Inspection·May 16, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to provide housekeeping and maintenance services in order to maintain a clean, comfortable, sanitary and home like environment in 9 of 30 rooms and the Community Shower Room. The findings included: On 05/16/24 at approximately 2:00 PM, an environmental tour was conducted with the Director of Maintenance. The following was observed: a. In room [ROOM NUMBER], the hand washing sink in the bathroom was clogged in a manner that the basin was slow to drain. b. In room [ROOM NUMBER], the toilet was clogged and the faucet at the hand washing sink was not secured to the sink. c. In room [ROOM NUMBER], there was no drain plug in the tub to allow the tub to hold water, and there was duct tape covering a screen on the sides of the window mounted air conditioning unit. d. In room [ROOM NUMBER], the basin and faucets of the tub and the were dirty and there were urinals in need of being changed. e. In room [ROOM NUMBER], the surface of the over bed table for the door bed was worn to a point that the particle board underneath was exposed. f. In room [ROOM NUMBER], there was no overbed table provided to the resident in the door bed. g. In room [ROOM NUMBER], there was duct tape covering screens on the sides of the window mounted air conditioning unit. h. In room [ROOM NUMBER], the rails that were attached to the seat of the toilet were loose to a point that they were not sturdy and the residents would not be able to rely on the rails for support while toileting. i. In room [ROOM NUMBER], there was an accumulation of debris on the floor under the bed. j. In the Community Shower Room, there was an odor similar to smell of sewage from the shower and sinks. At the conclusion of the tour, the Director of Maintenance acknowledged understanding of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 2 of 26 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 05/16/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review and observation, the facility failed to maintain residents' fingernails for 2 of 6 sampled residents identified with long fingernails, Resident #45 and Resident #48. Residents Affected - Few The findings included: The facility's policy, titled, Fingernails/Toenails Care, from MED-PASS, Inc, (Revised February 2018), under General Guidelines, item 3 documented in part, Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. a. On 05/13/24 at 3:28 PM, an interview was conducted with Resident #45. At that time, it was noted that Resident #45 had fingernails that extended past his fingertips by about ½ inch, on both hands. When asked about the length of the fingernails, Resident #45 stated he would like to have his nails trimmed. On 05/15/24 at 10:02 AM, a second observation was made, and it was noted that Resident #45 still had untrimmed fingernails. On 05/16/24 at 2:30 PM, Resident #45 showed the surveyor that his fingernails had now been trimmed. The resident stated that the staff had trimmed his nails, and he was satisfied with the result. b. On 05/13/24 at 1:06 PM, an interview was conducted with Resident #48. At that time, it was noted that the resident had fingernails at least ½ inch beyond his fingertips. When asked if he was okay with the length of the fingernails, the resident stated he was not. When asked if he wanted them trimmed the resident stated yes, but they won't do it here (in the facility). The resident stated he has paid for someone to do it in the past. On 05/15/24 at 3:00 PM, an interview was conducted with Resident #48 who expressed that his nails were still not trimmed but he was going to ask the staff for it later. 05/16/24at 2:59 PM, an interview was conducted with Resident #48 regarding his fingernails. The resident revealed his fingernails were now trimmed and the resident was satisfied with the result. On 05/16/24 at 09:19 AM, an interview was conducted with Staff C, Certified Nursing assistant (CNA), who stated the Activities staff does the fingernail trimming but the responsibility for ensuring it is done falls to the nurses and CNAs. Staff C also stated the residents can ask for the nails to be trimmed themselves if they are capable, but the CNAs and nurses are responsible for noting when the nails need to be trimmed. The CNA stated she believed they were not allowed to trim the fingernails for Diabetic residents. She stated they were not allowed to trim toenails for Diabetics but she thought the same was true for fingernails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 3 of 26 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 05/16/2024 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** Based on observations, interviews and record reviews, the facility failed to ensure the safe transfer for 1 of 27 sampled residents, Resident #18, resulting in skin damage to the resident; and failed provide devices to ensure the safety of the resident while smoking for 1 of 2 sampled residents reviewed for smoking, Resident #80. The findings included: 1. Resident #18 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE] documented Resident #18 was not assessed for cognition due to 'resident is rarely/never understood'. The MDS documented Resident #18 was dependent upon staff for all Activities of Daily Living (ADLs) and was 'always incontinent' of urine and bowel. Resident #18's diagnoses at the time of the assessment included: Anemia, Atrial fibrillation, Hypertension, Orthostatic hypotension, Peripheral Vascular Disease (PVD), Gastro-esophageal reflux disease (GERD), Obstructive uropathy, Hyperkalemia, Aphasia, Cerebral Vascular Accident (CVA), Quadriplegia, Seizure disorder, Traumatic brain injury, Anxiety disorder, Depression, Cataracts, Encephalopathy, Anoxic brain damage, Idiopathic Peripheral Autonomic Neuropathy, Dysphagia, Contracture of muscle, Pain, open wound to right foot, Personal history of Methicillin Resistant Staph Aureus (MRSA). An interview was conducted with Resident 18's sister, 05/13/24 at 1:35 PM, who stated, on 04/24/24, I came in and he had a scrape on his arm. I was told that his shirt was wet from his feeding tube and they had to change his shirt and that was when she [referring to a Certified Nursing Assistant (CNA)] noticed a 4-inch cut that went to the white meat. I went to the Director of Nursing [DON] she told me that it was pressure (left elbow). I was fine until they told me that it was pressure, there is no pressure on his elbow [Left]. I called the police and he made a report that I am not privy to. They are unable to give me an accurate description of what happened and how he got the big tear on his arm. I called [another agency] for the tube feeding incident and the skin tear. Review of the record documented physician orders that included: 05/06/24 - Cleanse Left Elbow with Normal Saline, pat dry, apply Silverdene Cream I% to affected area, cover with dry protective dressing three times a week until resolved - every day shift every Mon, Wed, Fri [Monday, Wednesday, Friday] for Skin Abrasion. Review of the Nurse note, dated 04/26/24 at 19:31 [7:31 PM], documented, Note Text: All medication and treatment provided to patient on day shift by writer and CNA. Dressing to Left elbow was completed, feedings done and tolerated well. Resident placed in bed and in comfortable position, safety measures are in place, call light within reach. Patients mother and sister came to visit resident on day shift all questions and concerns addressed. Will continue to monitor resident. Review of the Nurse note, dated 04/26/24 at 16:00 [4:00 