Health inspection·May 6, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) Review of the medical record documented Resident #34 was admitted on [DATE] with a diagnosis of dysphagia (difficulty swallowing), s/p (status post) G tube (gastrostomy), malnutrition, generalized anxiety disorder, major depression, anemia, and chronic kidney disease. On 5/2/2022 at 9:37 AM Resident #34 was observed resting in bed on an air mattress. The call light was observed on the floor on the left side of her bed. On 5/03/2022 at 7:40 AM Resident #34 was observed resting in bed on an air mattress. The call light was observed on the floor on the left side of the bed. On 5/4/2022 at 7:10 AM Resident #34 was observed resting in bed. The call light was observed wrapped on the call light system on the wall out of the resident's reach. On 5/4/2022 at 7:15 AM Staff A, Licensed Practical Nurse, LPN verified Resident #34's call light was not within reach of the resident and was at the wall. She stated, Residents should have their call light within their reach. 3) Review of the admission Record for Resident #18 documented an admission date of 1/19/2021 with diagnosis that include right sided hemiplegia (paralysis of the right side), acute deep vein thrombosis (a blood clot), dementia, atrial fibrillation, coronary artery disease, and seizures. On 5/3/2022 at 9:53 AM Resident #18 was observed resting in bed with the call light observed on the floor. During an interview conducted on 5/03/22 at 11:15 AM Staff W, CNA she stated, I'm not sure why her call light is on the floor. We round every few hours and should check the call light. During an interview conducted on 5/4/2022 at 3:05 PM the Acting Director of Nursing stated, All staff should make sure the residents have their call lights within reach after they provide care. 4) Review of the Medical Record for Resident #78 documented diagnosis to include congestive heart failure, pacemaker, urinary tract Infection, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set for Resident #78's quarterly review dated 3/22/22 documented the resident had a brief interview for mental status (BIMS) score of 14 (cognitively intact). The resident requires extensive assistance with activities of daily living (ADL's), supervision/set up only eating. Limited assist with bathing. Resident remained wheelchair bound. Review of Resident #78's care plan documented Focus: ADL's. Interventions: Encourage resident to use call bell for assistance. Resident requires assistance to dress. Resident uses assistive device to transfer. Resident requires assistance with ADL's. On 5/3/22 at 7:57 AM an observation in Resident #78's room showed the call light system in the room was not working and the resident had a bell at bedside. The resident was calling out for help. On 5/5/22 at 2:21 PM an observation of the call light showed it was illuminated in the hallway. Resident #78 was resting in bed with his eyes closed. Resident #78's bell to be used to acquire staff assistance was up against the wall and out of reach of the resident. Resident #78's roommate, Resident #29, stated, The call light doesn't work. The light is on all the time. It has been broken for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 2 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0558 about a week. Level of Harm - Minimal harm or potential for actual harm On 5/5/22 at 2:26 PM during an interview with the Maintenance Manger, Maintenance Technician, and the Administrator, it was verified the call light is not working. Residents Affected - Few Review of the policy and procedure titled, Call Bell Policy and Procedure with an approval date of 2/23/2022 read, Intent: To keep a vital link with nursing staff and residents while ensuring resident's ability to exercise control over their care in a dignified manner. Policy: It is our policy to respond to resident call bells to monitor and deliver care to maintain the residents' highest practical well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 3 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were informed and provided written information concerning their right to choose and to formulate an advance directive for 5 of 20 residents reviewed for advanced directives, Residents #1, #26, #82, #287 and #288. Findings include: Review of the medical record for Resident #1 documented the resident was admitted to the facility on [DATE] with diagnosis to include wedge compression fracture of fourth lumbar vertebra, type 2 diabetes mellitus without complications, essential hypertension, restless legs syndrome, and other chronic pain. Review of Resident #1's admission packet revealed an unsigned, undated Advance Directives Policy and Record form with no selections made indicating DNR (Do Not Resuscitate) or full code status. Review of the medical record for Resident #26 documented the resident was admitted to the facility on [DATE] with diagnosis to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, facial weakness following cerebral infarction, dysphagia following cerebral infarction, anxiety disorder, and essential hypertension. Review of Resident #26's admission packet revealed an unsigned, undated Advance Directives Policy and Record form with no selections made indicating DNR or full code status. Review of the medical record for Resident #82 documented the resident was admitted to the facility on [DATE], with diagnosis to include rheumatoid arthritis, joint disorder, fibromyalgia, morbid obesity, type 2 diabetes mellitus with diabetic neuropathy, heart failure, and anxiety disorder. Review of Resident #82's admission packet revealed an unsigned, undated Advance Directives Policy and Record form with no selections made indicating DNR or full code status. Review of the medical record for Resident #287 documented the resident was admitted to the facility on [DATE] with diagnosis to include unspecified fracture of right lower leg, atrial fibrillation, essential hypertension, restless legs syndrome, celiac disease, and syncope and collapse. Review of Resident #287's admission packet revealed an unsigned, undated, Advance Directives Policy and Record form with no selections made indicating DNR or full code status. Review of the medical record for Resident #288 documented the resident was admitted to the facility on [DATE], with diagnosis to include unspecified dementia without behavioral disturbance, unspecified protein-calorie malnutrition, adult failure to thrive, gastro-esophageal reflux disease without esophagitis, acute kidney failure, chronic obstructive pulmonary disease, and hypertension. Review of Resident #288's admission packet revealed an unsigned, undated, Advance Directives Policy and Record form with no selections made indicating DNR or full code status. During an interview on 05/05/22 at 11:03 AM, the Administrator stated, It's up to them [residents] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 4 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if they want to give us a living will or power of attorney, we only require them to provide us with a DNR . There is no acknowledgement the residents sign. During an interview on 05/05/22 at 11:05 AM, the Admissions Liaison stated, The residents get the admissions packet when they come in and we give them information on advance directives. There is no place where they are required to sign specifically about the advance directives. They do sign that they received the admissions packet. Review of the facility policy titled Advance Directives dated 2/23/22 read, Policy Interpretation and Implementation. 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 5 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from medical neglect by allowing unqualified agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness and swelling can result in the likelihood of increased risk of serious harm and/or death. Findings include: 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, aftercare following explantation (re-implantation) of knee joint prothesis, acute systolic (congestive) heart failure, hyperlipidemia, atherosclerotic (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) heart disease, major depressive disorder, anemia, personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke is a brain lesion in which a cluster of brain cells die when they do not get enough blood) without residual deficits, and essential primary hypertension. During an observation for IV medication administration for Resident #56 on 5/4/2022 at 7:37 AM, Staff E, Licensed Practical Nurse (LPN), stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood transfusions and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty Vancomycin 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of Vancomycin, did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 6 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 needed to. I was just doing a flush. Level of Harm - Immediate jeopardy to resident health or safety Review of the physician order for Resident #56 dated 4/29/2022 read, Cefepime HCL [Hydrochloride] 2 gm [gram]/100 ml [milliliters] use 2 grams intravenously every morning and at bedtime. Residents Affected - Many Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg [milligrams]/200 ml use 1000 mg [milligrams] intravenously in the morning for prosthetic knee infection for 17 days. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg/200 ml use 1000 mg intravenously in the evening for prosthetic knee infection for 17 days. Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV Vancomycin HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Cefepime HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Vancomycin HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Cefepime HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Vancomycin HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV Vancomycin HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV Cefepime HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Cefepime HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Vancomycin HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses of pneumonia, sepsis (a life-threatening complication of infection in the blood stream), COVID-19 (Corona Virus Disease 2019), urinary tract infection, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 7 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of Resident #2's physician orders dated 4/21/2022 read, Cefazolin sodium-dextrose solution reconstituted 2-3 gm-% (50 ml). Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders dated 4/20/2022 read, Normal saline flush solution 0.9% sodium chloride (NS) flush - use 10 ml intravenously every shift for IV patency until 5/22/22 - flush with 10 ml normal saline prior to and after administration of medication. Review of the MAR for Resident #2 documented Staff F, LPN, administered IV Cefazolin Sodium-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV Cefazolin Sodium-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV Cefazolin Sodium-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV Cefazolin Sodium-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses to include disruption of external operation (surgical) wound, pseudomonas (type of bacteria that causes infection) as the cause of diseases, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, cellulitis (deep skin infection that spreads quickly), fall on same level from slipping, tripping and stumbling with subsequent striking against object, presence of right artificial hip joint, moderate protein calorie malnutrition, chronic obstructive pulmonary disease (chronic inflammatory lung disease), hyperlipidemia (elevated lipid levels), atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation (abnormal heart rhythm), nonrheumatic aortic valve stenosis (narrowing of the valve), obstructive sleep apnea, essential primary hypertension, muscle weakness, lack of coordination, weakness and peripheral vascular disease. Review of Resident #138's physician orders dated 4/5/2022 read, Flush each valved PICC catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 8 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 lumen with 10 ml NS before and after each use every 12 hours every 7 days for PICC line maintenance. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #138's physician orders dated 4/5/22 read, Cefepime HCL Solution 2 GM/100 ml Use 100 ml intravenously every 12 hours for pseudomonas infection of surgical hip site for 6 weeks. Residents Affected - Many Review of the MAR for Resident #138 documented Staff F, LPN, administered IV Cefepime on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV Cefepime on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses to include encounter for orthopedic aftercare, displaced bicondylar fracture of right tibia, tear of lateral meniscus, history of falling, hyperlipidemia, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (where the liquid content of the stomach refluxes into the esophagus), morbid obesity, hypothyroidism, benign prostatic hyperplasia (flow of urine is blocked due to the enlargement of prostate gland), anemia, major depressive disorder, and type 2 diabetes mellitus. Review of the physician orders for Resident #237 dated 5/2/2022 read, Sodium Chloride Solution 0.9%. Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 9 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 A request was made for all IV certifications for all nurses on staff and all agency staff. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. Residents Affected - Many During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 10 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [tuberculosis], and background checks. IV certification documentation is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 11 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 not one of the required documents. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. Residents Affected - Many During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled. Abuse, Neglect and Exploitation with an approval date of 2/23/2022 read, Abuse, neglect and exploitation is a complex and often hidden problem. Everyone has the responsibility to make a report when abuse, neglect or exploitation is suspected. Neglect: The failure or omission on the part of the caregiver to provide care, supervision, and services necessary to maintain the physical and mental health of a vulnerable adult. The failure of the caregiver to make a reasonable effort to protect a vulnerable adult from abuse neglect and exploitation by others. Review of the policy and procedure titled, Abuse Prevention Program with an approval date of 2/23/2022 read, It is the policy of this community to provide each resident with an environment that is free from verbal, sexual physical and mental abuse, corporal punishment, and involuntary seclusion. We have established policies and procedures that will provide personnel (including consultants, contractors, volunteers, and other caregivers who provide care and services to residents) with the knowledge to further ensure each resident is treated with individual respect and dignity. II. Orientation and Training of Employees: To assist in identification of abuse, the following definitions of abuse are provided during training: a. Abuse is defined as the willful infliction of injury, unreasonable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 12 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many confinement: intimidation: punishment with resulting physical harm, pain or mental anguish; or deprivation by an individual, including a caretaker, of goods and services that are necessary to attain and maintain physical, mental and psychosocial well-being; g. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. III, Preventing Resident AbuseEstablishing a Resident Sensitive Environment: This community desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach including the following: Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, incentive handling or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training, and if necessary or repeated, the community's progressive discipline policy. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, To be performed by: Licensed Nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine gluconate/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 13 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection. (o) Nursing management of special IV therapy procedures that are commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines. (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training[TRUNCATED] Event ID: Facility ID: 105705 If continuation sheet Page 14 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 4 of 14 residents reviewed for oxygen administration, Residents #11, #78, #19, and #25. Residents Affected - Some Findings include: 1. Review of Resident #11's medical record documented the resident was admitted to the facility on [DATE] with a diagnosis that includes chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), chronic kidney disease, hypertension (high blood pressure), weakness and a left femur fracture (a broken thigh bone). Review of Resident #11's physician orders dated 4/25/2022 read, O2 [oxygen] at 3 liters per nasal cannula [a small flexible tube that sits in the nose] every shift. During an observation of Resident #11 on 5/2/2022 at 12:42 PM, oxygen was being administered at 4.5 liters per minute via oxygen concentrator. The oxygen concentrator was positioned behind the resident's nightstand. During an observation on 5/3/2022 at 8:09 AM, oxygen was being administered at 4.5 liters per minute via nasal cannula. During an interview on 5/3/2022 at 8:17 AM, Resident #11 stated, I always wear oxygen, I have COPD. I just came back in because I needed therapy after I fell and broke my hip. I am not sure why the concentrator is behind my nightstand. The nurses never change it. They do change the tubing, but I never see them looking at the amount that the machine is set on. I have been wearing the oxygen since I came in. Review of the world wide web under https://www.webmd.com dated 10/29/2021 read, When you have COPD, too much oxygen could cause you to lose the drive to breathe. During an interview on 5/3/2022 at 1:53 PM, the Quality Improvement Nurse Manager verified Resident #11's oxygen was being administered at 4.5 liters a minute per nasal cannula and that the oxygen was ordered for 3 liters per nasal cannula, stating, Nurses should be verifying orders before placing residents on oxygen and check it daily to make sure it is being administered at the correct dosage. During an interview on 5/3/2022 at 1:42 PM Staff A, Licensed Practical Nurse (LPN) stated, We should check the amount of oxygen that residents are on when we administer their medications. I think that [Resident #11's name] is on 2 or 3 liters of oxygen. I did not check her oxygen today. I should have checked it. I did not know that she was getting the wrong amount. During an interview on 5/3/2022 at 3:32 PM, the Director of Nursing (DON) stated, It is my expectation that staff verify the physicians' orders for oxygen and check to ensure that the oxygen is being administered at the ordered amount. 2. Review of the medical record for Resident #78 documented the resident was admitted to the facility with diagnoses to include chronic congestive heart failure (a chronic condition in which the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 15 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 - Some heart does not pump blood as well as it should), atrial fibrillation (an irregular heartbeat), diabetes mellitus type 2, chronic kidney disease, peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the legs) and hypothyroidism (an underactive thyroid). Review of Resident #78's physician orders revealed there was no order for oxygen administration. Review of the physician orders dated 3/22/2022 documented oxygen at 2 liters nasal cannula was discontinued on 3/22/2022. During an observation on 5/2/2022 at 8:10 AM, Resident #78 was observed resting in bed; the resident was being administered oxygen at 4 liters per minute via nasal cannula. During an observation on 5/2/2022 at 2:59 PM, Resident #78 was observed with oxygen being administered at 4 liters per minute via nasal cannula. During an observation on 5/3/2022 at 1:10 PM, Resident #78 was observed with oxygen being administered at 4 liters per minute via nasal cannula. During an interview on 5/3/2022 at 1:10 PM, Resident #78 stated, I have been wearing oxygen since before I went to the hospital. I had some bleeding from my stomach, so I went to the hospital. I don't touch that machine ever. I have not seen the nurses check the machine like you have. Review of Resident #78's medical record documented the resident's most recent readmission from the hospital was 3/21/2022. During an interview on 5/3/2022 at 1:12 PM, the Quality Improvement Nurse Manager verified Resident #78 was being administered oxygen at 4 liters per minute via nasal cannula and there was no order contained in the medical record. We should have orders in place for all treatments. There is no order for this oxygen. He did have a hospitalization and may have come back with oxygen and needs an order. Nurses should be verifying orders before placing them on oxygen and daily that it is being administered at the correct amount. During an interview on 5/3/2022 at 1:42 PM, Staff A, LPN, stated, We should check orders before administering oxygen. He [Resident #78] has been on the oxygen since I got in today, so I didn't question it. During an interview on 5/3/2022 at 3:32 PM, the Director of Nursing (DON) stated, It is my expectation that staff verify the physicians' orders for oxygen and check to ensure that the oxygen is being administered at the ordered amount. 3. Review of the medical record for Resident #25 documented the resident was admitted on [DATE] with a diagnosis of cerebral infarction, hemiplegia and hemiparesis, depressive episodes, atherosclerotic heart disease, TIAs [transient ischemic attacks], type 2 diabetes mellitus, hypoglycemia, malignant neoplasm of lung and breast, history of PE [pulmonary edema], and HTN [hypertension]. During an observation on 5/2/2022 at 2:30 PM, Resident #25 was being administered oxygen at 2 liters per minute via nasal cannula. During an interview on 5/2/2022 at 2:30 PM, Resident #25 stated she used the oxygen most of the time. She stated she got short of breath and needed the oxygen to help her breathe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 16 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 During an observation on 5/3/2022 at 8:45 AM, Resident #25 was being administered oxygen at 2 liters per minute via nasal cannula. Review of the physician orders revealed there was no order in the record for Resident #25 to be administered oxygen. Residents Affected - Some During an interview on 5/3/2022 at 1:00 PM, Staff R, LPN, stated she was the nurse who was assigned to [Resident #25's name]. She stated the resident was on 2 liters of oxygen via nasal cannula. During an observation of Resident #25 on 5/3/2022 at 2:00 PM with Staff R, LPN, Staff R confirmed the resident was currently being administered oxygen at 2 liters per minute via nasal cannula. During an interview on 5/3/2022 at 1:15 PM, the Interim Director of Nursing verified there was no current order for oxygen for Resident #25, stating, It is my expectation that the nurse refers to the physician order to verify oxygen is infusing at the appropriate rate. If an order cannot be located, a call would be made to the physician. 4. Review of the medical record for Resident #19 documented the resident was admitted on [DATE] with diagnoses to include congestive heart failure, chronic obstructive pulmonary disease, and coronary artery disease. During an observation on 5/2/2022 at 10:40 AM, Resident #19 was being administered oxygen at 2.5 liters per minute via nasal cannula. During an interview on 5/2/2022 at 10:40 AM, Resident #19's niece stated her aunt was on oxygen to assist with her breathing. She has been on the oxygen every day that she has visited. During an observation on 5/3/2022 at 10:00 AM, Resident #19 was being administered oxygen at 2.5 liters per minute via nasal cannula. Review of the physician orders revealed there was no oxygen administration order documented in the record for Resident #19. Review of the Nursing Progress Note dated 4/10/2022 at 7:00 AM read, Resident alert and verbal. Resp [respirations] even and unlabored. Continue on oxygen at 2L/min via nc. [2 liters per minute via nasal cannula] Review of the Nursing Progress Note dated 4/9/2022 at 12:00 AM read, Resident alert and verbal. Applied oxygen at 2L/min. via nc for comfort. During an interview on 5/3/2022 at 10:00 AM, Staff S, Registered Nurse (RN), stated Resident #19 was on 2 liters of oxygen via nasal canula. The oxygen tubing was changed on 5/2/2022 and the resident was having no concerns with respirations at this time. During an observation of Resident #19 on 5/3/2022 at 1:00 PM with Staff T, RN, Staff T confirmed the resident was being administered oxygen at 2 L via nasal cannula. During an interview on 5/3/2022 at 1:15 PM, the Director of Nursing (DON) confirmed there was no order for oxygen in Resident #19's record. The DON confirmed the resident was currently being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 17 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 administered oxygen at 2L via nasal cannula. Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure titled, Oxygen Administration with a revision date of October 2010, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 18 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses had appropriate competencies and skills sets to provide nursing and related services to residents by allowing unqualified agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness and swelling can result in the likelihood of increased risk of serious harm and/or death. Findings include: 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, aftercare following explantation (re-implantation) of knee joint prothesis, acute systolic (congestive) heart failure, hyperlipidemia, atherosclerotic (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) heart disease, major depressive disorder, anemia, personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke is a brain lesion in which a cluster of brain cells die when they do not get enough blood) without residual deficits, and essential primary hypertension. During an observation for IV medication administration for Resident #56 on 5/4/2022 at 7:37 AM, Staff E, Licensed Practical Nurse (LPN), stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood transfusions and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty Vancomycin 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of Vancomycin, did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 19 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order for Resident #56 dated 4/29/2022 read, Cefepime HCL [Hydrochloride] 2 gm [gram]/100 ml [milliliters] use 2 grams intravenously every morning and at bedtime. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg [milligrams]/200 ml use 1000 mg [milligrams] intravenously in the morning for prosthetic knee infection for 17 days. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg/200 ml use 1000 mg intravenously in the evening for prosthetic knee infection for 17 days. Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV Vancomycin HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Cefepime HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Vancomycin HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Cefepime HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Vancomycin HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV Vancomycin HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV Cefepime HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Cefepime HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Vancomycin HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses of pneumonia, sepsis (a life-threatening complication of infection in the blood stream), COVID-19 (Corona Virus Disease 2019), urinary tract infection, congestive heart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 20 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 failure, chronic kidney disease, type 2 diabetes mellitus. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #2's physician orders dated 4/21/2022 read, Cefazolin sodium-dextrose solution reconstituted 2-3 gm-% (50 ml). Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Residents Affected - Many Review of Resident #2's physician orders dated 4/20/2022 read, Normal saline flush solution 0.9% sodium chloride (NS) flush - use 10 ml intravenously every shift for IV patency until 5/22/22 - flush with 10 ml normal saline prior to and after administration of medication. Review of the MAR for Resident #2 documented Staff F, LPN, administered IV Cefazolin Sodium-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV Cefazolin Sodium-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV Cefazolin Sodium-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV Cefazolin Sodium-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses to include disruption of external operation (surgical) wound, pseudomonas (type of bacteria that causes infection) as the cause of diseases, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, cellulitis (deep skin infection that spreads quickly), fall on same level from slipping, tripping and stumbling with subsequent striking against object, presence of right artificial hip joint, moderate protein calorie malnutrition, chronic obstructive pulmonary disease (chronic inflammatory lung disease), hyperlipidemia (elevated lipid levels), atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation (abnormal heart rhythm), nonrheumatic aortic valve stenosis (narrowing of the valve), obstructive sleep apnea, essential primary hypertension, muscle weakness, lack of coordination, weakness and peripheral vascular disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 21 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of Resident #138's physician orders dated 4/5/2022 read, Flush each valved PICC catheter lumen with 10 ml NS before and after each use every 12 hours every 7 days for PICC line maintenance. Review of Resident #138's physician orders dated 4/5/22 read, Cefepime HCL Solution 2 GM/100 ml Use 100 ml intravenously every 12 hours for pseudomonas infection of surgical hip site for 6 weeks. Review of the MAR for Resident #138 documented Staff F, LPN, administered IV Cefepime on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV Cefepime on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses to include encounter for orthopedic aftercare, displaced bicondylar fracture of right tibia, tear of lateral meniscus, history of falling, hyperlipidemia, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (where the liquid content of the stomach refluxes into the esophagus), morbid obesity, hypothyroidism, benign prostatic hyperplasia (flow of urine is blocked due to the enlargement of prostate gland), anemia, major depressive disorder, and type 2 diabetes mellitus. Review of the physician orders for Resident #237 dated 5/2/2022 read, Sodium Chloride Solution 0.9%. Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 22 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 A request was made for all IV certifications for all nurses on staff and all agency staff. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. Residents Affected - Many During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 23 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [tuberculosis], and background checks. IV certification documentation is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 24 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 not one of the required documents. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. Residents Affected - Many During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, To be performed by: Licensed Nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 25 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine gluconate/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection. (o) Nursing management of special IV therapy procedures that are commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines. (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 26 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnesses by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death as evidenced by review of Abuse and Neglect training provided by the Education Coordinator completed on 5/4/2022; review of Abuse and Neglect training provided by the Administrator completed on 5/4/2022 to include all leadership staff; review of daily audits dated 5/4/2022, 5/5/2022 and 5/6/2022 on current IV residents; review of the on-call schedule for May 2022 documenting an RN scheduled on call for each day of May; review of the posted list of the approved IV certified agency nurses posted at both nursing stations; review of the Ad Hoc Quality Assurance Meeting dated 5/4/2022 to discuss LPN staff qualifications to administer IV medications; interviews conducted on 5/6/2022 PM with six agency LPNs and three facility LPNs, five facility registered nurses who verified the provided training related to IV certification requirement to administer IV medications, and abuse and neglect; interviews with the Administrator, the Acting DON, the MDS Nurse, and the Quality Improvement Nurse Manager on 5/6/2022, who verified receiving training on scope of practice of LPNs, IV certifications, and abuse and