Health inspection·August 13, 2021

F 0584 it that it was impossible to keep up. Level of Harm - Minimal harm or potential for actual harm On 08/12/21 at 3:59 p.m., an interview was conducted with Staff N, Maintenance. He was observed replacing tiles in room [ROOM NUMBER]. Staff N stated that this was the only way to get rid of the smell. Staff N said, The tiles are lifting, you can tell they have been soaking wet. Residents Affected - Few On 08/11/21 08:48 a.m., an interview was conducted with Staff J, Housekeeping and Staff K, Housekeeping. Staff J stated that the two did not normally work at this facility. Staff J said, We are helping out from a sister facility because this facility is having staffing problems. Staff K said the resident rooms should be cleaned, Every day. We clean rooms daily, sweep floors, mop bathrooms, and disinfect end tables and chairs An interview was conducted with Staff L, Housekeeping Manager on 08/12/21 at 12:26 p.m. Staff L stated that she and her team clean resident rooms daily and all other areas. Staff L stated that she followed a checklist and checked under beds and furniture to make sure everything was cleaned. Staff L stated that she was aware some areas were bad. Staff L said, It is a lot of work. I am trying. I might not get to everything, but I am trying. Staff L stated that she cleaned resident's rooms at least once daily. Staff L said, We try to. I know it has been hard lately Staff L explained that she lost two staff members the previous week. Staff L stated that her expectation would be to not see anything on the floor such as bugs, food, or dirt. Staff L said, Toilet seats should be moved and cleaned and floors swept and mopped. On 08/12/21 at 12:28 p.m., an interview was conducted with Staff M, Housekeeping District Manager. Staff M stated that he was at the facility once a week and toured the entire facility. Staff M said, I'm trying to up the level of cleanliness. It was not up to par. Staff M stated that his expectation would be to deep clean each room and get rid of the smells. An interview was conducted with the DON (Director of Nursing) on 08/12/21 1:11 at p.m. The DON stated that they continuously check for spills, especially in room [ROOM NUMBER] and clean it up. She stated that the Housekeeping department was aware that a resident dumped urine on the floor. She said, We talk about it in our morning meetings. We should increase check-ups and mop it. A follow up interview was conducted with (NHA) Nursing Home Administrator on 08/12/21 at 01:31 p.m. She stated that she was aware the housekeeping department had staffing challenges. She stated, It was worse when I got here. There is no excuse. Housekeeping is definitely a problem. She stated that she expected that they would provide a sanitary place for their residents. Review of the facility's policy titled, Daily patient room cleaning and foot note header, Environmental services operations manual revised 09/05/17 showed that a 5-step room cleaning method should be followed.: 1. Empty trash. 2. Horizontal dusting with a cloth and disinfectant spot clean all vertical surfaces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 2 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0584 3. Level of Harm - Minimal harm or potential for actual harm Spot clean. With a cloth and disinfectant spot clean all vertical surfaces. 4. Residents Affected - Few Dust mop floor. Use dust mop to gather all trash and debris on floor. Sweep to the door, pick up with dustpan. 5. Damp mop floor with germicide solution. Damp mop floor working from back corner to door. Under Bathroom Cleaning the same policy showed an expectation to follow 7-step method. (6) Sanitize commode, tank, bowl, and base. Use brush inside of bowl. (7) Damp mop. Start in far corner. Get behind commode, move trash can, mop out the door. Use wet floor sign when finished. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 3 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility did not ensure that two residents (Resident #94 and Resident #97) out of 3 residents sampled for pre-admission screening had a correctly completed Pre-admission Screening and Resident Review (PASRR). Residents Affected - Few Findings included: 1. A review of Resident #97's Medical Record revealed that Resident #97 was admitted to the facility on [DATE] with a diagnosis of Trisomy 21 (a form of Down Syndrome). A review of Resident #97's Care Plan revealed a problem, last revised on 06/16/2021, that Resident #97 had impaired cognitive function and/or impaired thought process related to Trisomy 21. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A review of Resident #97's Minimum Data Set (MDS) assessment revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impact. Section C of the MDS assessment also revealed that Resident #97 had signs and symptoms of delirium as evidence by fluctuating occurrences of disorganized thinking. A review of Resident #97's PASRR Level I Screen, which was completed at the hospital prior to admission to the facility, revealed under Section 1B: Intellectual Disability (ID) or suspected ID (check all that apply), that the related condition of Down Syndrome was not selected from the choices given in the screening. The section titled Functional Criteria under Section 1B did not reveal any selections being checked, which included questions related to the condition resulting in substantial functional limitations in three or more life activities including capacity for independent living, learning, mobility, self care, self direction, and understanding and use of language. Section II of the PASRR, titled Other Indications for PASRR Screen Decision-Making included questions related to whether Resident #97 had a disorder which may result in functional limitations in major life events, characteristics of difficulty with interpersonal functioning, concentration, and adaptation to change, and indication of treatment for mental illness, which were all selected as No. Section IV of the PASRR, titled PASRR Screen Completion, documented that Resident #97 had no diagnosis or suspicion of Serious Mental Illness (SMI) or ID and that a Level II PASRR evaluation was not required. 2. A review of Resident #94's Medical Record revealed that Resident #94 was admitted to the facility on [DATE] with diagnoses of Cognitive Communication Deficit, Anxiety Disorder, Dementia with Behavioral Disturbance, and Schizoaffective Disorder. A review of Resident #94's Care Plan revealed a problem, last revised on 07/23/2021, that Resident #94 had impaired cognitive function and/or impaired thought process related to a diagnosis of dementia with behavioral disturbance. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A review of Resident #94's MDS assessment revealed, under Section C - Cognitive Patterns, a BIMS score of 3, which indicated severe cognitive impact. Section C of the MDS assessment also revealed that Resident #94 had signs and symptoms of delirium as evidence by continuous disorganized thinking, continuous inattention, and fluctuating episodes of altered level of consciousness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 4 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #94's PASRR Level I Screen, which was completed at the hospital prior to admission to the facility, revealed under Section 1A: Mental Illness (MI) or suspected MI (check all that apply), that the related conditions of Anxiety Disorder and Schizoaffective Disorder were not selected from the choices given in the screening. Section II of the PASRR, titled Other Indications for PASRR Screen Decision-Making included questions related to whether Resident #94 had a disorder which may result in functional limitations in major life events, characteristics of difficulty with interpersonal functioning, concentration, and adaptation to change, and indication of of treatment for mental illness, which were all selected as No. An interview was conducted on 08/12/2021 at 04:02 PM with the facility's Social Services Manager (SSM). The SSM stated that residents were reviewed upon admission to the facility to ensure a PASRR screening was completed. The SSM addressed that Resident #97 required a Level II PASRR due to her diagnosis of Down Syndrome and stated that she just obtained the ability to complete Level II PASRR screenings. The SSM stated that she was not sure who reviewed PASRR screenings for accuracy or who was responsible for correcting them if they were not completed properly. The SSM also stated that the Admissions department received all of the pre-admission paperwork and that they may ensure that the PASRR screenings are completed accurately. An interview was conducted on 08/13/2021 at 12:53 PM with the facility's Liaison of Admissions (LA). The LA stated that she reviewed residents prior to admission to ensure a PASRR screening was included in the admission paperwork, but they do not review the screening for accuracy of the diagnoses or details of the screening because the hospital is supposed to review them. The LA also stated that the Social Services department would be responsible for reviewing the PASRR screenings for accuracy and for necessity of a Level II screening. An interview was conducted on 08/13/2021 at 02:10 PM with the facility's Nursing Home Administrator (NHA). The NHA stated that when a resident is admitted to the facility, the LA verifies that the resident has a PASRR screening in their record prior to admission or with them if they are coming from the hospital. The SSM is responsible for verifying the information on the PASRR screening for accuracy and to determine if the resident would require a Level II screening. If a PASRR assessment was found to not be complete then it should be completed the following morning with whatever information is available. The NHA addressed that Resident #97's PASRR screening was not completed correctly and that the resident should have been identified as having a diagnosis of Down Syndrome. The NHA also addressed that Resident #94's PASRR screening was not properly completed and did not reflect his diagnoses of Anxiety Disorder, Dementia with Behavioral Disturbance, and Schizoaffective Disorder. The NHA stated that the mistakes on the PASRR screenings should have been identified. A review of the facility policy titled Pre-admission Screening for Serious Mental Illness (SMI) and Intellectually Disabled (ID) Individuals (PASRR), last revised in September of 2017, revealed that it is the responsibility of the center to assess and assure that the appropriate pre-admission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. The policy also revealed that if it is learned after admission that a SMI or ID Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 5 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement care plan interventions related to oxygen use, and proper oxygen flow rate for one (Resident #38) of thirty-one sampled residents, during two of four days observed (8/10/2021, and 8/11/2021). Findings included: Review of Resident #38's current care plans with next review date 9/13/2021 revealed the following areas: Resident #38 has Hypertension, Shortness of Breath with interventions in place Resident #38 has oxygen therapy as needed for shortness of breath with interventions in place to include but not limited to: Given medications as ordered by the Physician, Monitor for signs and symptoms of respiratory distress and report to the Physician as need On 8/10/2021 at 6:50 a.m. and 10:30 a.m., Resident #38 was observed in her room and lying in bed. The call light was placed within her reach. Resident #38 was observed with oxygen tubing leading from the oxygen concentrator to her nasal cannula. An interview with the resident revealed that there were times when her machine was not providing the air she needed. She had not spoken to anyone about it in the past, and