PM], documented, Note Text: in geri-chair at this time. Sister in room visiting states that she removed dressing to resident's left elbow. On assess shearing noted to left elbow. Treatment in place and consult for Wound care eval [evaluation] with [name of group] wound care group. Dressing reapplied. No grimacing noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 4 of 26 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 05/16/2024 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 Review of the Nurse note, dated 04/24/24 at 14:40 [2:40 PM], documented, Note Text: This writer called to room by aide to observe open area to resident left elbow. Upon further assessment resident has bilateral hand and forearm contracture. Open area located on the under surface of left elbow. Resident mother present at bedside and verbally notified. This writer cleansed area with normal saline and covered with dry protective dressing. Demonstrates no evidence of pain at this time. MD notified and treatment orders received and initiated. An interview was conducted on 05/16/24 at 12:32 PM with the Director Of Nursing (DON). When asked about the open area to Resident #18's left arm, the DON replied, the CNA was in the room transferring the resident via hoyer with the assistance of his mother. He got some shearing on his elbow from the hoyer lift pad. I asked the aide and she said that his mother was helping. I asked her why the mother was helping and why staff was not and she could not answer me. I called in the staff that worked 3-11 [PM] and 11-7 [PM, AM] and they all said that they did not see anything. The shift that reported was the 7-3 [AM, PM] shift. She said that the mother was in the room, so she asked for help. We don't have a policy for 2 persons hoyer lift. Safety wise, they should use 2 people on the hoyer lift - staff members. We don't have a policy on the hoyer lift. An interview was conducted on 05/16/24 at 3:42 PM with the Social Services Director [SSD] and the Administrator. When asked about staff transferring Resident #18 via the hoyer lift, the SSD replied, Staff H, CNA, was giving care and transferred him from the bed to the chair. During our investigation, it was found out that she did it alone, this is the first I am hearing of the resident's mother helping. I was told that the mom was present. When she was doing the transfer, she noticed the opening. We are assuming that the sling went up and caused the abrasion. There was no other opportunity for it to happen. She [CNA] felt like she was comfortable to do it alone and while the mom was there. She didn't want to wait for anyone to come and help. The DON reported to me [SSD]that she felt that she could do it herself. Staff D was not available for interview due to being out of the country. 2. The facility's policy, titled, Smoking Policy - Residents, most recently revised on 10/05/22, documented, in part: The center will establish and maintain a safe designated smoking area and safe smoking practices for the residents .The center will have safety equipment available in designated smoking areas including: a fire blanket, smoking aprons, smoking aprons, a fire extinguisher, and non-combustible self-closing ashtrays. Record review documented Resident #80 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, an admission MDS, dated [DATE], documented Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Resident #80's diagnoses at the time of the assessment included Heart Failure, Hypertension, PVD, GERD, DM, Anxiety disorder, Depression, Post-Traumatic Stress Disorder (PTSD), Chronic lung disease, Acute Respiratory Failure with hypoxia, Pain in thoracic spine, Hereditary and idiopathic neuropathy, Nicotine dependence, Morbid Obesity due to excess calories, Disorder of adrenal gland, Absence of left leg below the knee, Achalasia of Cardia, Chronic pain syndrome, Impingement syndrome of right shoulder. Review of the Smoking evaluation, dated 04/18/24, documented: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 5 of 26 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 05/16/2024 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 Resident Smokes safely - Yes. Level of Harm - Minimal harm or potential for actual harm Resident must wear smoking apron at all times. Residents Affected - Few Resident #80's care plan for smoking, initiated on 04/26/24, documented, Resident desires to smoke. Resident has been assessed as able to smoke: with supervision; Resident has been informed of the facility smoking policy. The goal of the care plan was documented as, Resident will demonstrate safe smoking practices through the next review date 04/26/24 with a target date of 07/25/24. Interventions to the care plan included: Apply/remove smoking apron. On 05/13/24 at 10:45 AM, six residents were observed in the designated smoking area with the Activities Director, including Resident #80. It was noted that none of the residents were provided with a smoking apron. On 05/15/24 at 9:04 AM, five residents were observed on the smoking patio, including Resident #80 with supervision provided by Staff D, CNA. It was noted that none of the residents were provided a smoking apron. An interview was conducted on 05/15/24 at 1:48 PM with Resident #80, who when asked stated she has never been offered apron and was not aware of the benefits, Resident #80 further stated, Sometimes I get distracted by watching on my phone and I drop ashes. An interview was conducted on 05/15/24 at 3:36 PM with the Activities Director, who when asked about the smoking aprons, stated, we keep them (aprons) in the Activities closet. We bring them for the residents who need them. We leave them on Division 2 when we leave. An interview was conducted on 05/15/24 at 3:43 PM with the Staffing Coordinator, who when asked, was unable to locate smoking aprons at nurse's station. An interview was conducted on 05/15/24 at 3:53 PM, with Staff E, Licensed Practical Nurse / Nursing Supervisor, who when asked about the residents using smoking aprons, Staff E stated, We have 2 patients that need them, Resident #53 and Resident #80. When Activities leave, they bring the aprons and cigarettes to the nurses' station for the evening nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 6 of 26 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 05/16/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and record reviews, the facility failed to assess a resident for the risks associated with the use of bed rails, obtain physician's orders for the use of bed rails, and initiate a care plan for the use of bed rails for 1 of 2 sampled residents reviewed for the use of bed rails, Resident #134. The findings included: The facility's policy, titled, Bed Safety and Bed Rails, revised August 2022, documented, in part: Use of Bed Rails 5. If attempted alternatives do no adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs. b. the resident's risk associated with the use of bed rails. c. input from the resident and/or responsible party. d. consultation with the attending physician. 