Health inspection·May 25, 2023

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/25/23 at 09:02 a.m., The SSD stated they had located Resident #60's money. She said, It was in the safe the whole time. His money was here, and no one knew about it. The SSD stated she did not know who had put the money in the safe and why it was not accounted for per their procedures. She stated she did not know how much it was but would find out and update Resident #60. On 05/25/23 at 09:32 a.m., an interview was conducted with Staff I. She stated if the resident brought in cash, someone should have gone to get him a money order so they can deposit the money. She stated social services would normally do this. Staff I said, someone should have documented that the money and his personal belongings were in the safe. On 05/25/23 at 09:40 a.m., a follow up interview was conducted with the NHA, DON (Director of Nursing) and The Regional Clinical Nurse. The DON stated if nursing would have received the resident's wallet it would have been inventoried. A review of the inventory sheet revealed these items were not indicated. The DON stated the resident was originally admitted in December. The DON said, We should have accounted for it. The NHA stated this was before her time, and she could not speak of the process. She said, I would expect a resident to have access to their personal belongings and personal funds. She stated Resident #60 should have had his money this whole time. On 05/25/23 at 11:10 a.m. the NHA stated they did not have a policy on personal funds/personal belongings, but they exercise the Resident's Rights and Responsibilities expectations. She said, However, I would expect staff to complete a full inventory when the resident comes in. If they are alert and oriented ask them what they would like with their belongings. If something needs to be secured, we put it in the safe. We should keep an inventory of what is in the safe and SSD should have a copy. A review of an undated document titled Resident's Rights and Responsibilities, showed the resident has a right to know in advance what charges the facility may impose against your personal funds. Choose to deposit your personal funds with the facility in which the facility must act as a fiduciary and hold, safeguard and manage your funds. Earn interest on any funds in excess of $100.00 that is deposited with the facility. Choose not to deposit your personal funds with the facility. Receive full complete and separate accounting of your funds according to acceptable accounting principles. Receive financial statements at least quarterly and upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 2 of 23 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 05/25/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility did not ensure a safe, clean, and homelike environment related to proper cleaning and maintenance in nine resident bathrooms (400, 401, 402, 403, 404, 405, 406, 407, and 409) out of ten bathrooms reviewed, two resident room baseboards (402 and 407) out of ten resident rooms observed, and one resident room wall (407) out of ten resident rooms observed. Findings included: An observation was made on 5/22/23 at 9:30 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet, a space between the base of the toilet and the floor was visible. The screws for the bowl base were rusted and dusty. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 9:40 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a brown substance at the base of the toilet. On the window wall beneath the air conditioner the baseboard was not sticking to the wall. The baseboard was protruding past the air conditioner. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 9:45 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a brown substance at the base of the toilet. On the window wall beneath the air conditioner the baseboard was protruding past the air conditioner, not attached to the wall. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 9:50 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet. There was a gap between the toilet base and floor. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:02 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black substance around half of the toilet base. There was a gap between half of the base and floor, that had no caulking. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:15 a.m., in resident room [ROOM NUMBER] and the bathroom. The bathroom toilet had a brown substance at the base of the toilet. On the window wall the baseboard was protruding past the air conditioner. The baseboard was not sticking to the wall. The wall of the resident's over bed light to 407 B was a hole, directly next to the headboard. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:33 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet. There was a gap between the toilet base and floor. The screws for the toilet base were rusted and had dust build up on them. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 10:38 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a brown substance at the base of the top of the tank of the toilet. (Photographic Evidence Obtained.