. The Built-Up utensils were provided. Interview, conducted with the Certified Dietary Manage (CDM) on 03/02/23 ay 10:00 AM, noted that the Built-Up utensils failed to be provided on observed meal trays. The CDM further stated that the dietary department was not notified by department communication form by Skilled Therapy that Resident #32 was assessed to require a Divided Plate and ordered by the physician on 02/27/23. Interview with the Director of Skilled Therapy on 03/01/23 at 11:00 AM confirmed the resident was assessed as to require a Divided Plate to assist in independent eating, and that the Skilled Therapy department failed to notify the Dietary Department via Department Communication Form on 02/27/23 of the physician's order for the Divided Plate with all meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 13 of 14 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain mechanical and electrical equipment in the main kitchen in a safe operating condition. Residents Affected - Some The findings included: During a second kitchen / food service observation tour conducted on 02/28/23 at 11:30 AM and accompanied with the Certified Dietary Manager (CDM), the following were noted: 1. The wall mounted air-conditioning unit located near the dish machine was steadily dripping condensation. Further observation noted the dripping condensation had pooled and was dripping further down onto the dish machine run. It was discussed with the CDM the potentially contaminated condensation could come into contact with clean dishes and staff. The surveyor requested the unit be shut down and repaired prior to further use. It was also reviewed that the unit required to be moved to different location within the kitchen that is not threat to to food or dish contamination. 2. Observation of the exhaust hood system noted a [NAME] pipe ran from the commercial steamer up into the hood exhaust unit. Further observation noted that the steam blowing into the hood melted the grease on the unit's surface. It was noted the hood system did not contain a basin to catch the grease. It was further noted the grease was dripping down onto the food preparation equipment and was a potential for food borne illness. An interview with the facility's administration team at this time revealed that steam pipe exhaust was never completed and that a catch basin was never installed into the exhaust hood. 3. Observation of the ceiling exhaust noted there was a screen covering the exhaust vent. Further observation noted the screen was covered with dead insects. Further observation noted the vent was located near / over the dish machine room and food preparation area sink area, and the clean food transportation carts. Interview with the CDM at the time of the observation revealed the screen requires cleaning daily and it was not being done by the maintenance staff. It was also reviewed with the CDM that the dead insects could fall into clean dishes, clean carts, and prepared foods. 4. Observation of the kitchen ceiling noted there was a large section of peeling paint. Further observation noted the ceiling area was directly near the dish machine room and food preparation sink. The surveyor requested the ceiling be repaired and to ensure that clean dishes and foods are not located below the peeling ceiling area until repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 14 of 14