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: (2) The resident or part of his/her body could be caught between rails, the openings, or between the bed rails and mattress. Record review documented Resident #134 was admitted on [DATE]. Review of the resident's most recent full assessment, an admission Minimum Data Set (MDS), dated [DATE], documented Resident #134 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented the resident was dependent on staff for transfer and bed mobility, was frequently incontinent of urine and was always incontinent of bowel. Resident #134's diagnoses at the time of the assessment included: Anemia, Hypertension, Gastro Esophageal Reflux Disease, Hyperlipidemia, Malnutrition, Chronic Lung Disease, Dependence on Renal Dialysis, Thrombosis due to Vascular Prosthetic, Kidney Transplant Rejection, Toxic Nephropathy, Vitamin D deficiency, and Hypocalcemia. Review of Resident #134's care plan for Activities of Daily Living (ADLs), initiated on 04/26/24, documented, Resident has a selfcare deficit with dressing, grooming, bathing as evidenced by needs assistance with personal care tasks mobility and transfer skills. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 7 of 26 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 05/16/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The goal of the care plan was documented as, Resident will have clean, neat appearance daily thru the next review date; date of 04/26/24 with a target date of 05/28/24. An intervention to the care plan included: May use 1/4 side rails X2 as an enabler for bed mobility. On 05/14/24 at 9:48 AM, Resident #134 was observed in bed with half side rails on the bed. During an interview with the resident and the spouse, when asked about the use of the bed rails, Resident #134 replied, they keep me from falling out of the bed. Resident #134 further stated the bed rails were provided per his request. Review of Resident #134's medical record revealed the resident had not had the bed assessed for the risks associated with the use of the rails. There was no care plan and there were no physician orders for the use of the rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 8 of 26 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 05/16/2024 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 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 record review, interview, and policy review, the facility failed to follow physician's orders related to the timing for administration of medication for 3 of 6 sampled residents, Residents #19, #63 and #68, as evidence by: Resident #19 was receiving two medications with a potential drug to drug interaction, in which nursing staff failed to administer at the ordered time; and Residents #63 and #68 complained medications were not provided timely. The findings included: Review of the policy, titled, Administering Medications, revised April 2019 documented, in part, . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of the record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses to include major depression and anxiety disorders. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 was receiving both an antianxiety medication and an antidepressant. Review of the current orders revealed Resident #19 was receiving the antidepressant medication mirtazapine 15 milligrams (mg) which was ordered at bedtime, and scheduled for 9:00 PM. Resident #19 was also receiving the antianxiety medication alprazolam 0.25 mg which was ordered for the evening at 6:00 PM. The order for the alprazolam specifically documented, Please do not administer with mirtazapine. Review of the corresponding Medication Administration Record (MAR) documented Resident #19 was receiving both medications at 9:00 PM. During a side-by-side record review and interview on 05/16/24 at 1:18 PM, when asked about the timing of the mirtazapine and alprazolam, Staff E, Licensed Practical Nurse (LPN)/Unit Manager, agreed with the concern and identified the staff who entered the alprazolam order scheduled it for 9:00 PM, instead of 6:00 PM, upon admission on [DATE]. 2. Review of the record revealed Resident #63 was admitted to the facility on [DATE]. Review of the current admission MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 05/13/24 at 11:38 AM, Resident #63 stated he was not getting his night medications at bedtime, but was getting them whenever staff wanted. The resident stated his bedtime medications were given anywhere from 6:30 PM to after midnight. Review of the current orders revealed Resident #63 had the following medications ordered for bedtime, which was scheduled for 9:00 PM: a) Trazodone 25 mg, an antidepressant ordered to help with sleep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 9 of 26 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 05/16/2024 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 0755 b) Flonase Allergy Relief nasal spray. Level of Harm - Minimal harm or potential for actual harm c) Risperidone 1 mg, an antipsychotic medication. Residents Affected - Few Review of the May 2024 Medication Administration Record (MAR) documented these three medications were documented as ordered, as evidenced by a checkmark at the 9 PM time-slot, and with the nurse's computer identification. Review of the Administration Detail for these three medications revealed the timestamp as to when the medication was documented as administered and was as follows: 05/02/24 at 10:59 PM, 05/04/24 at 12:44 AM, 05/06/24 at 3:12 AM, 05/07/24 at 12:06 AM, 05/08/24 at 12:42 AM, 05/09/24 at 2:58 AM, 05/10/24 at 12:09 AM, 05/11/24 at 11:17 PM and 12:15 AM, 05/14/24 at 2:26 AM, and 05/15/24 at 2:38 AM. Upon receipt of the Administration Detail from the Consultant Nurse on 05/16/24, she agreed with the findings. 3. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Generalized Anxiety Disorder Major Depressive Disorder, Insomnia, and Attention Deficit Hyperactivity Disorder (ADHD) Predominately Hyperactive Type. Review of the Minimum Data Set (MDS) for Resident #6 dated 02/23/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. Review of the Physician's Orders for Resident #68 revealed an order dated 05/25/23 for Dextroamphetamine Sulfate 10 MG give 2 tablet by mouth three times a day (6:00 AM, 12:00 PM, and 4:00 PM) for ADHD. Review of the Physician's Orders for Resident #68 revealed an order dated 03/28/23 for Bupropion HCl Extended Release 24 Hour 150 MG give 3 tablet by mouth one time a day for depression. Review of the Physician's Orders for Resident #68 revealed an order dated 05/03/24 Lunesta Oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 10 of 26 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 05/16/2024 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 0755 Tablet 3 MG give 3 mg by mouth at bedtime for Insomnia. Level of Harm - Minimal harm or potential for actual harm Further review of the Physician's Orders for Resident #68 revealed an order dated 05/06/24 Xanax Oral Tablet 1 MG give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 Days. Residents Affected - Few Further review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Outcome codes: Improved=[+], Unchanged=[0], worsened=[W] every day and night shift for monitoring. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Intervention Codes: 0= None/ no behaviors noted 1= Redirect 2= 1:1 3= Ambulate/ Exercise 4= Diversion Activity [CP] 5= Give food/ fluids 6= Toileting 7= Repositioned 9= Removed stimulus 10= Psych. Eval 11= Re-approach 12= Other every day and night shift for Monitor. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Medication Management: Diagnosis (Dx) Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every day and night shift for Monitor. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for side effects related to psychoactive medication: 0= None 1= movement side effects 2= non-movement side effects every day and night shift for Monitoring. Review of the Medication Administration Record (MAR) for Resident #68 for the month of May revealed the Dextroamphetamine Sulfate was administered three times (6:00 AM, 12:00 PM, and 4:00 PM) as ordered. Review of the Medication Actual Administrated times for Resident #68 for Dextroamphetamine Sulfate for the month of May 2024 documented the following: for 9 times out of 45 opportunities the medication was given more than 1 hour late. This included on 05/09/24 when the medication was scheduled for 6:00 AM and was given at 8:02 AM, indicating over 2 hours late. An interview was conducted on 05/13/24 at 9:50 AM with Resident #68 who stated they do not give her the ADHD medications like they are supposed to be given as they are often late and she needs the medication on time or it interferes with her sleep. An interview was conducted on 05/15/24 at 11:35 AM with the Director of Nursing who was asked about medication administration. She said medications are administered as prescribed. When asked what is an acceptable time to give scheduled medications, she said generally it is within an hour to the medication scheduled time. During an interview conducted on 05/16/24 at 9:30 AM with the Director of Nursing and the Regional Clinical Consultant who were asked about Resident #68 and the medication Dextroamphetamine Sulfate when shown the actual medication administration documented time, they acknowledged the medication was given several times outside of the hour before or after the scheduled times. On 05/16/24 at 12:45 PM, an interview was conducted with the Licensed Practical Nurse / LPN who stated she works a 12-hour shift at the facility. When asked if she documents behaviors for the residents who are on any psychotic medications, she said yes, every shift we document behaviors, even if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 11 of 26 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 05/16/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they have no behaviors, we document that as well. When asked where this is documented, she said on the behavior monitoring flowsheet in the Medication Administration Record. When asked about medication administration, she said we have an hour before and an hour after the medication scheduled time to give the medication. On 05/16/24 at 1:00 PM, an interview was conducted with the Registered Nurse / RM who stated she works a 12-hour shift at the facility. She was asked if she documents behaviors for residents who are on any psychotic medications, she said she documents behaviors every shift. When asked where this is documented, she said it is on the MAR (Medication Administration Record). When asked about medication administration, she said we give the medications when they are scheduled. When asked if she did not administer a medication at the exact time, what was acceptable to be considered administered on time, she said it can be an hour before or after the scheduled time. An interview was conducted on 05/16/24 at 1:50 PM with the Consultant Pharmacist who was asked about the medication Dextroamphetamine Sulfate. He stated the medication is a stimulant and he would expect it to not be given later than 6:00 PM or it may interfere with sleep. When asked about Resident #68 having the medication ordered 3 times per day with last dose scheduled for 4:00 PM and given as late as 8:00 PM, he acknowledged it would most likely interfere with this resident's sleep. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 12 of 26 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 05/16/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the pharmacist failed to identify a timing issue with a possible drug to drug interaction for 1 of 5 sampled residents, Resident #19. The findings included: Review of the record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses to include major depression and anxiety disorders. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 was receiving both an antianxiety medication and an antidepressant. Review of the current orders revealed Resident #19 was receiving the antidepressant medication mirtazapine 15 milligrams (mg) which was ordered at bedtime, and scheduled for 9:00 PM. Resident #19 was also receiving the antianxiety medication alprazolam 0.25 mg which was ordered for the evening at 6:00 PM. The order for the alprazolam specifically documented, Please do not administer with mirtazapine. Review of the corresponding Medication Administration Record (MAR) documented Resident #19 was receiving both medications at 9:00 PM. During a side-by-side record review and interview on 05/16/24 at 1:18 PM, when asked about the timing of the mirtazapine and alprazolam, Staff E, Licensed Practical Nurse (LPN)/Unit Manager, agreed with the concern and identified the staff who entered the alprazolam order and scheduled it for 9:00 PM, instead of 6:00 PM, upon admission on [DATE]. Pharmacy reviews from January 2024 through April 2024 lacked any recommendations for Resident #19. During a phone interview on 05/16/24 at 3:32 PM, when asked if he identified that both mirtazapine and alprazolam where being administered at the same time, despite the fact that the order documented not to do so, the Consultant Pharmacist stated it was overlooked. When asked why the medications were not to be administered at the same time, the Consultant Pharmacist explained given together may cause added sedative affects, CNS (Central Nervous System) depression, and respiratory depression. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 13 of 26 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 05/16/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review revealed Resident #19 was admitted to the facility on [DATE]. Review of the current orders revealed the resident was currently taking an antidepressant and an antianxiety medication. Further review of the orders revealed as of 01/08/24 nursing staff was to monitor for resident behaviors twice daily on day and night shifts, and document any intervention provided and outcomes, and monitor for side effects of these medications. Review of the current May 2024 Behavior Monitoring Flow sheet revealed a lack of monitoring on the 05/01/24 day shift, 05/06/24 day shift, 05/07/24 day shift, 05/08/24 day shift, 05/13/24 night shift, and the 05/14/24 night shift. This resulted in a failure to monitor behaviors on 6 of 29 shifts. Review of the April 2024 Behavior Monitoring Flow Sheet revealed a lack of monitoring on the folowing shifts: 04/02/24 day shift, 04/03/24 night shift, 04/07/24 day shift, 04/08/24 both shifts, 04/09/24 both shifts, 04/10/24 day shift, 04/13/24 day shift, 04/14/24 night shift, 04/16/24 day shift, 04/17/24 night shift, 04/22/24 both shifts, 04/23/24 day shift, 04/24/24 both shifts, 04/26/24 day shift, 04/26/24 day shift, 04/29/24 day shift, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 14 of 26 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 05/16/2024 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 0758 04/30/24 day shift. Level of Harm - Minimal harm or potential for actual harm This resulted in a failure to monitor behaviors on 20 of 60 shifts. Residents Affected - Few Based on interviews and record reviews the facility failed to monitor behaviors as ordered by physician related to psychotropic medications for 5 of 6 sampled residents reviewed for medications, (Residents #35, #64, #68, #236, and #19). The findings included: Review of the facility's policy, titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, included, in part, the following: Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. 