she did not have the capabilities to change the flow rate herself. On 8/11/2021 at 12:50 p.m., an interview was conducted with Resident #38 in her room. She was observed lying flat in her bed and had her meal tray placed on the over the bed table. She revealed she was finished eating. Resident #38 had the oxygen tubing leading from the O2 concentrator to her Nasal Cannula. She said she could not really feel the air and said that the flow rate should be at 3 liters per minute. At 1:00 p.m., an interview with a Registered Nurse, Staff A was conducted. He was not sure what the oxygen flow rate should have been and went to the room to verify. He stated the oxygen flow rate gauge on the oxygen concentrator read about 2 liters per minute. He then went to the nurse station and reviewed electronic medical records to verify that Resident #38 should have oxygen ran routinely at 3 liters per minute. Staff A revealed that it was the nurse's responsibility to read, assess, and adjust the oxygen flow rate on the oxygen concentrator and that other staff to include Certified Nursing Assistants were not to touch the machine. He confirmed that the resident was not able to reach and change the flow rate on her own. He indicated he must not have adjusted to the right flow rate this a.m. On 8/13/2021 at 1:00 p.m., an interview with the South Unit Manager was conducted. She confirmed that only nurses could adjust the oxygen flow rate on the oxygen concentrators. She said staff should always review the medical record to verify the correct oxygen flow rate. She confirmed that Resident #38 could not adjust the flow rate on her own. She said the care plans reflect that oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 6 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications should be followed, which would indicate to keep the oxygen concentrator flow rate at 3 liters per minutes. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the admission diagnosis sheet revealed diagnoses to include: Shortness Of Breath, Anxiety, Depression, COPD (chronic obstructive pulmonary disease). Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 6/5/2021, revealed: Brief Interview Mental Status or BIMS score - 13 of 15, intact cognition, Activities of Daily Living (ADL)s Extensive assist two person assist with Bed Mobility, Total dependence with Transfers, Extensive assist with one person with Dressing; Treatments - Utilizes Oxygen Review of the current Physician's Order Sheet for the month of 8/2021 revealed Resident #38 orders included: Respiratory Oxygen continuous 3 liters via nasal cannula (original order date 6/1/2021). On 8/13/2021 at 2:00 p.m. the Director of Nursing provided the Plans of Care policy and procedure with a revision date of 9/25/2017, for review. The policy indicated; An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representatives to the extent practicable and updated in accordance with state and federal regulatory requirements. Under the procedure section, it was revealed: Develop and implement an individualized person-centered comprehensive plan of care by the IDT team that includes but is not limited to: The attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and to the extent practicable, the participation of the resident and the resident's representatives within seven days after completion of the comprehensive (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 7 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure assistance with Activities of Daily Living (ADL)s was provided for one (Resident # 54) of three residents sampled. Residents Affected - Few Findings included: Resident #54 was admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia with behavioral disturbance, generalized anxiety disorder, difficulty walking, and mood disorder. Review of the MDS (minimum data set) dated 06/25/21 revealed a BIMS (brief interview for mental status) of 13. Section G, Functional status, under dressing revealed that Resident #54 required extensive assistance for dressing - how resident put on, fastened and took off all items of clothing, including putting on and changing clothing. Under Toilet use, how the resident used the toilet room, commode, bed pan or urinal, cleaned self after elimination, changed and adjusted clothes. Resident #54 required one-person physical assist. Care plan with a last review date 07/05/21 revealed that Resident #54 had an ADL self-care performance deficit related to activity intolerance, limited mobility, dementia, and anxiety. Resident #54 was occasionally incontinent of bowel and bladder. Performance of ADL's fluctuated and gradual decline was anticipated due to terminal prognosis. The intervention under dressing indicated, staff will offer to help with changing soiled clothes. During multiple tours on 08/10/21, 08/11/21 and 08/12/21, Resident #54 was observed in his wheelchair outside his room wearing wet pants. Resident #54 was seen wearing khaki, stained, soiled pants. On 08/12/21 at 03:52 p.m., Resident #54 was wearing blue jeans noted soiled from the front. On 08/12/21 at 10:00 a.m., an interview was conducted with Staff Q,Certified Nursing Assistant (CNA) who worked with Resident #54 regularly. Staff Q confirmed that Resident #54 occasionally is seen with wet pants. Staff Q stated that when they saw that, they asked him to change. Staff Q said, If he needs help, I assist him. Staff Q stated that Resident #54 soiled his pants about once daily, or twice. An interview was conducted with Staff R, CNA on 08/12/21 at 10:37 a.m. Staff R stated that sometimes Resident #54 needed assistance with his pants because he had wet pants on. Staff R said, He goes on himself. We change him every day. On 08/12/21 at 03:52 p.m. Staff S, CNA was observed standing in the hallway next to Resident #54. Resident #54 was in his wheelchair outside his room interacting with a maintenance personnel. Staff S noticed the surveyor looking at Resident #54. Staff S noticed the resident was wearing soiled jeans pants. Staff S walked over to the surveyor and stated that Resident #54 went to the bathroom by himself. Staff S said, Sometimes he (Resident #54) struggles to unbutton his pants. Maybe they should get him elastic pants. Staff S said the resident should be checked more often. Staff S proceeded to escort resident to his room after interview. On 08/12/21 10:53 a.m., an interview was conducted Staff B, Unit Manger. Staff B stated that occasionally Resident #54 pants were wet. Staff B said, This week is worse. he tries to be independent it doesn't help. Staff B stated that Resident #54 had requested new clothes the previous week, because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 8 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he only had a couple pairs of pants. Staff B said that the resident's pants were either stained or they did not fit. Staff B stated that they try and prompt him before he goes on himself. Staff B stated that they should probably be checking on him every hour. An interview was conducted with the DON (Director of Nursing) on 08/12/21 at 1:13 p.m. The DON stated that she was familiar with the resident. She said, He needs to be changed often. He can do a lot for himself. He needs assistance or cues.The DON said, I do not expect a resident to be sitting in wet clothes Review of the facility's policy titled, Activities of Daily Living (ADL), with an effective date 01/07 showed all residents will remain at their highest practical level of ADL function, unless a medical condition demonstrates a decline is unavoidable. Purpose: To have the resident achieve the highest level of self-help or independence. The role of the clinical services staff is to teach, support, and supervise the resident in regaining and maintaining these function. Under procedure: (3). Make sure the resident is comfortable. (4). Provide verbal cues, demonstrations and physical assistance as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 9 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, observation, and policy review the facility did not ensure a hospice care plan and/or assessment and appropriate communication related to hospice services including updates for a change of condition were in the medical record for one resident (#64) of nine residents receiving hospice care at the facility. Also based on interview and policy review the facility did not ensure there was a contract with the hospice provider for one resident (#64) of nine residents receiving hospice care. Residents Affected - Few Findings included: Resident #64 was readmitted to the facility on [DATE] with diagnoses including but not limited to, heart failure, type II diabetes mellitus, and Afib (atrial fibrillation), according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #64 was cognitively intact. Further review under Functional Status reflected the need for supervision with set up help for eating. A review of Section K, Swallowing/Nutritional Status, revealed Resident #64 did not have a swallowing disorder at the time of the assessment, nor was he receiving a therapeutic diet. Review of Section O, Special Treatments, Procedures, and Programs reflected Resident #64 was receiving hospice care. Speech-Language Pathology and Audiology Services were not marked, indicating Resident #64 was not receiving any services. On 8/12/21 at 11:38 AM an interview was conducted with the resident's nurse, Staff E, LPN (licensed practical nurse). Staff E, LPN said Resident #64s' hospice care plan was comfort measures and remain pain free. Staff E, LPN said Resident #64 stopped eating as much as he used to eat. His appetite is poor now. Staff E, LPN also said she has spoken to Resident #64's wife and asked her to talk to him on the phone to get him to eat. He is confused sometimes. He seems to understand. He can answer questions appropriately. Staff E, LPN said a hospice nurse came about a week ago and she told the hospice nurse about his poor intake. His food is pureed now. I thought he was having trouble so I consulted speech therapy who evaluated him and changed it to pureed. He can't cut and eat the meat. It's too hard. We keep jello in there. He will take that. On 8/12/21 at 11:47 AM an interview was conducted with the unit manager, Staff D, LPN. Staff D, LPN unit manager said Resident #64 was at hospice house at (Company Name) hospice. They had to repair the building so they sent their patients out. Resident #64 has been here before. His wife wanted him here. His wife ended up in the hospital and when she got out she didn't want him home because she can't take care of him. So he will be staying here. Hospice is supposed to put progress notes in the chart when they visit. The hospice care plan was at hospice house, but it didn't get transferred to us on admission. He was only supposed to be here a few days so that might be why. Staff D, LPN unit manager said she has not asked for it and the only documents provided were a discharge form and a 3008 (transfer form). When the hospice nurse comes in Staff D, LPN asks for a progress report in the chart. She said hospice does medication changes if he needs it. Staff go by the care plan that's in the chart. MDS makes the care plans. On 8/12/21 at 12:39 PM an observation was conducted in Resident #64's room. There were two gelatin cups on the bed side table in front of Resident #64, that were unopened. The lunch meal tray was on the dietary cart outside Resident #64's room in the hallway. The meal was untouched. There was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 10 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 pureed meat, a pureed vegetable, mashed potatoes, pureed lemon cake, and tea. Level of Harm - Minimal harm or potential for actual harm On 8/13/21 at 9:37 AM an interview was conducted with Staff F, OT (occupational therapist). Staff F, OT said the last speech evaluation for