neglect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 27 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards for 5 of 5 medication carts reviewed for medication labeling and storage. Findings include: During an observation of medication cart #1 on 5/2/2022 at 9:10 AM with Staff B, Licensed Practical Nurse (LPN), there were two opened Lispro insulin pens with no date opened or expiration dates, one unlabeled medication cup with a small round yellow pill with no resident identifier and no identification of what the medication was, two opened Latanoprost 0.005% ophthalmic solution with no date opened or expiration dates and one unopened Latanoprost 0.005% ophthalmic solution with pharmacy instructions to keep refrigerated until opened. During an interview conducted on 5/2/2022 at 9:20 AM, Staff B, LPN, stated, Insulin should be labeled and dated when they are opened and when they expire. There shouldn't be medications that have been poured in the cart without them being labeled. I did not pour that medication. All eye drops should be labeled, and I did not take out the Latanoprost, it should stay in the refrigerator until its ready to be used. During an observation of medication cart #2 on 5/2/2022 at 9:25 AM with Staff S, Registered Nurse (RN), there were three insulin pens in one pharmacy bag - one opened Humalog insulin pen, one opened Lispro insulin pen and one opened Aspart insulin pen with no dates opened or expiration dates, and one opened Lumigan 0.01% ophthalmic solution with no date opened or expiration date was in the cart. During an interview conducted on 5/2/2022 at 9:35 AM, Staff S, RN, stated, The insulin should not be in one container, and the eye drops should be labeled when they are opened. During an observation of medication cart #3 on 5/2/2022 at 10:00 AM with Staff D, LPN, there were two opened Aspart insulin pens with no date opened or expiration dates, one unopened Aspart insulin pen with pharmacy instructions to refrigerate until opened and one opened bottle of Prednisolone Acetate ophthalmic solution with no date opened or expiration date. During an interview conducted on 5/2/2022 at 10:15 AM, Staff D, LPN, stated, Insulin and eye drops should have the date they are opened on them. Insulin should remain in the refrigerator until it is ready to be used. During an observation of medication cart #4 on 5/2/2022 at 10:20 AM with Staff A, LPN, there were two opened Lantus insulin pens with no dates opened or expiration dates, one opened bottle of Novolog insulin with no date opened or expiration date, one opened bottle of Prednisolone acetate ophthalmic solution with no pharmacy packaging or resident identifier. There were three medication cups, one contained 3 brown medications and on the outside of the cup written in black marker was FE (Iron), the second medication cup contained 12 unidentified medications in it, and the third medication cup contained two unidentified medications in it. During an interview conducted on 5/2/2022 at 10:30 AM, Staff A, LPN, stated, I don't know why the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 28 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 - Many iron is in a medicine cup. I didn't put them in here. Those other two are for residents that were busy, so I just put them back until they were ready. I shouldn't pre-pour medications. Insulin and eye drops should have been labeled when they are opened. During an observation of medication cart #5 on 5/2/2022 at 10:35 AM with Staff Q, LPN, there were two medication cups with unlabeled and unidentified medications in them, one cup contained three pills and one cup contained two pills. There was one opened Novolog insulin with no date opened or expiration date. During an interview conducted on 5/2/2022 at 10:40 AM, Staff Q, LPN, stated, I shouldn't pre-pour the medication. The patient weren't available to take them, so I put them in here. I guess I should have labeled them with what they were and who they are for. Insulin should be labeled when its opened. Review of the policy and procedure titled, Labeling of Medication Containers with an approval date of 2/23/2022 read, Policy Statement all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Policy interpretation and implementation: 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; f. The date that the medication was dispensed; g. Appropriate accessory and precautionary statements; h. The expiration date when applicable; i. Directions for use. 4. Labels for each floor stock medications shall include all necessary information, such as: a. The name and strength of the drug; c. The expiration date when applicable; d. Appropriate accessory and cautionary statements; e. Directions for use. Review of the policy and procedure titled, Storage of Medications with an approval date of 2/23/2022 read, Policy statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only issuing pharmacy is authorized to transfer medications between containers. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 29 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to properly store food in accordance with professional standards for food service safety, store cooking utensils under sanitary conditions, and maintain resident nourishment rooms to prevent the possible foodborne illness. Findings include: During a tour on 05/02/22 beginning at 9:10 AM of the main kitchen with the Food Services Director (FSD) in the walk-in cooler is a stainless-steel square food storage container covered with plastic wrap that held leftover chopped meat that was labeled with a used by date of 05/01/22. During an interview on 05/02/22 at 9:22 AM the FSD confirmed the use by date on the container of leftover meat and stated, I expect the staff to throw out leftover food if not used by the use by date. Review of the policy and procedure titled, Refrigerated Leftover Storage, dated 08/31/21 and reviewed on 2/23/22 read, Procedure: 2. Date container with use by date .note-Once a product is opened, do not store longer than the total unopened time. During an observation on 05/02/22 at 9:40 AM of the dish washing area there are seven clean, damp sheet pans stacked with no space between each other on a drying rack. Review of the policy and procedure titled, Dry Storage-Dishes and Utensils, dated 2/1/12 and reviewed on 2/23/22 read, 6. Dishes must be stored to promote air drying i.e. use dish racks or trays with plastic mesh that allow air to circulate and air dry the dishes. During an observation on 05/02/22 beginning at 2:00 PM of the 300 Hall nourishment room there is one opened plastic bottle of water with approximately 10 ounces of liquid in it and one opened plastic bottle of juice with approximately eight ounces of liquid in it located in the cabinet above the sink. The bottles are not labeled with open dates or name of the owner/owners. During an observation on 05/02/22 at approximately 2:10 PM of the 400 Hall nourishment room there is a Styrofoam container of leftover cooked food stored in the cabinet above the sink with a plastic bottle of opened water with approximately 14 ounces of liquid in the bottle sitting on top of the container. The Styrofoam container and the bottle are not labeled with an open dates or name of the owner/owners. During an interview on 05/02/22 at 2:15 PM the Dietary Manager confirmed the presence of the opened bottles of liquid in the 300 Hall nourishment room and the container of leftover food and water in the 400 Hall nourishment room and stated, There should be no opened containers of drinks or food left in the nourishment rooms. All of the resident's food should be in the refrigerator labeled with their name and dated. Review of the policy and procedure titled, Nourishment Refrigerator/Freezer Storage Guide, reviewed on 2/23/22 read, Procedure 1. All foods must be appropriately covered and if opened must be covered with a non absorbent lid or material. 2. All items must be dated with a placed date. 8. Food from outside sources for residents must be labeled with the resident's name, date item placed and a use by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 30 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0812 date. Monitor for freshness. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 31 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility by allowing unqualified agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness and swelling can result in the likelihood of increased risk of serious harm and/or death. Residents Affected - Many Findings include: Review of the job description for the Administrator (effective date August 3, 2021) read, General summary/major function: The administrator is responsible for assisting the Chief Administrative Officer/Executive Director in the overall administration of the Community. S/he supervises the operation of the service departments as directed by the Executive Director, with primary emphasis on the health center. Essential duties and responsibilities: Supervise assigned department directors, attend and participate in department director meetings Monitor in-service education for employees, oversee/conduct in-service education for employees. Review of the job description for the Director of Clinical Services (Director of Nursing) (effective date 02/2020) read, The Director of Clinical Services is responsible for the overall supervision, provision, and quality of nursing care in the Health center and residential apartments. He/She is responsible for the selection, training, discipline, and supervision for all nursing related Health center personnel. Principle Duties: Essential job duties . 7. Develops and participates in a new staff orientation program for his/her employees, including private duty and agency staff. Review of the job description for the Quality Improvement Nurse (effective date 02/2020) read, General Summary: Monitors and manages the quality measures and indicators of the community through planning, developing, directing and evaluating educational and clinical training programs. Evaluates and develops policies for the community's risk management systems in accordance with regulations to protect residents, staff and facility from loss. Principle duties: 2, documents and reviews medication and treatment sheets for accuracy and compliance with physician orders, professional standards, federal and state regulations and company policies. 5. Directs and coordinates all in-service educational programs of the facility in accordance with regulations. Develops, maintains and directs orientation programs for skilled nursing personnel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 32 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, aftercare following explantation (re-implantation) of knee joint prothesis, acute systolic (congestive) heart failure, hyperlipidemia, atherosclerotic (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) heart disease, major depressive disorder, anemia, personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke is a brain lesion in which a cluster of brain cells die when they don't get enough blood) without residual deficits, and essential primary hypertension. During an observation on 5/4/2022 at 7:37 AM, when the surveyor requested Staff E, Licensed Practical Nurse (LPN), to observe IV medications administration for Resident #56, Staff E stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood transfusions and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty Vancomycin 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of Vancomycin, did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order for Resident #56 dated 4/29/2022 read, Cefepime HCL [Hydrochloride] 2 gm [gram]/100 ml [milliliters] use 2 grams intravenously every morning and at bedtime. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg [milligrams]/200 ml use 1000 mg [milligrams] intravenously in the morning for prosthetic knee infection for 17 days. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg/200 ml use 1000 mg intravenously in the evening for prosthetic knee infection for 17 days. Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV Vancomycin HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Cefepime HCL solution (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 33 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Vancomycin HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Cefepime HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Vancomycin HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV Vancomycin HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV Cefepime HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Cefepime HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Vancomycin HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses of pneumonia, sepsis (a life-threatening complication of infection in the blood stream), COVID-19 (Corona Virus Disease 2019), urinary tract infection, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus. Review of Resident #2's physician orders dated 4/21/2022 read, Cefazolin sodium-dextrose solution reconstituted 2-3 gm-% (50 ml). Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders dated 4/20/2022 read, Normal saline flush solution 0.9% sodium chloride (NS) flush - use 10 ml intravenously every shift for IV patency until 5/22/22 - flush with 10 ml normal saline prior to and after administration of medication. Review of the MAR for Resident #2 documented Staff F, LPN, administered IV Cefazolin Sodium-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV Cefazolin Sodium-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV Cefazolin Sodium-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 34 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV Cefazolin Sodium-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses to include disruption of external operation (surgical) wound, pseudomonas (type of bacteria that causes infection) as the cause of diseases, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, cellulitis (deep skin infection that spreads quickly), fall on same level from slipping, tripping and stumbling with subsequent striking against object, presence of right artificial hip joint, moderate protein calorie malnutrition, chronic obstructive pulmonary disease (chronic inflammatory lung disease), hyperlipidemia (elevated lipid levels), atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation (abnormal heart rhythm), nonrheumatic aortic valve stenosis (narrowing of the valve), obstructive sleep apnea, essential primary hypertension, muscle weakness, lack of coordination, weakness and peripheral vascular disease. Review of Resident #138's physician orders dated 4/5/2022 read, Flush each valved PICC catheter lumen with 10 ml NS before and after each use every 12 hours every 7 days for PICC line maintenance. Review of Resident #138's physician orders dated 4/5/22 read, Cefepime HCL Solution 2 GM/100 ml Use 100 ml intravenously every 12 hours for pseudomonas infection of surgical hip site for 6 weeks. Review of the MAR for Resident #138 documented Staff F, LPN, administered IV Cefepime on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV Cefepime on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses to include encounter for orthopedic aftercare, displaced bicondylar fracture of right tibia, tear of lateral meniscus, history of falling, hyperlipidemia, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (where the liquid content of the stomach refluxes into the esophagus), morbid obesity, hypothyroidism, benign prostatic hyperplasia (flow of urine is blocked due to the enlargement of prostate gland), anemia, major depressive disorder, and type 2 diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 35 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of the physician orders for Resident #237 dated 5/2/2022 read, Sodium Chloride Solution 0.9%. Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. A request was made for all IV certifications for all nurses on staff and all agency staff. During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 36 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 37 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [tuberculosis], and background checks. IV certification documentation is not one of the required documents. During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 38 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, To be performed by: Licensed Nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine gluconate/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 39 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection. (o) Nursing management of special IV therapy procedures that are commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines. (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid admi[TRUNCATED] Event ID: Facility ID: 105705 If continuation sheet Page 40 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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. Based on observation, interview, and record review, the facility failed to ensure their quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies for hand hygiene to prevent the possible spread of infection. Findings include: During the medication observations on 05/04/2022 beginning at 7:37 AM to 8:25 AM it showed licensed practical nurses did not perform hand hygiene when administering medications to six of seven residents resulting in deficient practice for infection control. During an interview conducted on 05/06/22 at 10:20 AM the Quality Improvement Nurse stated, We identified a concern with hand washing two weeks ago when we had an inspection from the Joint Commission. I have just not had the time to get around to writing the Performance Improvement Plan. Review of the policy and procedure titled, Quality Assurance Improvement Plan (QAPI) Committee, with an approval date of 2/23/2022 read, The facility shall establish and maintain a QAPI committee that oversee the QAPI system .Goals of the committee . 6. Coordinate the development, implementation, monitoring and evaluation of performance projects to achieve specific goals. 7. Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents and family members. Review of the policy and procedure titled, Quality Assurance and Performance Improvement (QAPI) Program revised date April 2014, approval date 2/23/2022 read, Policy statement: This facility shall, develop, implement and maintain ongoing facility wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and assurance program to actively pursue quality of care and quality of life goals. Policy Interpretation and Implementation: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Five strategic elements: 2. Governance and leadership: c. Members of the facility leadership are accountable for QAPI efforts. 3. Feedback, data systems and monitoring: e. Action plans are implemented to prevent the recurrence of adverse events. 4. Performance Improvement projects: Performance improvement projects (PIPs) are initiated when problems are identified. B. PIPs involve systematically gathering information to clarify issues and to intervene for improvements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 41 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper infection control standards were maintained for central line dressings for 2 of 3 residents reviewed with central line catheters, Residents #56 and #2, and failed to ensure hand hygiene was performed during medication administration to prevent the possible spread of infection for 6 of 7 observations. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility with on 3/18/2022 with a diagnosis of encounter for other orthopedic aftercare, aftercare following explantation (re-implantation) of knee joint prothesis, acute systolic (congestive) heart failure, hyperlipidemia, atherosclerotic (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) heart disease, major depressive disorder, anemia, personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke is a brain lesion in which a cluster of brain cells die when they don't get enough blood) without residual deficits, and essential primary hypertension. During an observation of medication administration for Resident #56 on 5/4/2022 at 7:37 AM , Staff E, Licensed Practical Nurse (LPN) entered the resident's room, the resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood transfusions and other drugs). The PICC was observed to have no needleless connector on the left port and two needleless connectors on the right port of the PICC line. An empty Vancomycin 1000 mg bag of antibiotics was observed connected to the right port of the PICC line. Staff E removed the empty bag of Vancomycin and without performing hand hygiene or donning gloves flushed the right port of the PICC line that had two needleless connectors attached with 10 milliliters of normal saline. Staff E did not aspirate to check for line patency to ensure the line is open and in the correct position. Staff E did not perform hand hygiene, left the resident's room and returned to the medication cart. During an interview on 5/4/2022 at 7:40 AM Resident #56 stated, The connector came off in the night and the night nurse did this when she saw it. I called her and told her that the connector was off. During an interview on 5/04/22 at 7:47 AM Staff E, LPN stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I didn't really see anything wrong with the PICC line it looked fine to me. I don't know what the green cap is or where to get one. I didn't really notice that there were two needleless connectors on the one port. I don't think that there is anything wrong with the PICC line it looked ok to me. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. On 5/4/2022 at 8:17 AM the Acting Director of Nursing (DON) confirmed the PICC line had two needleless connectors and a green cap on the PICC line ports. During an interview on 5/04/22 at 8:17 AM the Acting DON stated, I am responsible for all the care delivered in the facility. I am not sure why the night nurse did not call the physician immediately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 42 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 - Many when the PICC line became compromised. It should not have been used and the doctor notified. I would expect that when the PICC is compromised that the nurses assess them and call the physician for orders and to have them removed. This is definitely an infection control concern and a competency issue. During an interview on 5/04/22 at 8:20 AM Staff E, LPN stated, I did not clean the PICC line port before I administered the normal saline. I did not check for a blood return before I administered the normal saline. I should have put gloves on before I did the flush. I should have used alcohol to clean the port. I do not have the 30-hour IV course. I just got nervous. During an interview on 5/4/2022 at 8:38 AM the Acting DON stated, This is a compromised PICC line, and we should not be using it. We should have called the doctor and obtained orders to get a new PICC line or midline inserted immediately. The resident tells me that it happened last evening, and we should have called right away. It is a nursing standard of practice to notify the doctor right away when things like this happen. We should not be using that PICC line until we speak to the doctor. Review of the physician order dated 5/4/2022 read: Change PICC Line. During an observation on 05/5/22 at 9:30 AM, Resident #56 had a single lumen PICC line in the right upper arm with a date on the dressing of 5/4/2022. During an interview on 5/05/22 at 5:40 AM Resident #56 stated, I noticed at about 11:30 PM the connector was off of the port, and it had nothing on it, it was not bleeding. I called the nurse and she put that green cap on the one that was off. They changed the PICC line yesterday and put it in the other arm. They told me that it was an infection risk, so they needed to change it. During an interview on 5/6/2022 at 8:30 AM the Medical Doctor stated, [Resident #56's name] needed to have a new PICC line inserted because the other was compromised and there was a greater risk of infection because it was compromised. I expect staff to call and let me know that a PICC line has been compromised so we can get the old one out and a new one in quickly. During an observation conducted on 5/6/2022 at 9:22 AM Resident #56's right upper arm PICC line dressing was dated 5/4/2022. During an interview on 5/6/2022 at 9:25 AM Resident #56 stated, I just got the PICC line changed because the end of it came off the other night and they told me it might cause an infection, so it needed to be changed. They removed it and put a new one in the other arm 2 days ago. The dressing has not been changed since it went in. During an interview on 5/6/2022 at 9:35 AM Staff B, Licensed Practical Nurse (LPN) stated, [Resident #56's name] had a new PICC line inserted 2 days ago because it had a needleless connector come off, so it needed to be changed. It got changed on 5/4/2022. I am not sure if the dressing has been changed. It should be changed after the first twenty-four hours. I see that the dressing is dated 5/4/2022 and therefore it has not been changed. It is policy to change the dressing after twenty-four hours. During an interview on 5/6/2022 at 9:45 AM the Acting Director of Nursing stated, I am not sure why