1. Record review for Resident #35 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE], with diagnoses that included Lymphedema, Major Depressive Disorder, and Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #35 dated 02/16/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition is intact. Review of the Physician's Orders for Resident #35 revealed an order dated 09/06/23 for Medication Management: Dx. Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other. Review of the Physician's Orders for Resident #35 revealed an order dated 09/06/23 for Outcome codes: Improved=[+], Unchanged=[0], worsened=[W] every day and night shift for monitoring. Review of the Behavior Monitoring Flow Sheet for Resident #35 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented for 8 of 30 opportunities. 2. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Generalized Anxiety Disorder Major Depressive Disorder, Insomnia, and Attention Deficit Hyperactivity Disorder (ADHD) Predominately Hyperactive Type. Review of the MDS assessment for Resident #68 dated 02/23/24 revealed, in Section C, a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Medication Management: Dx Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every shift for Monitor. Review of the Behavior Monitoring Flow Sheet for Resident #68 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented 15 of 30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 15 of 26 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 05/16/2024 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 0758 opportunities. Level of Harm - Minimal harm or potential for actual harm 3. Record review for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder, Unspecified Mood Disorder, and Unspecified Psychosis. Residents Affected - Few Review of the MDS assessment for Resident #64 dated 04/18/24 revealed, in Section C, a BIMS score of 5 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #64 revealed an order dated 01/13/23 for Medication Management: Dx. Mood Disorder/Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every shift for Monitor. Review of the Physician's Orders for Resident #64 revealed an order dated 01/10/23 for Intervention Codes: 0= None/ no behaviors noted 1= Redirect 2= 1:1 3= Ambulate/ Exercise 4= Diversion Activity [CP] 5= Give food/ fluids 6= Toileting 7= Repositioned 9= Removed stimulus 10= Psych. Eval 11= Re-approach 12= Other every shift for Monitor Review of the Behavior Monitoring Flow Sheet for Resident #64 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented 20 out of 45 opportunities. 4. Record review for Resident #236 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Major Depressive Disorder, and Unspecified Psychosis. Review of the MDS for Resident #236 dated 05/13/24 revealed in Section C, a BIMS score of 0 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #236 revealed an order dated 05/14/24 for Medication Management: Dx. Mood Disorder/Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every shift for Monitor. Review of the Physician's Orders for Resident #236 revealed an order dated 05/14/24 for Intervention Codes: 0= None/ no behaviors noted 1= Redirect 2= 1:1 3= Ambulate/ Exercise 4= Diversion Activity [CP] 5= Give food/ fluids 6= Toileting 7= Repositioned 9= Removed stimulus 10= Psych. Eval 11= Re-approach 12= Other every shift for Monitor Review of the Behavior Monitoring Flow Sheet for Resident #236 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented 2 out of 3 opportunities. An interview was conducted on 05/16/24 at 12:00 PM with the Director of Nursing and Regional Clinical Conslutant, who acknowledged the behavior monitoring for Residents #35, #64, #68, #236 were not documented as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 16 of 26 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 05/16/2024 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 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 interview and record review, the facility failed to ensure accuracy of records for 1 of 3 sampled residents, reviewed as closed records, Resident #83, as evidenced by failure to ensure accurate documenation in the residnet's record that reflected the resident's discharge. The findings included: Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Anxiety Disorder, Alcohol Abuse, and Nicotine Dependence of Cigarettes. Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 01/29/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive response. Review of the MDS for Resident #83 dated 02/29/24 titled and documented that Discharge Return Anticipated. Review of the MDS for Resident #83, dated 02/29/24, titled and documented that 'Discharge Return Not Anticipated (Modification).' Review of the Nurses Note for Resident #83 dated 03/02/24 documented: 'Report received that patient signed out on 2/29 (02/29/24) and has not returned since.' Review of the Nurses Note for Resident #83 dated 02/29/24 documented: 'Resident alert and oriented x3 verbally responsive left facility ambulated with walker, sign out book.' During an interview conducted on 05/14/24 at 2:30 PM with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM), she stated she has worked at the facility since the 3rd week in February of 2024. When asked about Resident #83 leaving the facility, she stated on 02/29/24 the resident left the facility after signing himself out. The resident often signed himself out and would return the same day with several bags from various stores. On 02/29/24, the resident told his nurse Staff A, LPN, he would not be back until the following Monday. Staff E stated she believes Staff A told the Administrator and the Administrator called her to go see what was happening. Staff E spoke to Staff A and was informed the resident 'was not planning to return to the facility until Monday, Saturday at the earliest.' Staff E further stated she was able to get in touch with the resident by phone on 02/29/24 and the resident told her he was not planning to return to the facility until Monday. After her conversation with the resident, she notified the Administrator of what had happened, and he instructed her to call the resident back to inform him he would need to return to the facility tonight before midnight or he would be discharged . Staff E attempted to call the resident, but he would not answer his phone. She called the resident's family member who stated she was out of town. Within 5 minutes, the resident called Staff E back and she instructed the resident he needed to return to the facility by midnight, and he said, 'the Administrator messed screwed up his Medicaid, now he will screw him back.' Staff E said that on Monday 03/04/24 when she returned to work at the facility, she was made aware by Staff A that the resident had not returned to the facility. Staff E spoke to the Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 17 of 26 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 05/16/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Staff E notified the police to request a wellness check. She informed the police they did not have an address for the resident, only a phone number. The police said they would follow up. Staff E said the physician was notified on 02/29/24 that the resident had informed the staff he was not coming back to the facility, and the resident seemed to have slurred speech when she spoke to him on the phone on 02/29/24. Staff E stated she considered the resident gone and left against medical advice (AMA) when he did not return on Monday 03/04/24. When asked