Resident #64 was completed on 4/29/21. Residents Affected - Few On 8/13/21 at 9:39 AM an interview was conducted with the director of therapy. The director of therapy said there has not been a therapy referral for Resident #64. Normally hospice will come and give us any information for him. Review of physician's orders in the medical record reflected a diet order dated 6/25/21 Regular diet, regular texture, regular thin liquids consistency. Further review of the orders revealed speech therapy services were not ordered. An order dated 8/5/21 indicated hospice services with (Company Name) Hospice Dx (diagnosis) CHF (congestive heart failure). A review of the care plan dated 4/28/21 revealed, The resident is at nutritional risk r/t (related to) multiple medical dx (diagnoses) including UTI (urinary tract infection), DM (diabetes mellitus), htn (hypertension), anemia, BMI/obese class 1, potential for weight fluctuation r/t hx (history) edema, usually declines to be weighed, weight changes noted on readmit, end stage dx-provided hospice services. Interventions included provide and serve diet as ordered. A review of nurses' notes in the electronic medical record from readmission on [DATE] to 8/12/21 reflected no documentation of any changes or communication with hospice. An 8/10/21 dietary note indicated a regular diet. Continue with nutritional care plan. An IDT note dated 7/14/21 indicated a care plan meeting was held with Resident #64 regarding his desire for therapy services so that he can develop enough strength to return home and that hospice will be contacted by SS (social services) regarding this. There wasn't any further documentation if this occurred or hospice had been contacted for any other reason. There was also no note indicating the provider or hospice had been contacted regarding a change to Resident #64's diet and the reason. Review of the physical chart at the nurses' station on 8/12/21 also reflected no documented communication to or from hospice, and a hospice care plan or assessment could not be found either. On 8/13/21 at 10:17 AM an interview was conducted with the CDM (certified dietary manager) at the facility. The CDM said staff give her a yellow slip that says diet change. She gets on the computer and enters it in meal tracker. Whatever staff give her is what she enters in the meal tracker. The CDM was shown the physician's order for a regular diet, regular texture, and she confirmed the order. The CDM provided a yellow Diet Order and Communication form dated 8/9/21, indicting a change to Dysphagia puree. Review of the form during the interview reflected it did not match the physician's order. The CDM also provided the meal ticket dated 8/13/21, which was reviewed and reflected pureed food for breakfast, lunch, and dinner. A telephone interview was conducted with Staff U, RN (registered nurse) manager of (Company Name) hospice on 8/13/21 at 11:08 AM. Staff U, RN manager said there is a packet with consents with advance directives, certs and recerts, IDT (interdisciplinary) notes, care plans and contact information. I made one for him. I go by monthly and check to see if its there. I check the chart and if its not there I recreate it for them. We admitted him on 5/13. I made him a brand new one when he came back. I don't know what the facility does with it. I don't see an order for a pureed diet. They should contact us for a diet change. We would approve a speech consult if they wanted one as well. We have him on a regular diet. The latest note said regular. That was last Friday. It was 8/6. We meet every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 11 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few two weeks to review all our patients. That note (8/6) indicated a regular diet. I don't see where the facility notified us or requested a speech eval. The last note says his appetite varies related to agitation and facility versus outside food. We have not approved a speech evaluation. On 8/13/21 at 1:24 PM a follow up interview was conducted with Staff D, LPN unit manager. Staff D, LPN unit manager said He got choked one day. Hospice won't cover an eval (for speech therapy). The hospice nurse said she can't guarantee any visits for speech therapy. She might be able to get an eval. Staff E, LPN said she talked to the speech therapist who told her to down grade his diet. Staff D, LPN unit manager said she doesn't know if Staff E, LPN told hospice his diet was down graded. Staff D, LPN unit manager confirmed there should be documentation of a change of condition indicting the physician and family were notified, as well as notification to hospice. On 8/13/21 at 1:45 PM an interview was conducted with the SLP (speech language pathologist) at the facility. She said she did not get a referral. We have to wait for hospice to refer them before we go in and see them. She has not heard anything about Resident #64. She has not laid eyes on him. No one has said anything to her about him. Hospice referred him today. On 8/13/21 at 2:29 PM an interview was conducted with the DON. She said if we observe a patient having chewing or swallowing problems while eating we as nurses can down grade the diet. Then they should make a therapy referral for speech to come and do a screen. The DON also confirmed there should be notification to the doctor, the family, hospice, and speech therapy. If the nurse down grades the diet there should be documentation. She also confirmed there should be a change of condition completed. Staff will come to her if their is a concern. The nurses notify hospice of a change of condition. It should be documented. Hospice should be notified of any changes. A hospice contract with the facility was requested for Company Name Hospice during the interview. The DON said Company Name Hospice won't provide a contract. Review of the Hospice Nursing assessment dated [DATE], revealed it had been faxed to the facility on 8/12/21. There were also two additional Hospice Nursing Assessments dated 7/25/21 and 8/1/21 also with a fax date of 8/12/21. Attached to the faxed assessments was a Recertification Heart Disease dated 8/6/21. Review of the policy Notification of Change in Condition, dated 12/16/20, reflected the following: Policy: The Center to promptly notify the patient. resident, attending physician, and the resident representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and resident representative when there is a(n): Significant change in he patient/resident's physical, mental, or psychosocial status Need to alter treatment significantly New treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 12 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Discontinuation of a current treatment due to but not limited to: Level of Harm - Minimal harm or potential for actual harm acute condition exacerbation of a chronic condition Residents Affected - Few The nurse to complete an evaluation of the patient/resident. Document evaluation in the medical record. The nurse will contact the physician. Notify the patient/resident and the resident representative of the change of condition. Document notification in the medical record. Review of the policy, Physician Orders, revised 3/3/21 revealed the following information: Policy: The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure: Routine orders: A nurse may accept a telephone order from he physician, physician assistant, or nurse practitioner (as permitted by state law). The order will be repeated back to the physician, PA, or ARNP (nurse practitioner) for his/her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record). Review of the policy, Hospice Care, revised 9/20/17, reflected the following relevant information: Policy: The center supports the patient/resident's right to a dignified existence and self determination. The center will assist the patient/resident and/or legal representative in arranging hospice services. Procedure: When hospice are provided in the center, the center should meet the following: Ensure hospice services meet professional standards and principles that apply to individuals providing services in the center, and to the timeliness of the services. The center will have a written agreement with hospice that is signed by an authorized representative from the hospice and the center (prior to providing services to a patient/resident). The agreement to include but not limited to: the services that hospice will provide Hospice's responsibilities for determining the appropriate hospice plan of care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 13 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The services the center will continue to provide according to the patient/resident's plan of care. Level of Harm - Minimal harm or potential for actual harm The communication process, including how the communication should be documented between the center and the hospice, to ensure the needs of the patient/resident are met 24 hours a day. Residents Affected - Few The center should immediately notify the hospice when: The patient t/resident experiences a significant change in condition including physical, mental, social or emotional Clinical changes suggest a need to alter the plan of care. The center will furnish 24 hour room and board, and meet the patient/resident's personal and nursing care needs in coordination with hospice based on the patient/resident's individual plan of care. Hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. Hospice responsibilities include but are not limited to: Provide medical direction and management of the patient/resident, nursing, counseling, social work To ensure continuity of care between the center and the hospice provider, the director of nursing will designate a clinical member of the interdisciplinary team to work with hospice including the following: Coordination of the care plan process between the hospice and the center Communication with hospice representatives, hospice medial director and the patient/resident's attending physician to ensure coordination of care Ensure the following information is obtained from the hospice: Most recent hospice plan of care Provide education to the hospice staff on the center policies and procedures, including: resident rights, documentation and forms The center will ensure the care plan includes the most current hospice plan of care and the center's plan to attained or maintain the patient/resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 14 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide respiratory care in accordance with professional standards for 2 (Resident #499 and Resident #17) of 3 residents sampled for respiratory care. Residents Affected - Few Findings included: 1. A review of Resident #499's Physician's Orders revealed that Resident #499 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #499's Physician's Orders revealed an order, dated 08/03/2021, for continuous oxygen at 4 liters per minute (lpm) via nasal cannula. A review of Resident #499's Care Plan revealed a problem, revised on 08/05/2021, that Resident #499 had Emphysema/COPD. Interventions included continuous oxygen via nasal prongs at 4 lpm (liters per minute), monitor for difficulty breathing on exertion, and monitor/document any signs and symptoms of respiratory infection. An observation was conducted on 08/10/2021 at 11:47 AM in Resident #499's room. A nasal cannula with oxygen tubing was observed connected to an oxygen concentrator next to Resident #499's bed. Resident #499 was not in the room at the time of the observation. The nasal cannula and oxygen tubing were observed laying on the floor next to Resident #499's bed. No date was observed on the oxygen tubing or nasal cannula and no storage bag for the respiratory equipment was observed in Resident #499's room. Staff H, Certified Nurse's Aide (CNA) was observed entering the room, picked up the