Inspection·October 25, 2023

F 0641 diet was unchecked. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/24/2023 at 10:34 AM, the MDS Coordinator stated, Yes, I see [Resident #6] has orders for a pureed diet. The MDS needs to be corrected. Residents Affected - Few 4. Review of Resident #21's physician order dated 9/8/2023 reads, CCHO [Controlled Carbohydrate] diet. Refer to diet type for texture texture [Sic.], Regular /Thin liquids consistency. Order Status: Active. Review of Resident's #21's Admission/Medicare 5-day MDS dated [DATE] revealed no nutritional approaches identified for the resident under Section K-Swallowing/Nutritional Status. During an interview on 10/24/2023 at 12:42 PM, the MDS Coordinator stated, The diet was coded incorrectly. It needs to be corrected since the resident has an order for CCHO diet. 5. Review of Resident #35's physician order dated 6/22/2023 reads, Oxygen administration 4 LPM [liters per minute] PRN [as needed] for sats [oxygen saturation] below 90% as needed for low oxygen level. Order Status: Active. Review of Resident #35's quarterly MDS dated [DATE] revealed no information for oxygen therapy under Section O- Special Treatments, Procedures, and Programs. Review of Resident #35's Weights and Vitals Summary for September 2023 showed oxygen saturation of 96% (Oxygen via Nasal Cannula) on 9/27/2023 at 5:51 PM, and 93% (Oxygen via Nasal Cannula) on 9/25/2023 at 12:55 AM. During an interview on 10/24/2023 at 10:35 AM, the MDS Coordinator stated, I do see where [Resident #35's name] used oxygen during the look back period. It was not coded accurately. Review of the facility policy and procedures titled Comprehensive Assessments last reviewed on 1/4/2023 reads, Policy Statement: Comprehensive assessments are conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation . 6. Chapter 2 of the Resident Assessment Instrument (RAI) User Manual provides detailed Guidelines for Determining a Significant Change in a Resident's Status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 2 of 17 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 10/25/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to develop a person-centered care plan for 1 of 4 residents reviewed for oxygen therapy (Resident #35) and failed to implement weight orders for 1 of 6 residents reviewed for nutrition (Resident #48). Findings include: 1. Review of Resident #35's physician order dated 6/22/2023 reads, Oxygen administration 4 LPM [liters per minute] PRN [as needed] for sats [oxygen saturation] below 90% as needed for low oxygen level. Order Status: Active. Review of Resident #35's care plan did not show the resident was care planned for oxygen administration. During an interview on 10/24/2023 at 10:37 AM, the MDS (Minimum Data Set) Coordinator stated, I oversee care plans. I do not think that [Resident #35's name] has a care plan focus for oxygen. 2. Review of Resident #48's physician order dated 4/17/2023 reads, Weekly weight. Order Status: Active. Review of Resident #48's care plan initiated on 4/17/2023 reads, [Resident #48's name] is at increased nutritional risk r/t [related to] hx [history of] dx [diagnosis] protein calorie malnutrition, GERD [gastroesophageal reflux disease], constipation, HD [hyperlipidemia], SOB [shortness of breath], lymphedema, and hx osteomyelitis of vertebra . Interventions/Tasks . monitor weights as ordered. Review of Weight and Vital Summary for Resident #48 showed the resident's weight was documented as 173.8 pounds on 10/2/2023, 173.6 pounds on 9/22/2023, 173 pounds on 9/2/2023, 173.2 pounds on 8/2/2023, 170 pounds on 7/4/2023, 175.4 pounds on 6/5/2023, 178.4 pounds on 6/1/2023, 174.2 pounds on 5/27/2023, 172.4 pounds on 5/17/2023, 171.2 pounds on 5/13/2023, 171.2 pounds on 5/9/2023, 172.2 pounds on 5/3/2023, 172.2 pounds on 4/25/2023, and 171.4 pounds on 4/17/2023. During an interview on 10/24/2023 at 10:48 AM, the Registered Dietician stated, That is such an old order put in. We made the mistake of not removing it. I do not know why the weekly weights is even there. Typically, the order should have been questioned. No one came to me prior to today. Whatever the order says, it should be followed. Review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered last reviewed on 1/4/2023, reads, Policy Statement. A comprehensive, person-center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 3 of 17 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 10/25/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to treat pressure ulcers for 1 of 3 residents reviewed for skin conditions (Resident #54). Residents Affected - Few Findings include: Review of Resident #54's Wound Evaluation and Management Summary dated 10/17/2023 revealed the resident had a stage 3 pressure wound of left distal lateral calf and a stage 4 pressure wound of the right heel. The wounds were assessed as not at goal. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse L [left] distal lateral calf with NS [normal saline], apply collagen sheet and cover with dry protective dressing every day shift for wound care. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse right heel with NS, pat dry and apply collagen powder followed by santyl and cover with dry protective dressing every day shift for wound care. During an observation on 10/22/2023 at 11:11 AM, Resident #54 was lying in bed with her feet offloaded on top of a pillow with a dressing dated 10/20/2023 on left distal lateral calf. During an observation on 10/23/2023 at 11:05 AM, Resident #54 was sitting in a wheelchair in her room. Both feet were offloaded on a pillow. There were dry brownish stains and serous serosanguinous drainage on the pillowcase. Staff A, License Practical Nurse (LPN), removed Resident #54's blue nonskid sock. There was an open wound on the right heel with no dressing. Resident #54's nonskid sock did not have any dressings adhered to it and there were dried dark substances observed on the sock. During an interview on 10/23/2023 at 11:05 AM, Staff A, LPN, stated, [Resident #54's name] should have a dressing on her heel. I will go ahead and do her wound care now. During an interview on 10/24/2023 at 1:05 PM, the Director of Nursing stated, [Resident #54's name] twists her heel and rubs it [her heel] on the bed. I did talk to the nurse [Staff A] and asked her to look. They could not find it [the dressing]. At that point they had already stripped the bed. I cannot tell you what happened to the dressing, but she has those behaviors. I do know that if a dressing is ordered to be changed daily, staff should be changing them daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 4 of 17 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 10/25/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as is possible and each resident received adequate supervision while being transferred utilizing a mechanical lift for 1 of 2 residents reviewed for accidents (Resident #17). Findings include: During an observation on 10/22/2023 at 10:00 AM, Staff C, Restorative Specialist, was using a mechanical lift and sling independently to weigh Resident #17 above his bed. Review of Resident #17's admission records showed the resident was admitted initially on 11/1/2013 and most recently on 10/7/2022 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and chronic obstructive pulmonary disease. Review of Resident #17's physician order sated 2/13/2023 reads, Total mechanical lift with large sling. Order Status: Active. Review of Resident #17's care plan dated 5/21/2020 reads, Focus: [Resident #17's Name] has an ADL [Activities of Daily Living)] Self Care Performance Deficit. Activity Intolerance, Hemiplegia, Impaired balance, Stroke . Interventions . The resident requires full body mechanical lift large sling with all transfers OOB [Out of Bed] into wheelchair with 2 persons assist. During an interview on 10/22/2023 at 9:59 AM, Staff B, Licensed Practical Nurse (LPN), verified that Staff C was by herself in the room weighing Resident #17 with a mechanical lift. During an interview on 10/22/2023 at 10:03 AM, Staff C, Restorative Specialist, stated, We are supposed to have two people to do a Hoyer [Brand name of mechanical lift] lift. Review of the facility policy and procedures titled Lifting Machine last reviewed on 1/4/2023, reads, Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 5 of 17 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 10/25/2023 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 Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as prescribed by the physician for 2 of 4 residents reviewed for oxygen administration (Residents #20 and #64). Residents Affected - Some Findings include: 1. Review of Resident #20's physician order dated 10/9/2023 showed oxygen to be administered at 2 liters per minute via nasal cannula for shortness of breath every shift. During an observation on 10/22/2023 at 9:33 AM, Resident #20 was lying in her bed, with oxygen being administered via nasal cannula at 3.5 liters per minute. During an observation on 10/23/2023 at 8:17 AM, Resident #20 was lying in her bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 10/24/2023 at 8:23 AM accompanied with the Weekend Supervisor Registered Nurse, Resident #20 was being administered oxygen via nasal cannula at 2.5 liters per minute. During an interview on 10/24/2023 at 8:23 AM, the Weekend Supervisor Registered Nurse confirmed Resident #20 was being administered oxygen at 2.5 liters per minute. He stated he was not aware of Resident #20 changing the rate of her oxygen. 