about when a resident leaves AMA what the facility does, Staff E LPN/UM said they notify the doctor, notify family, also for safety do a wellness visit (done by police) and document this in the resident's chart. Staff E LPN/UM said if the resident is found, they try to see if the resident will come back and advise them, they have rights to make their own decision. She stated that another agency [name provided] is notified if the resident lacks mental capacity or if suspect manipulation from an outsider. When asked about documentation of the incident with Resident #83, she said she thought she had documented it in the resident's EMR. When it was brought to her attention on 05/14/24 that there was no documentation from her in the resident's chart, she hand wrote a statement to what happened and signed it with the date of 05/14/24. She acknowledged that there was no documentation of the incident or any phone calls in the resident's chart until 05/14/24. During an interview conducted on 05/14/24 at 3:07 PM with Administrator who was asked about Resident #83, the Administrator said the resident left AMA. When asked what the process was for a resident who leaves AMA, he said they call another agency [name provided]. When asked if a resident leaves AMA, do they code the Minimum Data Set (MDS) as discharge return anticipated, he said no. When asked who spoke to the resident or attempted to reach the resident after leaving, the Administrator said it was a combination of nursing and admissions. The Administrator acknowledged there was no documentation in the resident's chart about the resident leaving AMA or any conversation that the resident did not wish to return to the facility. During an interview conducted on 05/16/24 at 9:30 AM with the Administrator who was asked about the process they follow when a resident leaves AMA, such as Resident #83, he stated it is the Director of Nursing's (DON's) responsibility to ensure documentation is in the resident's chart so that the resident can be discharged out of the system. During an interview conducted on 05/16/24 at 1:00 PM with MDS Director who was asked about the coding of the discharge for Resident #83, she stated on 02/29/24 she coded it as discharge return anticipated. When asked when she uses the code discharge return not anticipated, she said she does not document a discharge that way until she sees some supporting documentation that the resident is not returning, this could be in a progress note, or a physician's order. She stated that once she saw the order on 05/14/24 to discharge the resident, she then entered a discharge for the resident that identified the resident as discharged return not anticipated. The MDS Director acknowledged the Discharge Return Not Anticipated was not entered into the resident's chart until 05/14/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 18 of 26 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 05/16/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow facility-wide policies and procedures for 17 of 18 residents on Enhanced Barrier Precautions (EBP), including Residents #9, #1, #29, #236, #18, #13, #45, #54, #48 and #53, as evidenced by no gowns at or outside of the residents' doors; and failed to maintain an appropriately clean environment in the facility's laundry rooms to prevent cross contamination of the laundry with various forms of debris. The census at the time of survey was 83 residents. Residents Affected - Some The findings included: 1. Review of the policy, titled, Enhanced Barrier Precautions, not dated, provided by the Director of Nurses (DON) on 05/16/24 at 1:45 PM revealed the following, in part: .EBPs are utilized to prevent the spread of multi-resistant organisms (MDROs) for residents . Under 11. PPE [Personal Protective Equipment]is available outside of the resident rooms . Review of the Center for Disease Control (CDC) guidelines, as the website provided by the DON, documented, in part, that for residents on EBPs that PPE (gowns and gloves) are to be located at the residents' doors. The CDC website is: CDC_Implementation_Of_Personal_Protective_Equipment_(PPE)_Use_In_Nursing_Homes_To_Prevent_Spread_Of_Mult Observation and review of the posted sign on residents' doors on 05/1624 at approximately 1:20 PM, for Residents #9, #1, #29, #236, #18, #13, #45, #54, #48 and #53, who were designated as being on EBP, noted instructions for staff to wear gowns and gloves when providing care. On 05/16/24 at 1:20 PM to 1:40 PM, observation revealed the following 18 rooms had EBP signs posted on their doors, and there were no gowns at or outside the residents' doors: Division 1 had 7 rooms with an EBP sign posted on the door that stated gowns and gloves were required for care. Division 2 had 2 rooms designated the same as Division 1. Division 3 had 3 rooms designated the same as Division 1. room [ROOM NUMBER], at this time, had a yellow PPE over-the-door holder or caddy with several slots in it. The holder was empty of PPE. Division 4 had 6 rooms designated the same as Division 1. On 05/16/24 at approximately 1:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they have a policy they follow for Enhanced Barrier Precautions (EBP) and they follow the CDC guidelines. The DON stated for residents on EBP, the door should have a sign posted on it. She stated PPE gowns are located on 3 Blue linen carts, one for Division 4, one for Division 3, and one shared with Divisions 1 and 2. She stated that extra gowns and gloves were located in the central supply room. She stated gloves were also located in each of the residents' rooms. She stated if needed, masks are available in the central supply room. Observation with the DON on 05/16/24 at approximately 1:50 PM of the units revealed the following: Division 1 and 2: One Blue Cart utilized for both units with a packet of 10 PPE gowns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 19 of 26 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 05/16/2024 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 0880 Division 3: no Blue linen cart, and 2 packets of 10 PPE gowns located in the linen closet. Level of Harm - Minimal harm or potential for actual harm Division 4: no Blue linen cart; and 1 and 1/2 packets of 10 PPE gowns located in the linen closet. There were no PPE gowns located at or near the residents' doors, except for room [ROOM NUMBER]. Residents Affected - Some 2. On 05/16/24 at approximately 1:00 PM, a tour of the facility's laundry room was conducted with the Director of Housekeeping and the Director of Nursing (DON) present. The following observations were noted: a. In the dirty laundry room, the floor was noted to have peeling paint with large, loose paint edges on a large area of the floor. Peeling paint with loose edges can break off and with activity and airflow have the potential to get into the sorting bin used to prepare the laundry for washing. b. The sorting bin in the dirty laundry area had a false bottom, which is a suspended platform that is mounted inside the cart with four springs that are cloth covered. The false bottom is removable. Beneath the false bottom, it was noted that there was an accumulation of dirt and refuse. This foreign matter has the potential to become entangled with the laundry and continue through to the clean laundry processing. A second bin was brought into the dirty laundry area by the Housekeeping Director from the clean laundry room. The Housekeeping director indicated that the second bin was used to transport the wet, clean laundry to the dryer and folding room. The