nasal cannula from off of the floor, coiled the tubing and nasal cannula, and placed it on Resident #499's bedside stand before exiting the room. An observation was made on 08/12/2021 at 02:15 PM of Resident #499 in her room resting in bed. Resident #499 was observed to have her nasal cannula in place with oxygen running. An observation of Resident #499's oxygen concentrator revealed the oxygen flow meter to be set at 5 lpm. Resident #499 stated that her oxygen was usually set to 4 lpm. An interview was conducted on 08/12/2021 at 02:18 PM with Staff E, Registered Nurse (RN) at the unit nurse's station. Staff E, RN verified in Resident #499's Physician's Orders an order for continuous oxygen at 4 lpm via nasal cannula. An observation was conducted with Staff E, RN in Resident #499's room. Staff E, RN addressed that Resident #499's oxygen flow meter was set to 5 lpm. Staff E, RN stated that she conducted rounds in the morning when she came in to verify that oxygen flow meters were set to ordered levels and was not able to state why Resident #499's oxygen flow meter was set to 5 lpm. An observation as conducted on 08/13/2021 at 07:50 AM of Resident #499 eating breakfast in her room. Resident #499 was observed to have her oxygen nasal cannula in place with oxygen running via oxygen concentrator. An observation of Resident #499's oxygen flow meter revealed an oxygen setting of 3.5 lpm. Following the observation, an interview was conducted with Staff E, RN. Staff E, RN stated that she had not completed her morning rounds yet to verify oxygen settings and addressed that Resident #499's oxygen flow meter was set to 3.5 lpm. Staff E, RN stated that Resident #499's oxygen flow meter should have been set to 4 lpm per her Physician's Order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 15 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 08/13/21 at 03:36 PM with the facility's Director of Nursing (DON). The DON stated that any oxygen tubing, nasal cannulas, or other respiratory equipment should be stored in a storage bag when not in use. The DON also stated that respiratory equipment should be kept off of the floor and she would not expect a staff member to place respiratory equipment back onto a bedside table after it had touched the floor. The DON would expect the staff member to notify the nurse so that the entire set would be changed out after touching the floor. The DON stated that the nurse on the floor was responsible for ensuring oxygen flow rates were set per the physician's order and that nurse's should be verifying the flow meter is set correctly any time they entered the resident's room. A review of the facility policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised in November of 2011, revealed under the section titled Infection Control Considerations Related to Oxygen Administration that staff are to change the oxygen cannula and tubing every seven days or as needed and keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use. Photographic evidence obtained. 2. On 08/11/21 at 02:16 p.m., an interview was conducted with Resident #17. He stated that he wears the CPAP (continuous positive airway pressure mask) every night. When asked if it had been cleaned, Resident #17 stated that he did not know the last time it was cleaned or changed. The CPAP was observed on the nightstand uncovered. A resident information sheet revealed that Resident #17 was admitted to the facility on [DATE] with diagnoses to include: Acute Respiratory failure, Gastro esophageal reflux disease, essential hypertension, obesity, Edema, idiopathic chronic gout, unspecified lack of coordination, muscle weakness, Body mass index, major depressive disorder, adjustment disorder with depressed mood and shortness of breath. An annual MDS (minimum data set) dated 11/17/20 revealed Resident #17 has a BIMS (brief interview for mental status) of 15, indicating intact cognition. Section J of the MDS under health conditions showed that Resident #17 had shortness of breath with exertion (such as walking, bathing, transferring), when sitting at rest and when lying flat. During an initial tour of hallway 200 on 08/10/21 at 08:13 a.m., an observation was made of Resident #17's CPAP (continuous positive airway pressure) on the floor in room [ROOM NUMBER]. Resident # 17's CPAP's mouthpiece was resting on a floor surface noted with dirt and food particles. Photographic evidence was obtained. During subsequent tours on 08/10/21 and 08/11/21 the CPAP machine was observed on the bedside table. The CPAP was not covered and the tubing was not dated. Photographic evidence was obtained. An interview was conducted on 08/11/21 at 02:21 p.m. with Staff O, LPN. Staff O stated that the CPAP machine should be cleaned per manufacturer's order. Staff O stated that the night-time nurse makes sure it has water before use and the day-time nurse should empty the water chamber and disinfect with wipes. Staff O looked at the CPAP stored on top of the nightstand. Staff O said, it should be in a bag, cleaned and dated. I honestly did not look at it. On 8/11/21 2:30 p.m. an interview was conducted with Staff P, ADON (assistant director of nursing). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 16 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Staff P stated that it is expected that the CPAP machine should be cleaned after each use and stored in a belonging's bag with resident's identifying information, such as name, date of birth , room number and date the tubing was changed. Staff P reviewed a photograph of observation of the CPAP on the floor and said, it should not be on the floor, definitely Residents Affected - Few Review of Resident #17's physician's orders showed the following: Clean mask and tubing every week and air dry. Every day shift, every Sunday, order date: 1/18/21. Change storage bag every Sunday. Order date 08/12/21. Device and settings per home setting. Order date 11/14/20 Fill water chamber with distilled water every HS (hours of sleep) order date 11/14/20 Empty water chamber and air dry every AM (morning) order date 11/14/20 An interview was conducted with DON (director of nursing) on 08/12/21 01:26 p.m. DON stated that she was made aware that there was a problem and that they have started education on infection control and proper storage for CPAP's and nebulizers. The DON stated the expectation is for the day shift nurse to clean and properly store the machine. The DON stated that the machine should never be on the floor or left open to the elements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 17 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interviews, the facility failed to post the current Nurse Staffing Information to include all shifts for the day/night, the resident census, and numbers of each disciplined nursing staff for each shift, during one of four days observed, (8/10/2021). It was observed that the facility had the Daily Staffing Sheet posted and displayed with a date of four days prior. Residents Affected - Few Findings included: On 8/10/2021 6:02 a.m., the front lobby doors were approached from the outside parking lot. Upon reaching the doors, they were observed locked. A sign on the door indicated to call a number to have someone come to the front door to let anyone in. The number was called and a staff member, Nurse Employee B indicated she would be right up to the door. At 6:06 a.m. Employee B came to the front door. However, another staff member let the team inside the facility. Upon entering the facility, Employee B was notified of the team and the visit reason. She indicates she was in charge during the current shift and is actually the North unit manager during the days. While Employee B was walking the team through to the interior of the facility, several administration offices were passed and there was a wall with a sheet of paper hanging on it. The sheet of paper revealed it was the Daily Staffing Sheet. The sheet was dated for 8/6/2021 and to include areas 1:1, House, North wing, South wing. The sheet included the following information: a. All shifts (6:45 a.m. - 3:15 p.m., 7:00 a.m. - 3:00 p.m., 9:30 a.m. - 5:00 p.m., 2:45 p.m. - 11:15 p.m., and 10:45 p.m. - 7:15 a.m.). b. Census - 105 c. Number of Certified Nursing Assistants (documented for each shift) d. Number of Licensed Practical Nurses (documented for each shift) e. Number of Registered Nurses (documented for each shift) It was found that this Daily Staffing Sheet was not current and had information that was four days old. On 8/12/2021 at 12:30 p.m. an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) was conducted. The DON revealed that the staffing coordinator is the person who is typically responsible for changing and updating the Daily Staffing Sheet on Mondays through Fridays. She further revealed that they had a weekend shift supervisor who was typically responsible for changing and updating the sheet. She revealed that as of recent they had to terminate a weekend supervisor and that is perhaps the reason the sheet was not updated since 8/6/2021. The DON and NHA both revealed that the Staffing Coordinator was not in the building this week to be interviewed related to the expectations of posting and updating the Daily Staffing Sheet. The DON further confirmed that this sheet is only posted in the lobby area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 18 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate below 5%. A total of 31 administration opportunities were observed with 4 errors for 4 (Resident #2, Resident #81, Resident #92 and Resident #502) of 5 residents observed for medication administration, resulting in a medications administration error rate of 12.9%. Residents Affected - Few Findings included: An observation of medication administration was conducted on 08/12/2021 at 08:55 AM with Staff A, Registered Nurse (RN) on the 500 unit of the facility. The following medications were administered to Resident #92 during the observation: - Multi Vitamin with Minerals 1 tablet by mouth. - Aspirin 81 milligrams (mg) by mouth. - Fluticasone propionate and salmeterol inhalation powder 250 micrograms (mcg)-50 mcg/dose 1 puff inhalation. - Celexa 20 mg by mouth. - Losartan 25 mg by mouth. - Metformin 500 mg by mouth. - Metoprolol 25 mg by mouth. - Artificial tears solution 1 drop in each eye. After verifying Resident #92's medications, Staff A, RN entered the resident's room and administered medications by mouth without difficulty. Staff A, RN also administered Artificial tears in each of Resident #92's eyes without difficulty. Staff A, RN then administered fluticasone propionate and salmeterol inhalation powder 250-50 1 puff inhalation to Resident #92. After administration of the inhalation powder, Staff A, RN exited the room. Staff A, RN did not instruct Resident #92 to rinse his mouth after administration of Fluticasone propionate and salmeterol inhalation powder. An interview was conducted following medication administration on 08/12/2021 at 09:02 AM with Staff A, RN. Staff A, RN addressed that he did not instruct Resident #92 to rinse his mouth after administration of fluticasone propionate and salmeterol inhalation powder. Staff A, RN stated that he would normally have a resident rinse out there mouth after inhaler usage if it was in the instructions but he felt like he was under a lot of pressure due to having someone watching him during his normal work duties and addressed that he made a mistake. An review of the manufacturer's box for fluticasone propionate and salmeterol inhalation powder 250-50 revealed instructions, under the section titled Remember, which read After each dose, rinse your mouth with water and spit it out. Do not swallow the water. An observation of medication administration was conducted on 08/12/2021 at 09:14 AM with Staff A, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 19 