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 3 of 23 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 05/25/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation was made on 5/22/23 at 10:45 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet. (Photographic Evidence Obtained.) On 5/25/23 at 1:10 p.m. an interview was conducted with the District Housekeeping/Laundry Manager (DM) stating there is a department head assigned to all rooms. The department heads are supposed to speak to the resident's and/or families and observe the physical plant for any needs of attention. During the interview, an observation was made with the DM in room [ROOM NUMBER] bathroom. When the DM noted the toilet base, she stated oh yes, that could probably be scrubbed, oh goodness, I think that the seal is gone. Maintenance would take care of that part. Continued observations with the DM into the hallway outside of room [ROOM NUMBER] and noted the baseboard protruding past the air conditioning unit. DM stated we should have noted this while mopping was being done and inform Maintenance. DM stated the expectations are for the housekeepers to clean and scrub to the best of their ability and notify their supervisor or Maintenance of any repairs that need or if they are unable to remove a substance. On 5/25/23 at 1:31 p.m. an interview was conducted with the Nursing Home Administrator (NHA), regarding the toilet bases, baseboards, and the hole in the resident room's wall. The NHA stated, oh yes, that needs to be caulked. NHA continued to state there is a lot of maintenance that is needed here, we have a lot to do. A facility policy titled, PREVENTATIVE MAINTENANCE PROGRAM, dated 4/1/22 and revised on 3/10/23, showed: The purpose: to develop and implement a preventative maintenance program that promotes a safe, functional, and comfortable environment for all residents. Procedure: 1. The facility's maintenance program is based on regular and routine maintenance designed to maintain a safe, comfortable, operating environment. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, significant event reviews, life safety requirements, and/or experience. 3. This should include but is not limited to: a. Essential mechanical, electrical, life safety and patient care equipment; b. Well lighted and well-ventilated rooms and common areas; c. Resident furniture such as bed-side cabinet or drawer spaces; d. Maintain comfortable sound levels; e. Secure handrails; f. Effective pest control; g. Maintain nurse call system; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 4 of 23 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 05/25/2023 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 h. Maintain comfortable and safe temperature level between 71-81 degrees Fahrenheit; Level of Harm - Minimal harm or potential for actual harm i. Kitchen/Dietary Equipment; j. Therapy Equipment; Residents Affected - Some 4. The Maintenance Director should maintain a system for routine audits of each of the areas above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 5 of 23 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 05/25/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of the admission Record for Resident #16 showed she was admitted on [DATE] with diagnoses of autistic disorder, dementia in other diseases classified elsewhere, unspecified severity, with agitation, anxiety disorder, mood disorder due to known physiological condition with mixed features, and major depressive disorder and the resident was not assessed for PASARR Level II. The PASARR Level I assessment dated [DATE] indicated a related condition of autism and no other qualifying mental health diagnoses. Section I Active Diagnoses of the Minimum Data Set (MDS) dated [DATE] showed Resident #16 had diagnoses to include depression, bipolar, and autistic disorder. A review of the admission Record for Resident #1 showed she was admitted on [DATE] with diagnoses of anxiety disorder, schizoaffective disorders, and major depressive disorder and the resident was not assessed for PASARR Level II. The PASARR Level I assessment dated [DATE] indicated diagnoses to include anxiety disorder, depressive disorder, and schizophrenia and showed that a Level II PASARR evaluation was not required. Section I Active Diagnoses of the MDS dated [DATE] showed Resident #1 had diagnoses to include anxiety disorder, depression, and schizophrenia. Based on record review, staff interviews, and review of the facility's policy, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR's) were completed accurately for 5 of 6 residents reviewed, (#60, #18, #68, #16 and #1). Findings included: A review of Resident #60's admission record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder. A review of current physician orders for Resident #60 dated 05/05/23 showed the resident was receiving Mirtazapine 7.5 MG (Milligrams) by mouth daily for depression. A minimum data set (MDS) dated [DATE], section I, showed the resident had a diagnosis of depression. A review of a level I PASARR for Resident #60 dated 12/20/22 revealed no diagnosis were checked. A review of Resident #18's admission record dated 05/23/23revealed the resident was admitted to the facility on [DATE] with diagnoses to include Major depressive disorder, Vascular Dementia with behavioral disturbance, and Mild cognitive impairment. A review of a level I PASARR for Resident #18, dated 5/23/17 showed upon admission no diagnosis were checked to indicate Resident #18 had any diagnoses of Mental illness or suspected mental illness. A review of Resident #68's record showed the resident was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 6 of 23 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 05/25/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm A review of Resident #68's Medication Administration Record (MAR) dated 05/25/23 showed the resident was receiving an antipsychotic medication, Depakote 500mg for encephalophagy, a disease of the brain, Levetiracetam oral solution for seizures, and Trazodone HCI oral tablet 50mg daily for depression, effective 1/18/23. Residents Affected - Some An MDS dated [DATE], Section I showed active diagnoses of a neurological diagnosis Aphasia, Cerebrovascular accident (CVA) a psychiatric diagnoses were not indicated. A review of resident #68's PASARR showed upon admission no diagnosis were checked to indicate Resident #68 had any diagnoses of mental illness or suspected mental illness. On 05/24/23 at 11:11 a.m. an interview was conducted with the Social Services Director (SSD). She stated the PASARRs should have been checked to indicate mental diagnoses present upon admission. She stated their process is review PASARRs on admission, but they had not gotten around to it. She stated the DON (Director of Nursing) should be completing them because she did not have access. She stated either way, they should have