this dressing was not done. It should have been done yesterday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 43 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 - Many 2. Review of the medical record for Resident #2 documented the resident was admitted most recently on 4/19/22 with diagnoses to include sepsis (a life-threatening complication of infection), urinary tract infection, altered mental status, diabetes mellitus with diabetic chronic kidney disease, cardiomyopathy, chronic systolic congestive heart failure, chronic kidney disease, and dementia without behavioral disturbance. Review of the physician orders dated 4/21/22 read, Change catheter site dressing one time a day every Friday, change catheter securement device and as needed change catheter securement device. Review of the physician orders dated 4/21/22 read, Change needleless connector-one time a day every Friday and as needed after blood transfusion or blood draws and every 24 hours as needed with PRN administration. During an observation conducted on 05/2/22 at 10:30 AM, Resident #2 was observed to have a mid-line catheter inserted in the right upper arm with a dressing dated 4/23. The skin and intravenous junction was unable to be observed due to a dark red substance, a reddened semicircular area approximately 1 cm (centimeter) was observed around the dark red substance. During an observation conducted on 05/03/22 at 2:30 PM, Resident #2 was observed to have a mid-line catheter inserted in the right upper arm with a dressing dated 4/23. The skin and intravenous junction was unable to be observed due to a dark red substance, a reddened semicircular area approximately 1 cm was observed around the dark red substance. During an interview on 5/3/22 at 2:31 PM Interim Director of Nursing confirmed the date (4/23) wrote on the midline dressing and stated, The dressing should have been changed after 7 days. Review of the facility's policy and procedure titled, Midline Dressing Changes, dated April 2016 and reviewed on 2/23/22 read, General Guidelines .1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days or it is wet, dirty not intact or compromised in any way. 3. Verify with state Nurse Practice Act as to LPN (Licensed Practical Nurse)/RN (Registered Nurse) scope of practice for this procedure. Review of the policy and procedure titled, Central Venous Catheter Dressing Changes revised date April 2016, approval date 2/23/2022 read, Purpose: The purpose of this procedure is to prevent Catheter-related infections that are associated with contaminated, loosened, soiled or wet dressings. Preparation: 1. Check the State's Nurse Practice Act for LPN's regarding scope of practice for changing a central venous catheter dressing 2. A physician order is not needed for this procedure. General guidelines: 1. Apply and maintain sterile dressings on intravenous access devices. Dressings must stay clean, dry, and intact. Explain to the resident the dressing must not get wet. 3. Catheter site care shall allow for the observation and evaluation of the catheter-skin junction and surrounding tissue. 4. After original insertion of CVAD [Central Venous Access Device], the dressing will consist of gauze and TSM. This must be changed within 24 hours. 5. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact). Review of the policy and procedure titled, Midline Catheter Flushing and Locking revision date of July 1, 2012, approval date 2/23/2022 read, To be performed by: Licensed Nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy. Considerations: 2. Positive pressure within the lumen of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 44 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 - Many the catheter must be maintained to prevent reflux of blood into the catheter. Intermittently used catheters must be clamped when not in use if clamp present, according to the manufacturer's instructions for catheter. 3. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions.4. Needleless connections require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter related bloodstream infection. 5. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures. Guidance: 5. Catheter patency must be verified prior to each access. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood. Procedure: 4. Perform hand hygiene, 6. [NAME] gloves. 7. Vigorously cleanse needless connector with alcohol allow to air dry. 9. Attach syringe filled with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency. 13. Remove gloves, 14. Perform hand hygiene. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections revised date of August 2012, approval date 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine gluconate/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 reads, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. During an observation on 5/04/2022 at 8:02 AM of medication administration for Resident #188, Staff E, LPN returned to the medication cart did not perform hand hygiene poured medications, entered the resident's room without performing hand hygiene, took the residents blood pressure and administered the medications. Staff E did not perform hand hygiene and left Resident #188's room returning to the medication cart and began preparing medications for another resident. 4. During an observation of medication administration for Resident #189 on 5/4/2022 at 8:08 AM Staff E, LPN did not perform hand hygiene and began preparing the medications. Staff E opened the Spiriva diskette, removed the old capsule, and put the new capsule into the diskette without performing hand hygiene or donning gloves. Staff E entered Resident #189's room, did not perform hand hygiene, administered the oral medications and held the Spiriva diskette while the resident did two inhalations. Staff E exited the room without performing hand hygiene and returned to the medication cart and began pouring medications for the next resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 45 of 46 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 105705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748 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 - Many 5. During an observation of medication administration for Resident #61 on 5/4/2022 at 8:18 AM, Staff E, LPN did not perform hand hygiene prior to pouring the medications. Staff E entered the resident's room, did not perform hand hygiene, took the resident's blood pressure, and administered the medications. Staff E exited the room and did not perform hand hygiene. During an interview on 5/04/22 at 8:20 AM Staff E, LPN stated, I should have washed my hands or used hand sanitizer when I poured the medications and after I left the rooms. 6. During an observation of medication administration for Resident #288 on 5/5/2022 at 8:17 AM, Staff I, LPN did not perform hand hygiene and poured medications, entered the resident's room, administered the medications, and left the room without performing hand hygiene and began preparing medications for the next resident. 7. During an observation of medication administration for Resident #190 on 5/5/2022 at 8:25 AM, Staff I, LPN did not perform hand hygiene, poured the medications, entered the resident's room, did not perform hand hygiene, donned gloves, took the resident's blood pressure, administered the medications, and left the room without performing hand hygiene. During an interview on 5/06/22 at 8:35 AM Staff I, LPN stated, I should have washed my hands each time that I went into the room or removed gloves. During an interview on 05/06/22 09:09 AM the Acting Director of Nursing stated, I expect all staff to administer medication per the policy and adhering to the five rights of administration. I expect that all nurses perform hand hygiene as appropriate, and according to universal precautions. Review of policy and procedure titled Handwashing/hand hygiene approval date of 2/23/2022 reads, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol- based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing and handling medications; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites i. After contact with resident's intact skin; m. after removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognize as the best practice for preventing health-care- associated infections. Implementation: Applying and removing gloves: 1. Perform hand hygiene before applying nonsterile gloves. 5. Perform hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 46 of 46