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 RN on the 500 unit of the facility. The following medications were administered to Resident #2 during the observation: Level of Harm - Minimal harm or potential for actual harm - Calcium-Vitamin D 600 mg-200 International Units (IU) by mouth. Residents Affected - Few - Apixaban 5 mg by mouth. - Senna S 8.6 mg-50 mg by mouth. - Effexor 150 mg by mouth. - Nudexta 20 mg -10 mg by mouth. After verifying Resident #2's medications, Staff A, RN entered the resident's room and administered medications by mouth without difficulty and exited the room. A review of Resident #2's Physician's Order revealed an order, dated 10/13/2020, for Calcium-Vitamin D 600 mg-400 IU by mouth twice daily for supplement. An interview was conducted on 08/12/2021 at 09:26 AM with Staff A, RN. Staff A, RN verified that he did not administer the right dose of Calcium and Vitamin D to Resident #2 and that the dosage of Vitamin D3 in the medication was not in accordance with the order. Staff A, RN stated that he had education related to the five rights of medications administration, which included verifying the right dose before administering. An observation of medication administration was conducted on 08/12/2021 at 09:45 AM with Staff E, RN on the 400 unit of the facility. The following medications were administered to Resident #502 during the observation: - Calcium-Vitamin D 600 mg-200 IU by mouth. - Amlodipine 5 mg by mouth. - Colace 100 mg by mouth. - Lovenox 30 mg/0.3 milliliters (ml) subcutaneous injection. - Gabapentin 300 mg by mouth. - Vitamin C 1000 mg by mouth. - Zinc 220 mg by mouth. After verifying Resident #502's medications, Staff E, RN entered the resident's room and administered medications by mouth and subcutaneously without difficulty and exited the room. A review of Resident #502's Physician's Order revealed an order, dated 07/29/2021, for Calcium-Vitamin D 600 mg-400 IU by mouth twice daily for vitamin deficiency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 20 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted 08/12/2021 at 10:02 AM with Staff E, RN. Staff E, RN observed the bottle of Calcium and Vitamin D3 600 mg-5 mcg and addressed that the physician's order was different from what she administered. Staff E, RN asked would that come from pharmacy?. Staff E, RN was able to locate Calcium and Vitamin D3 600 mg-10 mcg by mouth in the unit's medication room. An observation of medication administration was observed on 08/13/2021 at 11:38 AM with Staff E, RN. After obtaining a blood glucose reading of 293 from Resident #81, Staff E, RN verified a dosage of 4 units of Insulin Lispro to be administered per Resident #81's physician's order. Staff E, RN prepared administration of Insulin Lispro via KwikPen to Resident #81 by gathering Resident #81's Insulin Lispro KwikPen, an alcohol prep pad, and an insulin pen needle before entering Resident #81's room. Staff E, RN explained the procedure to Resident #81 and prepared the Insulin Lispro KwikPen by cleaning the needle hub and applying the needle to the top of the KwikPen. Staff E, RN then dialed 4 units on the dosage selector and administered the medication to Resident #81 in her left abdomen subcutaneously. Staff E, RN did not prime the needle of the insulin KwikPen before dialing the selector to 4 units. An interview was conducted on 08/13/2021 at 11:42 AM with Staff E, RN. Staff E, RN stated that normally she would simply apply the needle to the insulin pen, dial the dosage on the selector, and administer the insulin in accordance with the physician's order. Staff E, RN stated that she was not aware that insulin needles required priming before selecting the dose and administering it to the resident. A telephone interview was conducted on 08/13/2021 at 01:40 PM with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that nursing staff should be paying attention to any instructions included on the manufacturer's box related to medication administration. Nursing staff should instruct residents to rinse their mouth out with water after administration of an oral steroid, such as fluticasone, or they may risk developing oral thrush. The Consultant Pharmacist stated that most insulin pens did require the needle to be primed to remove any air before administration and verified that the Insulin Lispro Flex Pen would require the insulin needle to be primed. An interview was conducted on 08/13/2021 at 03:36 PM with the facility's Director of Nursing (DON). The DON stated that staff were educated on the five rights of medication administration and that nursing staff should be following the manufacturer's instructions when administering medications. If a resident was not instructed to rinse their mouth after receiving an orally inhaled steroid, their mouth could become irritated. The DON stated that the nursing staff may have been moving too fast and were not taking the time to verify the correct dosage as they should. The DON also stated that nursing staff should ensure that insulin pens are primed before administering insulin to residents because the resident may not get the correct dosage due to having air inside of the needle. A review of the facility policy titled Inhaler Administration, effective on 11/30/2014, revealed that staff should check the medication sheet against the instructions on the inhaler canister and to be certain to follow the specific directions that accompany the inhaler. A review of the manufacturer's instructions for the Insulin Lispro Injection KwikPen indicated the following steps under the section titled Priming your Pen: - Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 21 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - To prime your Pen, turn the Dose Knob to select 2 units. Level of Harm - Minimal harm or potential for actual harm - Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Residents Affected - Few - Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. - You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 22 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 - Some 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 review of facility policy and procedures, the facility failed to ensure medications and biologicals were stored, secured, and disposed of in accordance with professional standards related to 1.) not ensuring 1 of 2 treatment carts in the facility remained secured and locked, 2.) not ensuring that 1 of 5 medication carts in the facility remained secured and locked, 3.) not ensuring medications had proper labeling in 1 of 3 medication carts observed, 4.) not ensuring that medications were disposed of and stored properly during observation of medication administration for 1 (Resident #503) of 7 residents observed during medication administration and 5.) not ensuring medications were properly secured during a tour of the facility on 1 of 4 days. Findings included: An observation was made on [DATE] at 08:27 AM of a treatment cart on the 600 unit of the facility. The treatment cart was observed to be unlocked in the unit hallway with no staff members observed in the immediate area. The treatment cart was inspected until 08:36 AM and several staff members walked by the treatment cart during the inspection. An interview was conducted on [DATE] at 08:36 AM with Staff D, Licensed Practical Nurse (LPN) Unit Manager. Staff D, LPN stated that treatment carts on the unit should remain locked at all times when not in use and that all nurses on the unit were responsible for ensuring treatment carts remained secured. Staff D, LPN addressed that nursing staff on the unit were responsible for securing the treatment cart. An observation was conducted on [DATE] at 09:57 AM of a treatment cart on the 600 unit of the facility. The treatment cart was observed to be unlocked in the unit hallway. An interview was conducted following the observation with Staff C, LPN. Staff C, LPN stated that he needed to quickly get some wound care supplies and accidentally left the treatment cart unlocked. Staff C, LPN stated that normally the treatment cart would remain locked if not in use. An observation was made of medication administration on [DATE] at 08:47 AM with Staff A, Registered Nurse (RN). Staff A, RN was observed administering medication to Resident #503. Resident #503 was observed dropping 3 medications onto the floor of her room while trying to pick the medications up one at a time. Staff A, RN was observed picking the medications up and throwing them into Resident #503's trash can. Staff A, RN replaced the medications with new medications from the medication cart and administered them without difficulty. Two round white tablets and an oblong white tablet were observed in Resident #503's trash can following the observation. An interview was conducted on [DATE] at 09:37 AM with Staff A, RN. Staff A, RN stated that they would normally dispose of medications in the Drug Buster solution or in the black box in the unit medication room. Staff A, RN observed the three medications in Resident #503's trash can and stated that he did not even realize that he threw the medications away in the resident's trash can. Staff A, RN stated that he would not normally dispose of medications in a resident's trash can and stated I'm just not focused. Staff A stated that he had been a nurse for a long time and that he knew the proper way to dispose of medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 23 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 - Some An observation was conducted on [DATE] at 02:00 PM of a treatment cart on the 600 unit of the facility in front of room [ROOM NUMBER]. The treatment cart was observed to be unlocked at the time of the observation and a resident was observed opening the bottom drawer of the cart. An interview was conducted following the observations with Staff E, RN. Staff E, RN was observed closing and locking the cart while re-directing the resident away from the treatment cart. Staff E, RN stated that the treatment cart should remain locked at all times when a staff member is not present. An interview was conducted on [DATE] at 08:17 AM with Staff D, LPN Unit Manager. Staff D, LPN stated that nursing staff were to use the Drug Buster solution in the medication storage room to dispose of any non-controlled medications and would not expect the nursing staff to simply dispose of medications inside of a regular trash can. An observation of medication administration was conducted on [DATE] at 08:21 AM in the 200 hall of the facility with Staff V, LPN. Staff V, LPN was observed entering a resident's room after dispensing medications from the medication cart and left the cart unlocked while inside of the resident's room. After administering medications to the resident, an interview was conducted with Staff V, LPN. Staff V, LPN addressed that she had left the medication cart unlocked after stepping away from it and stated that she had left the cart unlocked because she had the cart positioned close to the resident's room and was able to keep an eye on it. An inspection of a medication cart was conducted on [DATE] at 09:05 AM with Staff I, LPN on the 100 unit of the facility. A vial of Latanoprost 0.005% eye drops were observed stored inside of the manufacturer's box and inside of a plastic storage bag. The plastic storage bag contained the medication label as well as a yellow label that read Date Opened and Discard After 42 Days. No date was documented in the Date Opened section of the label. The date of opening was also not documented anywhere on the manufacturer's box. An open manufacturer's box of Symbicort 160-4.5 was observed inside of the medication cart with a green label that read Date Opened and Discard After 90 Days. No date was documented in the Date Opened section of the label. An interview was conducted following the observations with Staff I, LPN. Staff I, LPN stated that