been reviewed and corrected. On 05/24/23 at 11:13 a.m., an interview was conducted with the Regional Clinical Nurse. She stated they were putting a plan in place to review all the PASARRs in all their facilities to make sure they were accurate. She stated when the residents are admitted to the facility, they come with PASARRs completed from the hospital that are often inaccurate. She stated it was their responsibility to ensure they were updated to match the admitting diagnoses. A review of a facility policy titled, PASARR, dated 04/01/22, showed the facility shall insure each resident in a nursing facility it's screened from a mental disorder (MD) or intellectual disability(ID) prior to admission and that individuals identified with MD or ID are evaluated to receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate state designated authority. The facility should ensure that individuals with a mental disorder or intellectual disability continues to receive care and services they need in the most appropriate setting when a significant change in their status occurs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 7 of 23 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 05/25/2023 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 observations, interviews, and record reviews, the facility failed to ensure proper treatment of newly identified skin impairments and failed to ensure proper treatment of existing skin conditions were implemented for one (Resident #12) of three residents sampled for skin conditions. Residents Affected - Few Findings included: A review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, hypertension, and muscle weakness. A review of Resident #12's physician's orders revealed a wound care order dated 5/22/2023 to cleanse wound to right shin with normal saline, pat dry, apply xeroform gauze layers, and cover with abdominal pad twice weekly on Monday and Thursday on the 7 AM to 3 PM (Day) shift and as needed. A review of Resident #12's care plan revealed a Focus, reviewed on 5/2/2023, Resident #12 has skin breakdown of a skin tear to the right shin. Interventions included to administer treatments as ordered and monitor for effectiveness and follow facility policies/protocols for the prevention/treatment of skin breakdown. Resident #12's care plan also revealed a Focus, revised on 2/15/2023, Resident #12 had the potential for impairment to skin integrity related to advanced age, fragile skin, history of edema, neuropathy, incontinence, and impaired mobility. Interventions included to follow facility protocols for treatment of injury. A review of Resident #12's Wound Report dated 5/22/2023 revealed Resident #12 non-pressure skin tear to the right shin measuring 4.0 centimeters (cm) by 3.0 cm by 0.1 cm with a small amount of serosanguineous drainage. The Wound Report did not reveal any other skin impairments. An observation was conducted on 5/24/2023 at 1:35 PM in Resident #12's room. Resident #12 was observed resting in bed with a blanket over her legs with Staff J, Certified Nursing Assistant (CNA) sitting near the bedside. Staff J, CNA stated Resident #12 had a skin tear on her left shin and she was not sure how long the skin tear had been present. Staff J, CNA also stated she was notified of the skin tear by the offgoing CNA at 7 AM and the Day shift nurse was notified. Staff J, CNA removed Resident #12's blanket covering her legs. Resident #12 was observed to have a small skin tear to her left shin with a small amount of serous drainage. The skin tear was observed not covered with a dressing and no dressing was observed in Resident #12's bed. Resident #12 was also observed to have a skin tear to the right shin with no drainage. The skin tear was observed not covered with a dressing and no dressing was observed in Resident #12's bed. Staff J, CNA stated Resident #12 sometimes removes the dressing to her right shin but the nurse was informed of the dressing not being on Resident #12's right shin when she came in at 7 AM. Staff K, License Practical Nurse (LPN) was observed in the hallway outside of the room and was also interviewed. Staff K, LPN stated she was aware of the skin tear to Resident #12's left shin and she was waiting to hear back from the Nurse Practitioner to initiate treatment orders for the wound. Staff K, LPN also stated she was notified of the skin tear earlier but was not able to state what time she was notified. Staff K, LPN addressed Resident #12's wounds to the left and right shins were not covered and was not able to state if Resident #12 had a treatment order in place for the wound to her right shin. Staff K, LPN reviewed Resident #12's physician's orders and verified Resident #12 should have a treatment in place to the wound on her right shin. Staff K, LPN stated when a new skin impairment is discovered on a resident, the nurse should fill out an incident report and a treatment should be initiated. Staff K, LPN reviewed Resident #12's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 8 of 23 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 05/25/2023 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 medical record and was not able to find any documentation related to the newly identified skin tear on Resident #12's left shin. An interview was conducted on 5/25/2023 at 1:10 PM with the facility's Director of Nursing (DON). The DON stated when a new skin impairment is identified on a resident, the nurse should contact the resident's physician, complete an incident report, and initiate a treatment for the wound. If the nurse is not able to contact the physician, the nurse should still attempt to close and cover the wound with a dressing. The DON stated she would expect nursing staff to treat wounds upon identification and for nursing staff to replace dressings that were soiled or removed. A review of the facility policy titled Nursing - Change in Condition, revised on 4/4/2023 revealed under the section titled Procedure All staff are encouraged to promptly report any changes in condition to the charge