2. Review of Resident #64's physician order dated 8/27/2023 showed oxygen to be administered at 2 liters per minute via nasal cannula every shift. During an observation on 10/22/2023 at 10:43 AM, Resident #64 was lying in her bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 10/23/2023 at 8:19 AM, Resident #64 was lying in her bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 10/24/2023 at 8:25 AM accompanied with the Weekend Supervisor Registered Nurse, Resident #64 was being administered oxygen via nasal cannula at 3 liters per minute. During an interview on 10/24/2023 at 8:25 AM, the Weekend Supervisor Registered Nurse confirmed Resident #64 was being administered oxygen at 3 liters per minute. He stated Resident #64 was not able to reach and adjust her oxygen administration level. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 6 of 17 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 10/25/2023 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Residents Affected - Many Findings include: During an observation on 10/22/2023 at 9:23 AM, the posted nurse staffing information showed the information for 10/20/2023. During an interview on 10/22/2023 at 9:28 AM, the Weekend Supervisor Registered Nurse stated, I believe the Staffing Coordinator is responsible for posting the weekend staffing numbers, possibly even me. During an interview on 10/22/2023 at 10:51 AM, the Administrator stated, The Weekend Supervisor is supposed to display the correct day [staffing for the day]. The nurse staffing information was completed in advance and the Weekend Supervisor was supposed to make any staffing changes daily and post accurate staffing data. Review of the facility policy titled Procedure on Required Daily Staff Posting reads, Purpose: To comply with the requirement of posting the daily staffing. Procedure: The facility Staffing Coordinator will prepare the Daily Staffing Posting daily for the following day and place in the placard in the lobby behind the current day. The 300 night shift nurse will be responsible for bringing the current day forward at the start of the night shift. Any changes throughout the current day will be recorded on the posting form. On Friday afternoons, the Staffing Coordinator will prepare the Daily Staffing Posting with the projected staffing for Saturday, Sunday, and Monday and place in the placard in the lobby behind the current day. The 300 night shift nurse will be responsible for bringing the current day forward at the start of the night shift. Any changes throughout the current day will be recorded on the posting form. On Saturday and Sunday nights, the Weekend Supervisor will ensure that the posting is changed over for the current day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 7 of 17 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 10/25/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the consulting pharmacist reported any irregularities to the attending physician and director of nursing, and these reports were acted upon for 3 of 5 residents reviewed for unnecessary medications (Residents #1, #36 and #59). Findings include: 1. Review of Resident #1's admission record showed the resident was admitted initially on 11/27/2014 and most recently on 10/14/2023 with diagnoses including unstable angina, anxiety disorder, type II diabetes mellitus, dementia, bipolar disorder, and muscle weakness. Review of the consulting pharmacist's recommendations for Resident #1 dated 7/13/2023 showed the recommendation for adding Sitagliptin 100 mg daily for diabetes was accepted by the physician. Review of Resident #1's medical records revealed no record for addition of Sitagliptin 100 mg daily for diabetes. 2. Review of Resident #36's admission record showed the resident was admitted initially on 9/30/2016 and most recently on 3/19/2023 with diagnoses including displaced intertrochanteric fracture of right femur, atherosclerotic heart disease, abdominal aortic aneurysm, spinal stenosis, dementia, psychosis, dysphagia, protein calorie malnutrition, dementia, behavioral disturbance, adult failure to thrive. Review of the consulting pharmacist's recommendations for Resident #36 dated 3/20/23 showed the recommendation for evaluating and considering changing Baclofen 10 mg (milligrams) routinely in the morning and at bedtime to as needed in the morning and at bedtime was accepted by the physician on 4/11/2023. Review of Resident #36's Medication Administration Record (MAR) for October 2023 showed the resident received Baclofen Oral Tablet 10 mg by mouth at bedtime for muscle spasms on 10/1/2023 through 