medications such as inhalers and eye drops should be dated when they were opened by either using the label provided by pharmacy or labeling the date somewhere on the box. Staff I, LPN addressed that the Latanoprost eye drops and Symbicort inhaler should have had dates labeled on them to indicate when they were opened. On [DATE] at 11:18 a.m., an unsupervised medication cart was observed positioned up against the wall between resident rooms [ROOM NUMBERS]. There were no nurses at or around the cart. Further, the nurse Employee C was overheard in a resident room down the hall, approximately twenty-five feet from the medication cart. Employee C was in another resident room assisting with medication pass. During the time of the observation, the unsupervised medication cart was observed with a small clear plastic cup placed on the top surface of the cart. The medication cup was observed with 10 various medication capsules and tablets. The cup was labeled in black marker, waste. Photographic evidence was taken. From 11:20 a.m. through to 11:23 a.m. there were two residents who were self propelling while seated in their wheelchairs, up and down the hallway and passing the medication cart with the cup of medications on it. There were no nursing staff at or around the medication cart where the unsecured medications were. At 11:24 a.m. Nurse Employee C was observed to walk out from a room down the hall and approximately twenty-five feet from the medication cart. He was then asked about the state of his medication cart and he confirmed the cup of medications. He explained that they are empty capsules and they are to be wasted/discarded. However, further evidence revealed two tablets, among the empty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 24 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 - Some capsules. He confirmed that the cup of medications were not supervised while he was in other residents' rooms and that he does know to secure the medications even if they are in a cup that is labeled waste. On [DATE] at 1:00 p.m. an interview with the Director of Nursing (DON) revealed that medications should never be left unsupervised, and especially left on top of a medication cart that is not supervised. She revealed that even though the medication cup read, waste on it, it still should have been locked in the medication cart and kept away from free access of passing residents in the hallway. A telephone interview was conducted on [DATE] at 01:40 PM with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that she was at the facility on [DATE]. During her visit she observed the facility for medication storage issues, including cleanliness of the carts, organization, and for any expired and undated medications. The Unit Managers would also conduct audits related to medication storage. Nursing staff should ensure that medication and treatment carts remain locked when they are not supervising them and that typically the nurse that has the keys to the cart would be the one responsible for ensuring that the cart is kept secured. The Consultant Pharmacist stated that she would expect nursing staff in the facility to follow facility policy related to disposal of medications. An interview was conducted on [DATE] at 03:36 PM with the facility's Director of Nursing (DON). The DON stated that nursing staff should be using the Drug Buster solution in the medication room to dispose of any medications that needed to be wasted and that she would not expect nursing staff to use a regular trash can to dispose of medications. Medication and treatment carts should remain locked at all times, even if the nurse quickly steps away from it. Unit Managers should also be ensuring that medication and treatment carts remain locked at all times. A review of the facility procedure titled Storage and Expiration of Medications, Biologicals, Syringes, and Needles, last revised on [DATE], revealed the following procedures: - The Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. - The Facility should ensure that medications and biologicals have an expiration date on the label. - Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. A review of the facility policy titled Medication and Medication Supply Storage and Disposal, effective on [DATE], revealed under the section titled Policy, that central storage of medications is required for prescription, prescribed over-the-counter medications, and Complimentary and Alternative Medicine will be kept in a locked area, in their original labeled container, and may not be removed more than 2 hours prior to the scheduled administration. Meds will be kept in a medication cart that locks and keys are only accessible to the licensed personnel distributing medications. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 25 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, observation, and policy review the facility did not ensure services were obtained to determine the appropriate therapeutic diet for one resident (#64) of nine residents receiving hospice care at the facility. Findings included: Resident #64 was readmitted to the facility on [DATE] with diagnoses including but not limited to, heart failure, type II diabetes mellitus, and Afib (atrial fibrillation), according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #64 was cognitively intact. Further review under Functional Status reflected the need for supervision with set up help for eating. A review of Section K, Swallowing/Nutritional Status, revealed Resident #64 did not have a swallowing disorder at the time of the assessment, nor was he receiving a therapeutic diet. Review of Section O, Special Treatments, Procedures, and Programs reflected Resident #64 was receiving hospice care. Speech-Language Pathology and Audiology Services were not marked, indicating Resident #64 was not receiving any services. On 8/12/21 at 11:38 AM an interview was conducted with the resident's nurse, Staff E, LPN (licensed practical nurse). Staff E, LPN said Resident #64 stopped eating as much as he used to eat. His appetite is poor now. Staff E, LPN also said she has spoken to Resident #64's wife and asked her to talk to him on the phone to get him to eat. He is confused sometimes. He seems to understand. He can answer questions appropriately. Staff E, LPN said a hospice nurse came about a week ago and she told the hospice nurse about his poor intake. His food is pureed now. I thought he was having trouble so I consulted speech therapy who evaluated him and changed it to pureed. He can't cut and eat the meat. It's too hard. We keep jello in there. He will take that. On 8/12/21 at 11:47 AM an interview was conducted with the unit manager, Staff D, LPN. Staff D, LPN unit manager said Resident #64 was at hospice house at Company Name hospice. They had to repair the building so they sent their patients out. Resident #64 has been here before. His wife wanted him here. His wife ended up in the hospital and when she got out she didn't want him home because she can't take care of him. So he will be staying here. Staff go by the care plan that's in the chart. MDS makes the care plans. On 8/12/21 at 12:39 PM an observation was conducted in Resident #64's room. There were two gelatin cups on the bed side table in front of Resident #64, that were unopened. The lunch meal tray was on the dietary cart outside Resident #64's room in the hallway. The meal was untouched. There was pureed meat, a pureed vegetable, mashed potatoes, pureed lemon cake, and tea. On 8/13/21 at 9:37 AM an interview was conducted with Staff F, OT (occupational therapist). Staff F, OT said the last speech evaluation for Resident #64 was completed on 4/29/21. On 8/13/21 at 9:39 AM an interview was conducted with the director of therapy. The director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 26 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy said there has not been a therapy referral for Resident #64. Normally hospice will come and give us any information for him. Review of physician's orders in the medical record reflected a diet order dated 6/25/21 Regular diet, regular texture, regular thin liquids consistency. Further review of the orders revealed speech therapy services were not ordered. An order dated 8/5/21 indicated hospice services with Company Name Hospice Dx (diagnosis) CHF (congestive heart failure). A review of the care plan dated 4/28/21 revealed, The resident is at nutritional risk r/t (related to) multiple medical dx (diagnoses) including UTI (urinary tract infection), DM (diabetes mellitus), htn (hypertension), anemia, BMI/obese class 1, potential for weight fluctuation r/t hx (history) edema, usually declines to be weighed, weight changes noted on readmit, end stage dx (diagnosis)-provided hospice services. Interventions included provide and serve diet as ordered. A review of nurses' notes in the electronic medical record from readmission on [DATE] to 8/12/21 reflected no documentation of any changes or communication with hospice. An 8/10/21 dietary note indicated a regular diet. Continue with nutritional care plan. There were no notes indicating the provider or hospice had been contacted regarding a change to Resident #64's diet and the reason. Review of the physical chart at the nurses' station on 8/12/21 also reflected no documented communication to or from hospice. On 8/13/21 at 10:17 AM an interview was conducted with the CDM (certified dietary manager) at the facility. The CDM said staff give her a yellow slip that says diet change. She gets on the computer and enters it in meal tracker. Whatever staff give her is what she enters in the meal tracker. The CDM was shown the physician's order for a regular diet, regular texture, and she confirmed the order. The CDM provided a yellow Diet Order and Communication form dated 8/9/21, indicting a change to Dysphagia puree. Review of the form during the interview reflected it did not match the physician's order. The CDM also provided the meal ticket dated 8/13/21, which was reviewed and reflected pureed food for breakfast, lunch, and dinner. A telephone interview was conducted with Staff U, RN (registered nurse) manager of Company Name hospice on 8/13/21 at 11:08 AM. Staff U, RN manager said there is a packet with consents with advance directives, certs and recerts, IDT (interdisciplinary) notes, care plans and contact information. I made one for him. I go by monthly and check to see if its there. I check the chart and if its not there I recreate it for them. We admitted him on 5/13. I made him a brand new one when he came back. I don't know what the facility does with it. I don't see an order for a pureed diet. They should contact us for a diet change. We would approve a speech consult if they wanted one as well. We have him on a regular diet. The latest note said regular. That was last Friday. It was 8/6. We meet every two weeks to review all our patients. That note (8/6) indicated a regular diet. I don't see where the facility notified us or requested a speech eval. The last note says his appetite varies related to agitation and facility versus outside food. We have not approved a speech evaluation. On 8/13/21 at 1:24 PM a follow up interview was conducted with Staff D, LPN unit manager. Staff D, LPN unit manager said He got choked one day. Hospice won't cover an eval (for speech therapy). The hospice nurse said she can't guarantee any visits for speech therapy. She might be able to get an eval. Staff E, LPN said she talked to the speech therapist who told her to down grade his diet. Staff D, LPN unit manager said she doesn't know if Staff E, LPN told hospice his diet was down graded. Staff D, LPN unit manager confirmed there should be documentation of a change of condition indicting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 27 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0808 physician and family were