nurse, supervisor, or DON or designee immediately. This may include accidents resulting in injury, or with the potential to require physician intervention and circumstances that may require a need to alter treatment, including new treatment and/or discontinuation of current treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 9 of 23 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 05/25/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 adequate nutrition to maintain acceptable parameters of nutritional status for one (Resident #32) of two residents sampled for nutritional requirements. Residents Affected - Few Findings included: A review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of pneumonia, muscular dystrophy, quadriplegia, and gastrostomy status. A review of Resident #32's physician's orders revealed an enteral feed order dated 2/28/2023 for Glucerna 1.2 Cal administered at 70 milliliters (ml) per hour over 20 hours, off at 10 AM and on at 2 PM. Resident #32's physician's orders also revealed an order dated 2/28/2023 for Nothing by Mouth (NPO). A review of Resident #32's care plan revealed a Focus, initiated on 2/28/2023, Resident #32 has impaired swallowing related to muscular dystrophy and was NPO. Interventions included follow diet as prescribed and enteral feedings as ordered. A review of Resident #32's weight record revealed Resident #32 weighed 136.4 pounds (lbs.) on 4/6/2023. Resident #32's weight record also revealed a weight recorded on 5/5/2023 of 120.8 lbs. Resident #32 had a weight loss of 15.2 lbs. or 11.44% in 29 days. An observation was conducted on 5/22/2023 at 10:27 AM of Resident #32 in the resident's room. Resident #32 was observed sleeping in bed with enteral feeding running to the resident's feeding tube at a rate of 70 ml per hour. A bottle of Glucerna 1.2 Cal was observed hanging from a pole in the room with a hand written date of 5/20/2023 at 6:00 PM. The Glucerna 1.2 Cal bottle was observed to have approximately 300 ml remaining out of the 1,000 ml bottle. Resident #32 was provided approximately 700 ml of Glucerna 1.2 Cal solution over 40 hours and 27 minutes. An interview was conducted on 5/24/2023 at 2:08 PM with Staff D, Licensed Practical Nurse (LPN). Staff D, LPN was Resident #32's assigned nurse on 5/22/2023 and confirmed Resident #32's order for Glucerna 1.2 Cal administered at 70 ml an hour over 20 hours. Staff D, LPN stated she would replace the resident's tube feed solution bottle upon turning off the resident's pump at 10 AM and ensure the solution was being administered properly when she conducted rounds at the beginning of her shift at 7 AM. Staff D, LPN was not able to state if Resident #32 was receiving the appropriate amount of nutrition as ordered. An interview was conducted on 5/25/2023 at 1:15 PM with the facility's Director of Nursing (DON). The DON stated nurses are responsible for ensuring residents with enteral feedings are getting the appropriate nutrition as per the physician's order and she would expect the nurse to verify the rate of administration, the functioning of the tube feed pump, and the patency of the resident's feeding tube. The DON verified Resident #32's physician's order for Glucerna 1.2 Cal administered at 70 ml per hour and stated she would not expect the resident to have 300 ml remaining after over 40 hours. The DON stated if a resident refused tube feeding or was turning off their own tube feeding pump, she would expect the nurse to restart the resident's pump and document refusals in the resident's chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 10 of 23 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 05/25/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #32's progress notes revealed a note dated 3/26/2023 at 2:27 PM, documenting Resident #32 turned his tube feeding pump off and was educated on the importance of keeping the tube feeding pump on by the nursing staff. Resident #32's progress notes did not reveal any other instances of Resident #32 turning off his feeding tube pump or refusing tube feedings. A review of the facility policy titled Nursing - Enteral Feedings - Safety Precautions with an effective date of 4/1/2022 revealed under the section titled Preparation the facility should remain current in and follow accepted best practices in enteral nutrition. The policy also revealed under the section titled Preventing errors in administration staff are to check the enteral nutrition label against the order before administration for the following information: - Resident name, ID, and room number. - Type of formula. - Date and time formula was prepared. - Route of delivery. - Access site. - Method (pump, gravity, syringe); and - Rate of administration (ml/hour). On the formula label document initials, date, and time the formula was hung/administered, and initial that the label was checked against the order. The policy revealed under the section titled Documentation staff are to document all assessments, findings, and interventions in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 11 of 23 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 05/25/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to provide pain medication to one (#40) of two residents surveyed for pain management. Residents Affected - Few Findings include: An interview was conducted with Resident #40 on 05/24/23 at 03:36 PM. Resident #40 is a [AGE] year old male admitted to this facility on 5/3/23 for rehabilitation and reconditioning after lengthy illness following complications from cardiac surgery. During the interview Resident #40 said he returned just from the hospital, because the facility did not have his pain medication. Resident #40 said on Monday (5/22/23) night he requested pain medication but the facility did not have it because they ran out and it was not reordered in time (Oxycodone 7.5 mg tablet by mouth every 6 hours as needed for pain). Resident #40 said that when he is in pain his breathing gets faster which leads to increased pain and starts a cycle that is hard to