10/23/2023 at 9:00 PM and received Baclofen Oral Tablet 10 mg by mouth in the morning for muscle spasms on 10/1/2023 through 10/23/2023 at 6:00 AM. 3. Review of Resident #59's admission record showed the resident was readmitted on [DATE] with diagnoses including fracture of left femur with onset date of 9/10/2023, peripheral vascular disease, age related osteoporosis, anxiety disorder, cognitive communication deficit, major depressive disorder, unspecified disorder of adult personality and behavior, muscle weakness and difficulty walking. Review of the consulting pharmacist's recommendations for Resident #59 dated 9/11/2023 reads, #2) Falls (F757): Resident has a history of falls. The following medications are commonly linked to falls. Please review and deprescribe to lowest effective regimen. Amlodipine 10 mg, Coreg 6.25 mg, Hydralazine 50 mg, sertraline 100 mg, Tamsulosin 0.4mg. #3. Excessive dose, change order to (F757): Aspirin 325 mg po [by mouth] BID [twice daily]. There is a risk of major bleeding from aspirin increases markedly in older age (sic). Increased risk of GI [gastrointestinal] bleeding or peptic ulcer disease in high-risk groups, including those greater than [AGE] years old or taking oral corticosteroids or antiplatelet agents; use of proton pump inhibitor or misoprostol reduces but does not eliminate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 8 of 17 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 10/25/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some risk. Also, it can increase blood pressure and induce kidney injury . Consider a dose reduction. (75-100 mg/ daily). The physician agreed to reduce Aspirin dosage, decrease hydralazine to 25 mg, and added monitor BP (blood pressure) on 9/19/2023. Review of Resident #59's physician orders showed active orders for Aspirin EC (enteric coated) tablet 325 mg delayed release, 1 tablet by mouth two times a day for TIA (Transient Ischemic Attack) prevention with a start date of 9/11/2023 and Hydralazine HCl (Hydrochloride) oral tablet 50 mg, 1 tablet by mouth every 12 hours for HTN (hypertension), Hold for SBP (Systolic Blood Pressure) less than 110 with a start date of 9/10/2023. Review of Resident #59's MAR for October 2023 showed the resident received Aspirin EC tablet delayed release 325 mg at 9:00 AM on 10/1/20123 through 10/24/2023 and at 5:00 PM on 10/1/2023 through 10/23/2024 and received Hydralazine HCl (Hydrochloride) oral tablet 50 mg at 9:00 AM on 10/1/2023 through 10/24/2023 and at 5:00 PM from 10/1/2023 through 10/23/2023. During an interview on 10/25/2023 at 11:30 AM, the Interim Director of Nursing verified that Residents #1, #36 and #59's physician-agreed changes as proposed by the consulting pharmacist had not been put into effect until 10/24/2023. Review of the facility policy and procedure titled Medication Regimen Reviews last reviewed on 1/27/2023 reads, Policy Statement: The consultant pharmacist reviews the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 1. The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medications . 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 9 of 17 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 10/25/2023 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 - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 4 medication carts and failed to ensure the medication were secured in 1 of 2 units. Findings include: During an observation of the Blue Medication Cart (300 Hall) on 10/22/2023 at 9:28 AM with Staff D, License Practical Nurse (LPN), there was one opened Novolog insulin pen with no opened or expiration dates. During an interview on 10/22/2023 at 9:31 AM, Staff D, LPN, stated, I do not see an opened date. Once we open an insulin pen, it should be labeled with the open and expiration date. During an observation of the Medication Cart 1-2 (400 Hall) on 10/22/2023 at 9:33 AM with Staff E ,LPN, there was one opened Systane Comp (complete) 0.6% eye drops with no opened or expiration dates, one opened Humulin N insulin pen with no opened or expiation dates, and one Fluoromethol 0.1% ophthalmic drops with no opened and expiration dates. During an interview on 10/22/2023 at 9:43 AM, Staff E, LPN, stated, Eye drops should be labeled with an opened date and an expiration date. I would check the manufacturer's instructions to know when they expire. Insulin should be labeled with an opened and an expiration date. Insulin will usually last 28 days after being opened. During an observation of the 300 Hall nursing station counter on 10/22/2023 at 10:15 AM, there was a package of Bacitracin antibiotic ointment unattended. During an interview on 10/22/2023 at 10:20 AM, the Weekend Supervisor Registered Nurse stated, The