second bin also had a false bottom where it was noted that there was debris under the false bottom. c. An observation of the clean laundry folding area was conducted. There were two housekeeping staff folding laundry from a bin with a false bottom. At that time, there was dirt and debris identified by the surveyor under the false bottom. The Housekeeping Director instructed one of the workers to lift the false bottom so he could see the debris. When the worker did this, she saw two washcloths at the bottom of the bin, which she then removed and tossed onto the clean surface of the folding table. One of the cloths struck an item that the second worker was folding. The second worker tossed one of the cloths into a clean rag bin even though the Housekeeping Director requested the items be given to him. d. The dryer tumblers in both Industrial dryers were noted to have foreign matter that was blue in appearance adhering to the drum surface. The blue matter matched in color to the disposable gloves used in the resident care area by staff. The drum in Dryer #1, closest to the door as approaching the dryers, had a dark rough spot with rust colored staining. There is potential for debris from the drum to flake off into the clean clothes/linens just washed. e. The floor in the clean laundry area also had a large areas of peeling paint that could break off and contaminate the clean laundry as people and equipment move throughout the area. Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 20 of 26 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 05/16/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to offer, educate, and obtain consent for pneumonia vaccine for 5 of 5 sampled residents reviewed for vaccine provision, Resident #53, Resident #35, Resident #22, Resident #18, and Resident #34; as evidenced by Residents #53 and #18 did not have Pneumococcal consents or refusals, and all 5 residents did not have evidence of being offered the vaccines or of being provided education. Residents Affected - Few The findings included: Review of the facility's policy regarding the Pneumococcal Vaccine had documentation, in part, for Policy Interpretation and Implementation that documented as follows: Section Item 3: Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine . Provisions of such education is documented in the resident's medical record. Item 7: Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccine. The CDC webpage https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.html, with the Edition date of 5/12/23, provides guidelines for Pneumonia vaccines. The guidelines are as follows: Pneumococcal conjugate vaccine helps protect against bacteria that cause pneumococcal disease. There are three pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20). The different vaccines are recommended for different people based on age and medical status. Your health care provider can help you determine which type of pneumococcal conjugate vaccine, and how many doses, you should receive. The limitations for Adults, per the CDC guidance, are listed below: Adults 19 through [AGE] years old with certain medical conditions or other risk factors who have not already received pneumococcal conjugate vaccine should receive pneumococcal conjugate vaccine. Adults 65 years or older who have not previously received pneumococcal conjugate vaccine should receive pneumococcal conjugate vaccine. 1. On 05/15/24 at 1:05 PM, a review of Influenza, Pneumonia and COVID-19 vaccine requirements was initiated. For Resident #53, the Influenza Vaccine was documented as refused under the Immunization tab in the Electronic Health Record (EHR). The same was documented for the Pneumonia vaccine and COVID-19 vaccines. Interview with the Director of Nursing at this time, who is also the Infection Preventionist, revealed consents would be found under the Miscellaneous tab of the EHR. A copy of the consent / refusal form for Influenza was found under the Miscellaneous tab as expected, but there was no consent / refusal found for any of the other vaccines. There was no evidence that education was provided. 2. For Resident #18, the record revealed the resident received the Influenza vaccine with the appropriate consent filed under Miscellaneous. There were no other consents found. There was no evidence that education was provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 21 of 26 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 05/16/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 3. All 5 resident records were reviewed, including Residents #22, #34, and #35, for vaccine education provided. None of the 5 residents had evidence that education was provided. On 05/16/24 at approximately 2:20 PM, the DON was questioned about the pneumonia vaccine not being offered the DON explained that she thought the CDC guidelines indicated that the Pneumonia Vaccine was only to be given if a person was [AGE] years old or older. The DON agreed that consents / refusals and education of vaccines should be documented in the Electronic Health Record. Event ID: Facility ID: 105640 If continuation sheet Page 22 of 26 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 05/16/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and record reviews, the facility failed to ensure bed rails were maintained in working condition and inspected for fitness and function for 1 of 2 sampled residents reviewed for bed rails. The findings included: The facility's policy, titled, Safety and Bed Rails, revised August 2022, documented, in part: Policy Interpretation and Implementation 6. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. 7. The maintenance department provides a copy of inspections to the administrator and report results to the QAPI (Quality Assurance Performance Improvement) committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee. 8. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 9. Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc.). Use of Bed Rails 5. If attempted alternatives do no adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs. b. the resident's risk associated with the use of bed rails. c. input from the resident and/or responsible party. d. consultation with the attending physician. 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: (2) The resident or part of his/her body could be caught between rails, the openings, or between the bed rails and mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 23 of 26 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 05/16/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review documented Resident #134 was admitted on [DATE]. Review of the resident's most recent full assessment, an admission Minimum Data Set (MDS), dated [DATE], documented Resident #134 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented the resident was dependent upon staff for transfer and bed mobility, was 'frequently incontinent' of urine and always incontinent of bowel. Resident #134's diagnoses at the time of the assessment included: Anemia, Hypertension, Gastro Esophageal Reflux Disease, Hyperlipidemia, Malnutrition, Chronic lung disease, Dependence on renal dialysis, HIV, Thrombosis due to vascular prosthetic, Kidney transplant rejection, Toxic nephropathy, Disorders of white blood cells, Vitamin D deficiency, and Hypocalcemia. Review of Resident #134's care plan for Activities of Daily Living, initiated on 04/26/24, documented, Resident has a selfcare deficit with dressing, grooming, bathing as evidenced by needs assistance with