notified, as well as notification to hospice. Level of Harm - Minimal harm or potential for actual harm On 8/13/21 at 1:45 PM an interview was conducted with the SLP (speech language pathologist) at the facility. She said she did not get a referral. We have to wait for hospice to refer them before we go in and see them. She has not heard anything about Resident #64. She has not laid eyes on him. No one has said anything to her about him. Hospice referred him today. Residents Affected - Few On 8/13/21 at 2:29 PM an interview was conducted with the DON. She said if we observe a patient having chewing or swallowing problems while eating we as nurses can down grade the diet. Then they should make a therapy referral for speech to come and do a screen. The DON also confirmed there should be notification to the doctor, the family, hospice, and speech therapy. If the nurse down grades the diet there should be documentation. She also confirmed there should be a change of condition completed. Staff will come to her if their is a concern. The nurses notify hospice of a change of condition. It should be documented. Hospice should be notified of any changes. Review of the policy Notification of Change in Condition, dated 12/16/20, reflected the following: Policy: The Center to promptly notify the patient. resident, attending physician, and the resident representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and resident representative when there is a(n): Significant change in he patient/resident's physical, mental, or psychosocial status Need to alter treatment significantly New treatment Discontinuation of a current treatment due to but not limited to: acute condition exacerbation of a chronic condition The nurse to complete an evaluation of the patient/resident. Document evaluation in the medical record. The nurse will contact the physician. Notify the patient/resident and the resident representative of the change of condition. Document notification in the medical record. Review of the policy, Physician Orders, revised 3/3/21 revealed the following information: Policy: The center will ensure that physician orders are appropriately and timely documented in the medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 28 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0808 record. Level of Harm - Minimal harm or potential for actual harm Procedure: Routine orders: Residents Affected - Few A nurse may accept a telephone order from he physician, physician assistant, or nurse practitioner (as permitted by state law). The order will be repeated back to the physician, PA, or ARNP (nurse practitioner) for his/her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record). Review of the policy, Hospice Care, revised 9/20/17, reflected the following relevant information: Policy: The center supports the patient/resident's right to a dignified existence and self determination. The center will assist the patient/resident and/or legal representative in arranging hospice services. Procedure: When hospice are provided in the center, the center should meet the following: Ensure hospice services meet professional standards and principles that apply to individuals providing services in the center, and to the timeliness of the services. The center will have a written agreement with hospice that is signed by an authorized representative from the hospice and the center (prior to providing services to a patient/resident). The agreement to include but not limited to: the services that hospice will provide Hospice's responsibilities for determining the appropriate hospice plan of care The services the center will continue to provide according to the patient/resident's plan of care. The communication process, including how the communication should be documented between the center and the hospice, to ensure the needs of the patient/resident are met 24 hours a day. The center should immediately notify the hospice when: The patient t/resident experiences a significant change in condition including physical, mental, social or emotional Clinical changes suggest a need to alter the plan of care. The center will furnish 24 hour room and board, and meet the patient/resident's personal and nursing care needs in coordination with hospice based on the patient/resident's individual plan of care. Hospice assumes responsibility for determining the appropriate course of hospice care, including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 29 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 0808 the determination to change the level of services provided. Level of Harm - Minimal harm or potential for actual harm Hospice responsibilities include but are not limited to: Provide medical direction and management of the patient/resident, nursing, counseling, social work Residents Affected - Few To ensure continuity of care between the center and the hospice provider, the director of nursing will designate a clinical member of the interdisciplinary team to work with hospice including the following: Coordination of the care plan process between the hospice and the center Communication with hospice representatives, hospice medial director and the patient/resident's attending physician to ensure coordination of care Ensure the following information is obtained from the hospice: Most recent hospice plan of care Provide education to the hospice staff on the center policies and procedures, including: resident rights, documentation and forms The center will ensure the care plan includes the most current hospice plan of care and the center's plan to attained or maintain the patient/resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 30 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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** 5. On 08/10/21 at 6:12 a.m. an observation was conducted. Staff T, Dietary Aide entered the facility through the front door entrance to the lobby. Staff T, Dietary Aide walked past the front desk through the double doors without screening or getting a temperature check. A lab technician was also observed entering through the front door of the facility. The lab technician walked past the screening area at the front desk and entered the facility through the double doors from the lobby. An interview was conducted with Staff B, RN/Unit Manager (UM) during the observation. Staff B, RN/UM did not stop the lab technician or Staff T, Dietary Aide to request a screening or temperature check. Staff B, RN/UM confirmed that Staff T, Dietary Aide and the lab technician did not stop at the desk for the COVID-19 screening or temperature check. Staff B, RN/UM confirmed they are supposed to fill out the screening form and get a temperature check prior to entering the facility. Residents Affected - Few On 8/12/21 at 12:34 p.m. an interview was conducted with the DON. The DON confirmed the lab technician and Staff T, Dietary Aide did not fill out a COVID-19 screening form or have their temperatures checked. She said the lab technician was already gone when she arrived. Staff T, Dietary Aide didn't do the screening. She said she did not know if Staff T, Dietary Aide came back and screened or not. On 8/13/21 at 11:31 a.m. an interview was conducted with the DON and Assistant Director of Nursing (ADON), who was the infection preventionist at the facility. The ADON said the expectation is that prior to entering the facility staff and vendors come through the front entrance and get a temperature check and then the receptionist asks the screening questions captured on the COVID screening form. During off hours they have their temperature checked and find a nurse who verifies the screening. A review of the COVID screening form for staff, revised 4/29/21, reflected a box for a temperature, screening questions for COVID-19 symptoms, exposure to COVID-19, screening for infection with COVID-19, return to work screening, travel questions, and an area at the bottom for the screener to fill out. A review of the Visitor/Vendor screening, dated 4/29/21, reflected a box to mark a temperature check, an area with COVID symptom screening, vaccination status, exposure, instructions for the screener to direct the visitor/vendor to perform hand hygiene, and provide PPE (personal protective equipment) for compassionate care givers or visitors. The bottom of the form indicated a line for a screener to sign, indicating the visitor/vendor was screened. A review of the policy, undated, titled, Emergency Procedure-Pandemic COVID-19, revealed the following findings: 1. The following procedure should be utilized in the event of a Pandemic COVID-19 outbreak in the community. 2. Employees including contract employees, should be evaluated and observed at the beginning of each shift for signs and symptoms of COVID-19 (including temperature check). Employees should be instructed to self report symptoms and exposure. 5. Health care personnel (including but not limited to, physicians, physician extenders, hospice providers, laboratory and radiology staff) will be screened and observed for COVID-19 signs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 31 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few symptoms (including temperature check) and instructed to perform hand hygiene, provided information on self monitor for respiratory symptoms for 14 days after visit and notify the facility of the date of the visit and location. Based on observations, interviews, record reviews, review of facility policy, and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 by 1.) failing to post appropriate signage related to transmission based precautions on 2 resident rooms (406 and 408) of 11 resident rooms under transmission based precautions, 2.) failing to ensure that two staff members (H, A) donned appropriate Personal Protective Equipment (PPE) before entering the rooms of 2 resident's rooms (606 and 608) of 11 resident rooms on transmission based precautions, 3.) failing to ensure that PPE was doffed by 3 staff members (G, H, A) prior to exiting the rooms of 2 residents (406 and 606) of 11 resident rooms under transmission based precautions, 4.) two staff members (H, W) failing to wear protective face masks properly throughout the facility in 2 hallways (200 and 600) of 6 hallways in the facility, and 5.) failing to ensure one staff member (T) and one visitor (Lab Technician) were appropriately screened for signs and symptoms of COVID-19 before entering resident care areas on 1 of 4 days observed with the potential to affect a census of 101 residents. Findings included: 1. An observation was conducted on 08/10/2021 at 6:57 a.m. in the 400 unit of the facility of Staff G, Certified Nursing Assistant (CNA) exiting room [ROOM NUMBER]. Staff G, CNA stated that the resident in 406 was on droplet isolation precautions. Staff G, CNA was observed wearing an N95 mask, an isolation gown, and eye protection when she walked out of room [ROOM NUMBER] and into the unit hallway. Staff G, CNA stated that she would not normally wear PPE in the unit hallways and doffed the isolation gown she was wearing while standing in the unit hallway, and then disposed of the isolation gown in the trash can near the exit of room [ROOM NUMBER]. No signage was observed on the door of room [ROOM NUMBER] indicating that the resident was on droplet isolation precautions. Staff G, CNA stated, They must have ran out. Staff G stated all of the residents in the 400 hallway were on droplet isolation precautions. No signage was observed on the door of room [ROOM NUMBER] to indicate the residents in the room were on droplet isolation precautions. (Photographic Evidence Obtained) 2. An observation was made on 08/10/2021 at 8:10 a.m. during a breakfast meal tray pass on the 600 unit of the facility. Staff H, CNA was observed exiting room [ROOM NUMBER] wearing an isolation gown, a surgical mask, and a face shield while