ointment should not be there. During an observation on 10/22/2023 at 10:24 AM, there was one bottle of Bausch + Lomb Advance Eye Relief eye drops on top of the drawer in Resident #224's room. During an observation on 10/22/2023 at 10:34 AM, there was Mupirocin ointment 2% on top of Resident #40's bedside table. During an interview on 10/22/2023 at 10:35 AM, Resident #40 stated, The nurses help me apply the ointment to my hand. During an interview on 10/24/2023 at 1:26 PM, the Director of Nursing stated, [Resident #224's name and Resident #40's name] do not have assessments in place to self-administer medication. I do not know where [Resident #224's name] eye drops came from. Maybe the family brought them in. In order for a resident to self-administer medication, the facility will do an assessment which involves demonstration. Physician orders would also be in place. Medication should be labeled upon opening with an open date and an expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 10 of 17 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 10/25/2023 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 - Few Review of the facility policy and procedure titled Medication Labeling and Storage last reviewed on 1/4/2023, reads, Policy heading. The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys . Medication Labeling . 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the facility policy and procedure titled Administering Medications last reviewed on 1/4/2023 reads, Policy Interpretation and Implementation . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 11 of 17 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 10/25/2023 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #17's physician order dated 6/2/2023 reads, Depakote level every night shift every 3 month(s) starting on the 2nd of 1 day(s) for repeat VPA level. Order Status: Active. Residents Affected - Few Review of Resident #17's Lab Results Report dated 6/3/2023 showed the result for Valproic Acid (Depakote) as 33 ug/ml, flagged for low. Review of Resident #17's laboratory records showed no labs completed for Depakote since 6/3/2023. During an interview on 10/24/2023 at 10:15 AM, the Director of Nursing stated, It appears we did not do Depakote levels for [Resident #6's name], [Resident #25's name], and [Resident #17's name]. We have a lab book and has an order it needs to get done. Trying to find out the root cause of what happened. We monitor Depakote for levels if too high can cause nausea and vomiting it is a way of monitoring them. On 10/25/2023 at 12:33 PM, the Director of Nursing was requested to provide the facility policy for laboratory services. No documentation was provided. Based on record review and interview, the facility failed to provide laboratory services for the monitoring of Valproic Acid levels for 3 of 7 residents reviewed for mood and behavior (Residents #6, #17, and #25). Findings include: 1. Review of Resident #6's physician order dated 4/4/2023 reads, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG [milligram] (Divalproex Sodium). Give 2 capsule by mouth two times a day for mood disorder. Order Status: Active. Review of Resident #6's physician order dated 6/2/2023 reads, Depakote level every night shift every 3 month(s) starting on the 2nd for 1 day(s). Order Status: Active. Review of Resident #6's Lab Results Report dated 6/3/2023 showed the result for Valproic Acid (Depakote) as 26 ug/ml [micrograms per milliliter], flagged for low. Review of Resident #6's laboratory records showed no Valproic Acid labs completed in September 2023. 2. Review of Resident #25's physician order dated 5/30/2023 reads, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, Give 1 capsule by mouth three times a day for mood disorder. Order Status: Active. Review of Resident #25's physician order dated 6/2/2023 reads, Depakote Level every night shift every 3 month(s) starting on the 2nd of 1 day(s) for Depakote use. Order Status: Active. Review of Resident #25's Lab Results Report dated 6/3/2023 showed the result for Valproic Acid (Depakote) as 21 ug/ml, flagged for low. Review of Resident #25's laboratory records showed no Valproic Acid labs completed in September (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 12 of 17 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 10/25/2023 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 0770 2023. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 13 of 17 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 10/25/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure treatment of pressure ulcers was accurately documented for 1 of 3 residents reviewed for skin conditions (Resident #54). Residents Affected - Few Findings include: Review of Resident #54's physician order dated 10/17/2023 reads, cleanse L [left] distal lateral calf with NS [normal saline], apply collagen sheet and cover with dry protective dressing every day shift for wound care. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse right heel with NS, pat dry and apply collagen powder followed by santyl and cover with dry protective dressing every day shift for wound care. During an observation on 10/22/2023 at 11:11 AM, Resident #54 was lying in bed with her feet offloaded on top of a pillow with a dressing dated 10/20/2023 on left distal lateral calf. Review of Resident #54's Treatment Administration Record (TAR) for October 2023 showed the wound care for left distal lateral calf was provided on 10/21/2023. During an observation on 10/23/2023 at 11:05 AM, Resident #54 was sitting in a wheelchair in her room. Both feet were offloaded on a pillow. There were dry brownish stains and serous sanguineous drainage on the pillowcase. Staff A, License Practical Nurse (LPN), removed Resident #54's blue nonskid sock. There was an open wound on the right heel with no dressing. Resident #54's nonskid sock did not have any dressings adhered to it and there were dried dark substances observed on the sock. Review of Resident #54's Treatment Administration Record (TAR) for October 2023 showed the wound care for right heel was provided on 10/22/2023. During an interview on 10/23/2023 at 11:05 AM, Staff A, LPN, stated, [Resident #54's name] should have a dressing on her heel. I will go ahead and do her wound care now. During an interview on 10/24/2023 at 1:05 PM, the Director of Nursing stated, [Resident #54's name] twists her heel and rubs it [her heel] on the bed. I did talk to the nurse [Staff A] and asked her to look. They could not find it [the dressing]. At that point they had already stripped the bed. I cannot tell you what happened to the dressing, but she has those behaviors. I do know that if a dressing is ordered to be changed daily, staff should be changing them daily. Staff should be documenting accurately for the medication and treatment being provided to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 14 of 17 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 10/25/2023 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 staff performed hand hygiene during medication administration, during wound care for 1 of 3 residents reviewed for wound care (Resident #54), and during providing direct care to Resident #64. Residents Affected - Few Findings include: 1. During an observation on 10/24/2023 at 8:29 AM, Staff F, Registered Nurse (RN), performed hand hygiene with hand sanitizer and began to prepare medication for Resident #26. Staff F opened the lower drawer of the medication cart and poured 30 milliliters of Prostat into a medication cup. Staff F did not don gloves. Staff F grabbed two Acidophlilus capsules with his hands and placed them in the medication cup. Staff F used the mouse and keyboard to type the reason why Norvasc was being held. Staff F grabbed 2 Arimidex, Ascorbic Acid, Baclofen, Bumex and Clopidogrel with his hands and placed them in a medication cup. Staff F touched the computer mouse in between preparing medications. Staff F used hand sanitizer and poured Pepcid without touching the medication. Then, Staff F, without donning gloves, began to grab with his hands Gabapentin and Cardizem tablets and placed them into a medication cup. Staff F typed into the system the reason why he was holding Metropol due to blood pressure parameters. Without any gloves, Staff F proceeded to pour singular and multivitamins by grabbing them with his hands and placing them into the medication cup. Staff F opened the medication cart drawer and poured 5 milliliters of Nystatin into a medication cup. Staff F, without wearing gloves, grabbed Protonix, Risperdal, Steglatro and Carafate with his hands and placed them into the medication cup. Staff F touched a total of 14 medications without gloves. During an interview on 10/24/2023 at 8:48 AM, Staff F, RN, stated, That is why I sanitized my hands at the beginning of preparing the medications. Ideally, we would wear gloves if we are going to touch the medication, but we do not have any place to put gloves in the medication cart. During an interview on 10/24/2023 at 1:16 PM, the Director of Nursing stated, Medications come in individual blister packages. They are to pop the medication into the medication cup. There is no reason to touch medication. If there is a need to touch a medication, gloves should be worn. Review of the facility policy and procedure titled Administering Medications last reviewed on 1/4/2023, reads, Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precaution, etc.) for the administration of medications, as applicable. 