get under control. He said he was told the facility was unable to provide him with the medication and would not be available until the morning when the next pharmacy delivery occurred. Resident #40 said the pain was getting unbearable and called 911 for transport to the hospital because the facility was unable to address his pain. Review of Nursing Progress Note from 5/22/23 at 21:30 showed: Resident alert and oriented, resident asked for pain pill nurse don't have the pain pill. Resident got 2 Tylenol, Nurse did a follow up with pharmacy about pain pill. Pharmacy said medication coming on the next round, resident said too long, resident called 911 to go to the hospital to get pain medication. Review of Nursing Progress Note from 5/23/23 at 02:49 showed: Resident was returned from Lakeland Regional Hospital by ambulance, on stretcher. Electrocardiogram testing and troponin levels in the emergency room were negative. No new orders given, resident to continue with meds as previously prescribed. Vital Signs within normal limits. On 05/25/23 at 08:10 AM an interview was conducted with Staff H LPN (Licensed Pratcial Nurse). She stated the medication is available in the Emergency Drug Kit (EDK) which is a machine where staff can get medications if they are not available. Staff H LPN stated it takes two nurses to retrieve controlled medications from the EDK and they did not have two regular staff on shift to pull the medication. She said pharmacy runs are at 2:00PM and 2:00AM and the next delivery would have been around 5:00AM. She said the resident did not want to wait for the next delivery so he called an ambulance for himself. During an interview with the Director of Nursing (DON) on 05/25/23 at 09:21 AM she stated that they did not have two nurses with access to the EDK. On shift were two agency nurses and one regular nurse. The agency nurses did not have access codes to the EDK machine, so they were unable to obtain medication for Resident #40. The DON said the facility does not have an evening/night supervisor and the staff on duty did not call anyone or she would have come in. She said they are changing their process and providing agency staff access to the EDK. Review of facility policy Nursing-Pain Assessment and Management revised 02/21/23 under General (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 12 of 23 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 05/25/2023 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 0697 Guidelines states: Level of Harm - Minimal harm or potential for actual harm 1. The pain management program is based on a facility-wide commitment to resident comfort. Residents Affected - Few 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Reporting Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain 2. Adverse effects from pain medications, such as gastrointestinal bleeding from anti-inflammatory drugs, anorexia, confusion, lethargy, severe constipation, or ileus related to opioids; and/or 3. Prolonged, unrelieved pain despite care plan interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 13 of 23 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 05/25/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to monitor behaviors and side effects of psychotropic medications for two (Resident #23 and 68) of the sampled five residents. Residents Affected - Few Findings included: 1. A review of the admission Record for Resident #23 showed she was admitted on [DATE] with diagnoses that included Alzheimer's Disease, persistent mood disorder, depression, schizophreniform disorder, mood disorder, and anxiety disorder. Section N Medications of the quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #23 took antipsychotic medications for seven days and antidepressants for seven days. A review of the Active Orders as of 05/25/23 revealed the following: -Olanzapine Tablet 5 MG (milligrams) - Give 1 tablet po (by mouth) daily related to Schizophreniform Disorder -Trazodone HCL Tablet 150 MG- Give 1 tablet po at bedtime for depression monitor for s/s (signs/symptoms) of depression There was no order in place for behavior and side effect monitoring. A review of the Medication Administration Record (MAR) and Treatment Administrator Record (TAR) for May and June 2023 revealed behaviors and side effects were not monitored. The care plan for antipsychotic medications initiated on 11/30/23 indicated to administer medications as ordered by physician. Monitor/document side effects and effectiveness every shift. On 05/25/23 at 9:38 a.m., the Director of Nursing (DON) confirmed the resident had orders for psychiatric medications and no orders for behavior and side effect monitoring. Stated she would expect to see orders for behavior and side effect monitoring. A review of Resident #68's medical record showed the resident was admitted to the facility on [DATE] with diagnosis to include cerebral infarction, encephalopathy and Aphasia. A Review of physician orders showed the resident was receiving antipsychotic medications to include Depakote 500mg for encephalopathy and Trazodone HCI oral 50 mg tablet for depression A Review of Medication Administration Record (MAR) showed. -Trazodone HCI oral tablet 50 mg (Milligram), administered daily for depression, effective 1/18/23 and Alprazolam oral tab administered every 8 hours PRN (as needed) for anxiety. A Psychiatric note dated 05/17/23 showed Resident #68 was taking Depakote 300mg TID (three times a day) for manic behaviors, Trazodone 50mg 1 via peg tube daily for depression, Levetiracetam 100mg/ml for seizures and alprazolam 0.5mg 1 every 6 hours PRN for anxiety. The record review showed no behavioral and side effects monitoring indicated for Resident #68. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 14 of 23 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 05/25/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm On 05/25/23 at 10:28 a.m., an interview was conducted with Staff D, Registered Nurse (RN) Agency. She confirmed if the resident was taking antidepressants and antipsychotics, they should be monitored. She stated there should be monitoring the effects of the medication to ensure it was working well. She said, we monitor side effects and how the resident is responding to the medication by observing for specified behaviors. Residents Affected - Few On 05/25/23 at 10:36 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). She confirmed behavior monitoring should be in place for anyone taking medications in some classes such as antipsychotics, antidepressants, and anticoagulants. She said, Yes, we should have put it in. On 05/25/23 at11:02 a.m., an interview was conducted with the Director of Nursing (DON). She reviewed resident #68's MAR and confirmed he was not being monitored. She stated they should have been monitoring side effects and behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 15 of 23 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 05/25/2023 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 error rate of less than 5%. A total of thirty medication opportunities were observed with three errors for two (Resident #56 and Resident #70) of five residents observed for medication administration, resulting in a medication error rate of 10%. Residents Affected - Few Findings included: A review of Resident #56's physician's orders revealed the following orders: - An order dated 5/4/2023 for Acetaminophen 325 milligrams (mg), 2 tablets = 650 mg, by mouth two times a day. - An order dated 3/20/2023 for Calcium-Carb (Carbonate) 600 mg by mouth three times a day. - An order dated 3/17/2023 for Cholecalciferol (Vitamin D3) 1,000 units by mouth one time daily. - An order dated 3/17/2023 for Divalproex Sodium 125 mg by mouth two times a day. - An order dated 3/17/2023 for Fish Oil capsule 1,000 mg give 2 capsules = 2,000 mg by mouth one time a day. - An order dated 3/17/2023 for Lisinopril 2.5 mg by mouth one time a day. - An order dated 3/18/2023 for Memantine Hydrochloride (HCl) 10 mg by mouth two times a day. An observation of medication administration was conducted on 5/24/2023 at 9:14 AM with Staff L, Registered Nurse (RN). Staff L, RN removed the following medications from the medication cart for administration to Resident #56: - Acetaminophen 325 mg 2 tablets = 650 mg. - Calcium-Carb 500 mg. - Vitamin D3 1,000 units. - Divalproex Sodium 125 mg. - Fish Oil capsule 500 mg, 2 capsules = 1,000 mg. - Lisinopril 2.5 mg. - Memantine HCl 10 mg. Prior to administering the medications, Staff L, RN assessed Resident #56's blood pressure. Resident #56's Lisinopril 2.5 mg was held do to having a blood pressure reading out of parameters. Staff L, RN administered the other six medications to Resident #56 in the resident's room without difficulty and exited the room. An interview was conducted with Staff L, RN following the observation. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 16 of 23 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 05/25/2023 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 L, RN reviewed Resident #56's physician's orders and addressed the resident had an order for Calcium-Carb 600 mg and not 500 mg. Staff L, RN stated she never seen it in 600 mg and stated if she had a question about a physician's order she would ask another nurse or the unit manager, but also stated she did not do that. Staff L, RN reviewed Resident #56's physician's orders and addressed the resident had an order for Fish Oil 1,000 mg 2 capsules and not for 500 mg 2 capsules. Staff L, RN stated she thought the order was for Resident #56 to receive 1,000 mg total and not 2,000 mg and she did not realize she had made an error. A review of Resident #70's physician's orders revealed the following orders: - An order dated 1/22/2023 for Ferrous Sulfate 325 mg by mouth two times daily. - An order dated 1/20/2023 for Klor-Con (Potassium Chloride) 10 milliequivalents (mEq), 2 tablets = 20 mEq, by mouth once daily. - An order dated 1/20/2023 for Magnesium Oxide 400 mg by mouth two times daily. - An order dated 1/20/2023 for multivitamin tablet, one tablet by mouth once daily. - An order dated 1/20/2023 for Pantoprazole Sodium 20 mg by mouth two times daily. - An order dated 3/3/2023 for Saccharomyces boulardii 250 mg by mouth once daily. An observation of medication administration was conducted on 5/25/2023 at 10:35 AM with Staff N, Licensed Practical Nurse (LPN). Staff N, LPN gathered the following medications from the medication cart for administration to Resident #70: - Ferrous Sulfate 325 mg. - Klor-Con 10 mEq, 1 tablet. - Magnesium Oxide 400 mg. - multivitamin 1 tablet. - Pantoprazole 20 mg. - Saccharomyces boulardii 250 mg. Staff N, LPN administered the six medications to Resident #70 in the residents room without difficulty and exited the room. An interview was conducted following the observation with Staff N, LPN. Staff N, LPN reviewed Resident #70's physician's order for Klor-Con 10 mEq 2 tablets and did not realize he only administered 1 tablet to Resident #70. Staff N, LPN stated he would normally verify the five rights of medication administration before administering medications to a resident, which include the right dose, right resident, right route, right medication, at the right time and if he only pulled one tablet instead of two it would by considered a medication error. An interview was conducted on 5/25/2023 at 1:25 PM with the facility's Director of Nursing (DON). The DON stated she would expect nursing staff to verify the resident's medication orders and verify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 17 of 23 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 05/25/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete they are following the five rights of medication administration before administering medications to residents. The DON stated if nursing staff do not follow the five rights, which include the right time, right route, right dose, right resident, and right medication, it could result in the nurse committing a medication error. A review of the facility policy titled Administering