personal care tasks mobility and transfer skills. The goal of the care plan was documented as, Resident will have clean, neat appearance daily thru the next review date. 04/26/24 with a target date of 05/28/24. An intervention to the care plan included: May use 1/4 side rails X2 as an enabler for bed mobility On 05/14/24 at 9:48 AM, Resident #134 was observed in bed with half side rails. During an interview with the resident and the spouse, when asked about the use of the bed rails, Resident #134 replied, they keep me from falling out of the bed. Resident #134 further stated that the bed rails were provided per his request. It was noted that the rail to the resident's right side of the bed was in the down position and that the resident was using the over bed table and nightstand to lean against. Resident #134 stated that the bed rails has not stayed in a raised position since being admitted . During an interview, on 05/15/24 at 3:25 PM, with the Director of Maintenance, when asked about the bed rails not staying in a raised position as a means to prevent Resident #134 from falling from the bed, the Director of Maintenance stated that he was not aware of the concerns with the rails. On 05/16/24 at 9:29 AM, the Director of Maintenance stated, I fixed it [side rails] last night. After 5:00, they (referring to the facility staff) hoyer lifted him out of the bed and I went in and readjusted the bed rail, tightened the holding mechanism and tightened the pin that holds it in place. If you don't put the pin in the hole, it won't stay up. The bottom bracket was loose, and I tightened it up. It was loose because of the pin. When I went in yesterday, the pin was in place, but the rail was loose. I tightened it and it seems to be operational. When asked about regularly inspecting the rails for fit and function, the Director of Maintenance stated that the Maintenance Department checks the bed rails and mattresses weekly in TELS - electronic system. When asked for documentation of the inspections that were performed, the Director of Maintenance stated that he was unable to generate documentation of audits / maintenance of side rails / bed from the electronic system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 24 of 26 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 05/16/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 05/14/24 at 10:23 AM, an interview was conducted with Resident #53. The surveyor noticed a blow through straw device for turning on the call bell to right and out of reach for Resident #53. When asked if the device was for his use, Resident #53 stated it was but the device was not working. Resident #53 stated he has been waiting for a new bed for two months because the specially adapted call bell had not been working. Resident #53 stated he calls out to his roommate to get him to use the call bell for assistance. Resident #53 stated that sometimes he has to wake his roommate to have the roommate use his call bell for Resident #53's needs. Residents Affected - Few On 05/16/24 at 9:39 AM, an interview was conducted with the Maintenance Director of the facility regarding the call bell issue experienced by Resident #53. The Maintenance Director stated he was unaware of the issue. The Maintenance Director accompanied the surveyor to re-interview Resident #53 for clarification of the problem. Resident #53 explained that he had informed the Assistant Maintenance Director about the problem when it first occurred. The Maintenance Director contacted his assistant who claimed he told the Maintenance Director. Review of the electronic work record system revealed there was no documentation placed regarding the issue. The Maintenance Director explained to Resident #53 that the problem was not the bed but the straw device itself. The Maintenance Director unsuccessfully attempted to fix the call device. The Maintenance Director arranged for the delivery of a new device for Resident #53. On 05/16/24 at 9:58 AM, an interview with Staff C, Certified Nursing Assistant (CNA), regarding call bell situation for Resident #53. Staff C stated she was aware of the problem and confirmed that Resident #53 was using his roommate to assist with the call bell. Staff C stated he had been on vacation when Resident #53 first reported the problem. Staff C stated she thought the problem had been previously entered into the electronic maintenance reporting system. On 05/16/24 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) regarding call bell. The DON agreed that Resident #53 needed to be able to call for assistance without disturbing his roommate. The DON stated they had implemented a 30-minute watch rotation where staff would check on the Resident #53 every 30 minutes until Resident #53's call system was repaired. Based on observations, interviews, and record review, the facility failed to ensure accessibility and functioning of call bells for 2 of 27 sampled residents, Residents #9 and #53. The findings included: Review of the facility's policy, titled, Call System, Resident, dated September 2022, documented, in part: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. Call system communication may be audible or visual. The system may be wireless. 3. The resident call system remains functional at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 25 of 26 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 05/16/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4. If the resident has a disability that prevents him/her from making use of the call system, an alternate means of communication that is usable for the resident is provided and documented in the care plan. 1. Record review for Resident #9 revealed the resident was originally admitted to the facility on [DATE] and had a most recent readmission to the facility on [DATE] with diagnoses that included Schizophrenia, Major Depressive Disorder Recurrent, and Anxiety Disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 02/13/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 13 indicating an intact cognitive response. Review of the Care Plan for Resident #9 dated 02/17/23, documented, with a focus on the resident has a self-care deficit with dressing, grooming, bathing r/t [related to]: as evidenced by needs assistance with personal care tasks and mobility skills. impaired mobility, generalized weakness, Resident at times chooses not to participate in ADLs, noted to refuse medications through tube, noting to be combative at times. The goal was for the resident to allow staff to assist with ADLs as deemed necessary for proper hygiene and safety thru the next review date. The interventions included: Provide/assist with range of motion during daily care. Encourage/remind the resident to ask for assistance as needed. On 05/13/24 at 10:20 AM, an observation was made of Resident #9 lying in bed with the call device on the floor next to the resident's bed. Photographic Evidence Obtained. On 05/13/24 at 12:20 PM, an observation was made of Resident #9 sitting in wheelchair next to the bed with no call bell in sight. During an interview conducted on 05/13/24 at 10:20 AM with Resident #9 who was asked if she uses her call device, she said yes, sometimes if she needs help. When asked if she can reach her call device, she said I don't know where it is. During an interview conducted on 05/13/24 at 12:20 PM with Resident #9 who was asked where her call bell was, she stated I have no idea, it is probably somewhere behind me. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105640 If continuation sheet Page 26 of 26