2. During an observation on 10/23/2023 at 11:10 AM, Staff A, License Practical Nurse (LPN), entered Resident #54's room and placed wound care supplies on top of the resident's bedside table inside a foam barrier container. Staff A performed hand hygiene and donned exam gloves. Resident #54 was sitting in her wheelchair with her feet resting on top of two pillows. There was large amount of light brown color dried stains and serosanguinous drainage on the pillowcase. Staff A removed the dressing, dated 10/22, from Resident #54's left lateral calf. Staff A did not perform hand hygiene. Staff A proceeded to clean the wound with a 4x4 gauze and normal saline. Staff A pat dried the wound area. Without performing hand hygiene, Staff A applied the treatment and placed a new dressing on Resident #54's left lateral calf. Staff A removed the left foot sock and there was a dressing dated 10/23 on the left heel. Staff A removed her gloves and without preforming hand hygiene, donned new exam gloves. Staff A removed the dressing from Resident #54's left heel without performing hand hygiene, cleansed the wound and placed Resident #54's heel back down on the pillows. Resident #54 tried to hold her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 15 of 17 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 10/25/2023 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 foot up, but rested her foot down twice on pillows allowing the left foot heel wound to come in contact with drainage present on the pillow while Staff A was labeling the dressing at the bedside table and applying treatment to the inside of the dressing. Staff A applied the dressing to the left heel wound. Without performing hand hygiene, Staff A removed Resident #54's right foot sock. No dressing was on the right heel wound. Staff A cleaned Resident #54's right heel wound. Residents Affected - Few During an interview on 10/23/2023 at 11:45 AM, Staff A, LPN, stated, I should have asked for help to pull her [Resident #54] feet up, so I could maneuver better. I should have done hand hygiene in between wound care and after removing gloves. Changing pair of gloves does not substitute hand washing. During an interview on 10/24/2023 at 1:30 PM, the Director of Nursing stated, Staff should have washed her hands during wound care. It is considered best practice to disperse bacteria. Any time you are going from dirty to clean, hand hygiene and donning gloves is required. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse L [left] distal lateral calf with NS [normal saline], apply collagen sheet and cover with dry protective dressing every day shift for wound care. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse right heel with NS, pat dry and apply collagen powder followed by santyl and cover with dry protective dressing every day shift for wound care. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse Left heel with NS, pat dry and apply collagen sheet and cover with dry protective dressing every day shift for wound care. Review of the facility policy and procedure titled Wound Care last reviewed on 1/4/2023 reads, Purpose. The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Steps in the Procedure . 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound . 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on clean field. 3. During an observation on 10/24/2023 at 8:25 AM accompanied with the Weekend Supervisor Registered Nurse, Resident #64's oxygen was running via nasal cannula at 3 liters. Resident #64's oxygen tube nasal cannula was not inserted into Resident #64's nostrils. At 8:27 AM, the Weekend Supervisor Registered Nurse offered to assist Resident #64 by reinserting the nasal cannula into Resident #64's nostrils. The Weekend Supervisor Registered Nurse began to don gloves to insert the nasal cannula into Resident #64's nostrils without washing or sanitizing his hands. Review of the facility policy and procedure titled Handwashing/Hand Hygiene last reviewed on 1/4/2023, 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 handwashing/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, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 16 of 17 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 10/25/2023 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 alternatively, soap (antimicrobial or non -antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc . k. After handlining used dressings, contaminated equipment, etc . m. After removing gloves . 9. The use of gloves does not replace washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105705 If continuation sheet Page 17 of 17