Medications, revised on 2/21/2023 revealed under the section of the policy titled Purpose the purpose of the policy is to ensure medications are administered in a safe and timely manner, and as prescribed. The policy also revealed under the section titled General Guidelines the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Event ID: Facility ID: 105693 If continuation sheet Page 18 of 23 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 05/25/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to document complete and accurate medical records for one (Resident #32) of forty-two sampled residents. Findings included: A review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of pneumonia, muscular dystrophy, quadriplegia, and sepsis. A review of Resident #32's physician's order revealed an order dated 3/10/2023 for oxygen saturation monitoring every shift. A review of Resident #32's Medication Administration Record (MAR) from 5/1/2023 on the 7 AM to 3 PM shift (Day) shift to 5/24/2023 on the Day shift revealed the task for oxygen saturation every shift was being documented as completed but no oxygen saturation readings were documented on the MAR. A review of Resident #32's oxygen saturation readings from 5/1/2023 on the Day shift to 5/24/2023 on the Day shift revealed Resident #32's oxygen saturation levels were not documented every shift as ordered. A total of fourteen oxygen saturation readings were not documented as ordered. Resident #32's most recent oxygen saturation reading was documented on 5/22/2023 at 7:04 AM. An interview was conducted on 5/24/2023 at 4:20 PM with Staff O, Licensed Practical Nurse (LPN). Staff O, LPN was Resident #32's assigned nurse for the 3 PM to 11 PM (Evening) shift and verified Resident #32's order for oxygen saturation readings every shift. Staff O, LPN was not able to state where Resident #32's oxygen saturation readings were documented in the medical record but stated she would normally document the oxygen saturation readings in the resident's progress notes. Staff O, LPN asked Staff P, LPN for assistance with locating Resident #32's oxygen saturation readings. Staff P, LPN reviewed Resident #32's vital signs record and addressed the last oxygen saturation level was documented on 5/22/2023 at 7:04 AM. Staff P, LPN reviewed Resident #32's orders and stated the order needed to be reviewed because it did not include an area for the nurse signing off on the order to document an oxygen saturation level. Staff P, LPN addressed Resident #32's oxygen saturation levels could be documented under the vital signs record but the readings were not being documented as ordered. A review of Resident #32's progress notes from 5/1/2023 to 5/24/2024 did not reveal any oxygen saturation readings documented. An interview was conducted on 5/25/2023 at 1:15 PM with the facility's Director of Nursing (DON). The DON confirmed Resident #32's physician's order for oxygen saturation readings every shift and stated the readings should be documented in the residents MAR every shift as ordered. The DON verified Resident #32's oxygen saturation levels were not being documented in the resident's MAR or vital signs record and stated she would expect nurse's to follow the physician's orders and document the readings as ordered. A review of the facility policy titled Nursing - Physician's Orders, revised 3/10/2023 revealed under the section titled Purpose the purpose of the policy is to ensure the plan of care is followed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 19 of 23 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 05/25/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm accordance with the orders established by the physician and/or nurse practitioner. The policy also revealed under the section titled Procedure monitoring orders including monitoring of height, weight, vital signs, blood sugar, pulse ox (oxygen saturation), etc. includes entering a value for the monitoring. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 20 of 23 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 05/25/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a recertification survey that was conducted on 5/22/23 through 5/25/23 and was cited F692. On 7/27/23 the facility was recited for F692. The facility had developed a Plan of Correction with a completion date 6/24/23. Findings included: Ongoing non-compliance was identified at the revisit related to the administration of nutritional supplement as ordered by the physician to ensure the resident received an adequate amount of nutritional supplement through his gastrostomy tube. The facility developed a plan of correction that included: Licensed nurses were re-educated by the Director of Nursing (DON)/designee on 6/5/23, the components of this regulation with emphasis on following a residents comprehensive care plan for administering tube feedings as ordered by the Physician. Newly hired clinical staff to be educated in this regard during orientation. Agency staff to be educated in this regard prior to working within the facility. The Director of Clinical Services/designee to conduct quality review to ensure residents tube feedings administered as ordered by the Physician weekly x 4 weeks, and then every 2 weeks x 2 months until substantial compliance achieved. Review of Resident #5's admission record revealed he was admitted on [DATE] from an acute care hospital. His medical diagnoses included but were not limited to gastrostomy, cerebral infarction, dysphagia following cerebral infarction, altered mental status, and type 2 diabetes mellitus without complications. During the revisit survey on 7/24/23 through 7/27/23, the facility failed to ensure nutritional supplement was administration according to physician orders for one (Resident #5) out of one resident ordered for continuous supplemental nutrition through a gastric tube. Review of Resident #5's physician orders revealed an order with a start date of 3/31/23 and no end date for Glucerna 1.2 cal [calorie] at 75/hr X 20 hours [75 milliliters per hour for 20 