carrying a resident's tray down the hall and onto the tray cart. An observation of the door of room [ROOM NUMBER] revealed that the residents in the room were on droplet isolation precautions. Staff H, CNA then went back into room [ROOM NUMBER] to doff the PPE before exiting the room again. Staff H, CNA then entered room [ROOM NUMBER] to retrieve a meal tray. An observation of the door of room [ROOM NUMBER] revealed that the residents in room [ROOM NUMBER] were on droplet isolation precautions. Staff H, CNA did not don an isolation gown or gloves before entering room [ROOM NUMBER]. Staff H, CNA was observed taking the meal tray out of room [ROOM NUMBER] and placing it onto the meal cart. Staff H, CNA then donned an isolation gown, dropped her face shield onto the floor of the hallway, placed the face shield back on, and entered room [ROOM NUMBER] again. An interview was conducted on 08/10/2021 at 8:49 a.m. with Staff H, CNA. Staff H, CNA stated that the residents in 606 and 608 were on droplet isolation precautions and that staff were to don an N95 mask, eye protection, an isolation gown, and gloves before entering the room. Staff H, CNA addressed that she was only wearing a surgical mask and stated she should have an N95 mask on, but she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 32 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not had time that morning to get an N95 mask from the front desk. Staff H, CNA was not able to explain why she did not obtain an N95 mask when she entered the building at the beginning of her shift. Staff H, CNA stated she would not normally wear PPE out in the unit hallways and was not able to state why she wore PPE in the unit hallway. Staff H, CNA stated that she did not don an isolation gown before entering room [ROOM NUMBER] because the isolation gown did not properly fit her, but then addressed that she donned an isolation gown when re-entering room [ROOM NUMBER]. Staff H, CNA stated they would normally use bleach wipes to sanitize face shields if they become soiled and addressed that she did not sanitize her face shield after dropping it on the floor of the unit hallway before putting it back on. 3. An observation was conducted on 08/10/2021 at 10:01 a.m. of Staff A, Registered Nurse (RN) on the 600 unit of the facility. Staff A, RN was observed entering room [ROOM NUMBER] to administer medications and wearing an N95 mask, face shield, gloves, and an isolation gown. The isolation gown was observed to be not tied in the back or at the neck and was observed to be hanging off of the shoulders of Staff A, RN while in room [ROOM NUMBER]. Staff A, RN was observed exiting room [ROOM NUMBER] with the isolation gown balled up in his hand. Staff A, RN then disposed of the isolation gown in the trash can of the medication cart. An interview was conducted on 08/10/2021 at 10:10 a.m. with Staff A, RN. Staff A, RN stated that the residents in room [ROOM NUMBER] were on droplet isolation precautions to monitor for signs and symptoms of COVID-19 and that an isolation gown, N95 mask, gloves, and eye protection were worn when inside of the room. Staff A, RN stated that he disposed of his isolation gown in the trash can of his medication cart because the trash can inside of room [ROOM NUMBER] did not have a trash bag in it. Staff A, RN stated he would normally dispose of PPE before exiting the resident's room. 4. An observation was conducted on 08/13 2021 at 8:38 a.m. on the 200 unit of the facility of Staff W, CNA. Staff W, CNA was observed wearing an N95 mask in the unit hallway with the bottom strap of the mask hanging below her chin. An interview was conducted following the observation with Staff W, CNA. Staff W, CNA stated that she would normally have both straps of the N95 mask in place, but she had taken the mask off in the bathroom and did not put both straps back on. Staff W, CNA addressed the proper way to don the N95 mask would be to have both straps properly in place. An interview was conducted on 08/13/2021 at 2:34 p.m. with the facility's Infection Preventionist (IP). The IP stated residents that were newly admitted to the facility were placed on droplet isolation precautions and monitored for fourteen days for any signs or symptoms of COVID-19. Signage should be placed on the door to indicate that a resident is on transmission-based precautions and PPE should be available outside of the resident's room. The IP stated signage and PPE should be put into place upon admission by the floor nurse. Staff should be conducting hand hygiene, applying the isolation gown tied around their waist and neck, KN95 with surgical mask over top, eye protection, and gloves when entering the room of a resident on droplet isolation precautions. Garbage cans should be right near the door of the resident rooms and staff should be taking off soiled gloves first, perform hand hygiene, clean eye protection, perform hand hygiene, untie gown, roll into itself, and dispose of it in the trash can, then remove the surgical mask on top of the KN95 mask and perform hand hygiene before exiting the room. The IP stated staff should not be wearing PPE in the unit hallways and staff should not be breaking the plane of the door with PPE still on. PPE should be disposed of in the resident's room before exiting and not in the medication cart trash can. Isolation gowns should be tied and should not have any strings hanging untied off the gown. A regular surgical mask should not be donned without an N95 or KN95 mask, which are available at the front of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 33 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 08/13/2021 at 3:36 p.m. with the facility's Director of Nursing (DON). The DON stated that any resident that is under transmission-based precautions should have the appropriate signage on the door and that Unit Managers or the floor nurses should be ensuring that the signage and PPE were put into place when the resident arrives at the facility. The DON stated that signage may not have been placed on the doors because the floor nurse may not have known where to find the appropriate signage to put on the door. The DON stated she would not expect to see a staff member wearing PPE in the unit hallways and they should be doffing PPE when in the resident's room. Staff are expected to wear either a KN95 or an N95 mask and not just a regular surgical mask when on the unit. Staff should be provided with an N95 mask when they enter the facility for their shift if they do not have one. The DON stated all staff were educated on the proper PPE donning and doffing procedures and how to proper wear PPE. The DON stated she would not expect to see staff wearing an isolation gown untied or wearing an N95 mask with a strap not properly in place. A review of the CDC website (https://www.cdc.gov/coronavirus/2019-nocv/hcp/infection-control-reommendations.html) revealed guidelines, dated 2/23/21 with updates as of 02/10/2021, to help prepare long term care facilities for COVID-19. The guidance revealed, under the section titled, Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19, that although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. Facilities should establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days. The section of the guidance titled, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 Infection, revealed that HCP (health care personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use an N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. HCP must receive training on and demonstrate an understanding of when to use PPE, what PPE is necessary, how to properly don, use, and doff PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE, and the limitations of PPE. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 34 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 observations, and staff interviews, the facility failed to ensure resident traffic areas and resident spaces were kept safe during three of four days observed (8/10/2021, 8/11/2021, and 8/12/2201). It was determined that a large remote air conditioner handler was plugged into an extension cord, which was stretched out causing a non-safe walking area. Two (#65, #69) of seven total residents that were ambulatory were observed to be walking near the cords. Residents Affected - Few Findings included: On 8/10/2021 from 6:10 a.m. through to at least 2:00 p.m. the North wing was toured and observed on the main floor, across from the nurse station and next to the soiled utility room, there was a large satellite air conditioner handler with tubing leading from the machine and going up through ceiling tiles. Interview with the floor staff had all indicated the air conditioning was not working well on the hallways and this unit has been placed in this spot for about three weeks or so. The unit was observed in an area where staff and resident frequent. Photographic evidence was taken. Further observations of the unit revealed it was plugged in to a long orange twenty foot extension cord and plugged into the wall approximately fifteen feet away from the machine. The cord was observed coiled on the floor at the machine and near the door frame of the soiled utility room. Further, the cord was on the floor passing two other doors/spaces to include the storage room and clean utility room. Residents were observed either walking at and near this area with the cord or seated in wheelchairs at and over the cord. Photographic evidence was taken. On 8/11/2021 at 6:50 a.m. the air handler was observed in the same place with the same observations with the power cord and unit cord coiled on the floor presenting a tripping hazard near the soiled utility closet, at the storage closet, and the clean utility closet. At 8:28 a.m. Resident #69 was observed walking from his room and shuffling his feet and walking with slightly unbalanced gait. He walked all the way to the air handler and started to go in the soiled utility closet behind a staff member. He walked and stepped on the power cord from the air handler and the aide then touched his right shoulder and backed him away from the area and walked with him to his room. Review of resident #69's medical record revealed he was admitted to the facility on [DATE]. Review of the 6/29/2021 Quarterly Minimum Data Set (MDS) assessment revealed the following areas: Cognition/Brief Interview Mental Status or BIMS score 3 of 15, which indicated the resident had severe cognitive impairment. Also Resident #65 was observed many times of the day walking out from her room and shuffling her feet while walking to the nurse station. She was observed shuffling her feet at and near the area of the air handler and extension and power cord. She had been noted several times touching the cords with her feet. Review of resident #65's medical record revealed she was admitted to the facility on [DATE]. Review of the 5 day MDS assessment dated [DATE] revealed the following areas: Cognition/BIMS score 3 of 15, which indicated the resident had severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 35 of 36 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/13/2021 at 1:00 p.m. an interview with the Nursing Home Administrator confirmed that the air handler was in the North unit hallway and has been there to provide air in the hallways for about three weeks. She revealed that they are awaiting parts to come in to fix the hallway air conditioner. The Nursing Home Administrator revealed that the Maintenance Director who set up the remote air handler is no longer employed by the facility and she, nor her floor staff paid enough attention that this device was plugged into an extension cord and stretched out on the ground passing several spaces/doors. Work orders or paperwork related to the use of the remote handler could not be obtained from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 36 of 36