hours] total 1500 ml [milliliters] to be infused every shift for ENTERAL FEED On at 2pm, off at 10am; until 1500ml infused. Resident #5 was observed on 7/24/23 at 11:20 a.m. The resident's nutritional supplement pump was off and disconnected from the resident with a bottle of Glucerna with Carbsteady, 1.2 cal hanging on the pump pole labeled with a date of 7/24 Start time written as 7 a.m. and rate written as 75 ml/hr. Resident #5 was observed on 7/24/23 at 2:30 p.m. The resident was not hooked up to his nutritional supplement and the nutritional supplement pump machine was turned off with the same bottle of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 21 of 23 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 05/25/2023 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 0867 Glucerna with Carbsteady 1.2 cal hanging on the pump pole. Level of Harm - Minimal harm or potential for actual harm Resident #5 was observed on 7/24/23 at 3:05 p.m. The resident was not hooked up to his nutritional supplement and the nutritional supplement pump machine was turned off with the same bottle of Glucerna with Carbsteady, 1.2 cal hanging on the pump pole. Residents Affected - Few Resident #5's nurse, Staff A, Agency, Registered Nurse (RN), was interviewed on 7/24/23 at 3:13 p.m. She stated she came to the facility about 3 to 4 times a week. She indicated she took the resident off his nutritional supplement around 10:00 a.m. and normally they put him back on his nutritional supplement around 3:00 p.m. before the change of shift. Staff A, Agency, RN stated, It is just like medications we have an hour before and an hour after to hang tube feedings. On 7/24/23 at 3:16 p.m. Staff A, Agency, RN placed the resident on his nutritional supplement of Glucerna Carbsteady 1.2 cal the nutritional supplement pump was observed to be set at an infusion rate of 75ml/hr. The volume delivered/dose limit revealed 3309 ml. which indicated the resident had received 3,309 ml's of his ordered formula. (Picture evidence obtained) Further interview was conducted with Staff A, Agency, RN on 7/24/23 at 3:44 p.m. She stated she received education from the facility related to tube feedings recently but could not recall exactly when. She stated she normally cleared out the pump to see how much total volume was infused. An interview was conducted with the facility's Regional Nurse Consultant, Staff P, on 7/24/23 at 3:45 p.m. She stated she consulted with the Assistant Director of Nursing (ADON) and she said she would have to reeducate the staff because they should be clearing the pump when they hung a new bottle and to do that they had to hit pause then hold the clear button until it says 0. Review of Resident #5's weights revealed on 7/18/23 the resident weighed 105.0 pounds (lbs.). On 7/11/23 he weighed 105.8 lbs. On 7/6/23 he weighed 104.6 lbs. and on 6/27/23 he weighed 105.2 lbs. Resident #5's care plan dated 11/2/22 revealed [Resident #5] requires tube feeding r/t [related to] Dysphagia. The goals included but are not limited to [Resident #5] will remain free of side effect or complications related to tube feeding through review date. The interventions revealed monitor/document PRN [as needed] any s/sx [signs and symptoms] of: Aspiration. RD [Registered Dietitian] to reevaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. [Resident #5] needs the HOB [head of bed] elevated 45 degrees during tube feed. ST [Speech Therapy] evaluation and treatment as ordered. Review of the facility's policy ENTERAL NUTRITION AND HYDRATION Purpose: To ensure adequate parameters of nutrition and hydration status, within the extent possible, through the provision of physician ordered enteral feedings. General Guidelines: .16 . a. A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills . An interview was conducted with the DON and the Nursing Home Administrator (NHA) on 7/26/23 at 11:17 a.m. The NHA stated We received the 2567 [summary of deficiencies] on 6/6/23 and on 6/7/23 we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 22 of 23 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 05/25/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed the 2567 during our ad hoc meeting. The DON indicated she was present and the medical director was present at this meeting. The NHA continued to say, we had a structured plan on what we were going to do at the ad hoc meeting. On 6/9/23 we had our QAPI [quality assurance performance improvement] meeting, the Medical Director was there but the DON was out. We discussed the citations and we discussed our plan of correction and set up our list of PIPs [performance improvement plans] and how we were going to monitor it. On 6/9/23 we had completed our plan for some of the citations Then the nursing monitoring came later. The DON said we started most of our audits on 6/18/23 because we had a larger majority of education to be provided. Daily, during our clinical meetings we reviewed audits with the interdisciplinary team. The NHA stated On 6/23/23 we had another ad hoc meeting where we discussed the approval of the plan of correction. The DON said when reviewing the audits we had to do additional education to all staff related to behavior monitoring to not put N/A.the NHA stated On 7/7/23 we had a QAPI meeting and we discussed how we were doing and our progress on the plan of correction. Both the DON and the NHA indicated upon their review they were on track making improvements and they have a follow up QAPI meeting coming up. The NHA stated usually on the second Friday of the month is when we have our QAPI meetings. Review of the facility's Quality Assurance and Performance Improvement policy with an effective date of 4/1/2022 revealed Purpose: The facility should ensure an effective Quality Assurance and Performance Improvement program including comprehensive data-driven activities that focus on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides are implemented and maintained in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105693 If continuation sheet Page 23 of 23