Inspection·February 18, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/17/22 at 3:54 PM, the Risk Manager stated if a resident had injuries of unknown origin, a report was completed and reviewed for Abuse/Neglect. All incidents of this nature are required to be reported to the Risk Manager within 2 hours and an investigation will be initiated which will include staff statements on all shifts. The Risk Manager confirmed the bruises on resident #65's right upper chest/neck area and stated, these bruises should have been reported to me immediately and they were not. I wish I had know about this sooner. Review of the Skin Care and Wound Management Policy, not dated. read, Policy: The overall goal of the Skin Care and Wound Management program will be to: identify residents at risk for skin impairment, provide care and services to attain or maintain intact skin, prevent complications and involve resident in self management . Procedure . c) Inspect resident skin on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted . Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policy, not dated, read, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of unknown source . are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing . 7. A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate procedures for conducting the investigation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 2 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #11 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and Alzheimer's disease. The resident's quarterly MDS assessment with Assessment Reference Date of 10/29/21 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 10/15. The resident required extensive assistance of two persons for bed mobility, dressing, toilet use and personal hygiene. Section G0400 Functional Limitation in Range of Motion revealed the resident had impairment of both sides of her upper extremities. Review of the resident's physician orders revealed an order dated 7/20/21 for hand roll with finger separators or carrot to Left and Right hands on at all times as tolerated. May remove for ADL (Activities of Daily Living) care. Monitor for placement, pain/discomfort, hand hygiene, splint hygiene, nail care, and skin integrity every shift. This order was not transferred to the current electronic medical record (EMR) until 2/15/22 On 2/14/22 at 4:38 PM, resident #11 was lying on her back in bed. The third, fourth, and fifth fingers of her left hand were contracted and there was redness, and a creamy substance to her left palm. The resident's right hand/ fingers were also contracted. There were no splint devices noted to the resident's hands. No splint device was observed. On 2/16/22 at 4:09 PM, CNA H stated resident #11 wore a splint on her left hand, which was placed by Restorative CNA, or the resident's CNA. The CNA stated the splint goes on during the day and was off in the evening. Observation of the resident's hands with CNA H showed no splint in place at this time. On 2/16/22 at 4:13 PM, the resident was lying in bed on her back. Both hands/fingers were contracted, and the resident did not have any splints in place. There was no rolled washcloth, or carrot in her hands. On 2/16/22 at 4:17 PM, the resident's primary nurse Licensed Practical Nurse (LPN) G, stated resident #11 had contracture of bilateral hands, but she was not aware if the resident had splints. On 2/17/22 at 10:16 AM, resident #11 was observed in bed and her hands were covered with a blanket. The resident stated she had a splint on her right hand, but none on the left hand. On 2/17/22 at 10:19 AM, CNA I stated resident #11 required total assistance with two persons assist for ADL care. She stated the resident had contracted hands and had a splint to her right hand. Observation of the resident's hands with CNA I revealed a splint to the resident's right hand, but no splint/carrot to her left hand. This was verified by CNA I. On 2/17/22 at 10:28 AM, the Director of Rehabilitation stated resident #11 was not currently on therapy caseload. He stated she was last seen by Occupational Therapy for the certification period May-July 2021 and was discharged to Restorative Nursing Program (RNP). The Director of Rehabilitation stated the resident was provided with hand roll with finger separator for both hands. He explained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 3 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that when a resident was discharged from therapy with any splint device the Restorative CNA would be trained to don/doff the device. He noted that Restorative CNA would manage the resident for 4 weeks, then train and transition care to the assigned CNAs, to continue therapy. On 2/17/22 at 1:28 PM, the DON stated resident #11 was discharged from therapy in July 2021 and was recommended to RNP for bilateral roll with finger separator application 3 times weekly for 12 weeks. She verbalized RNP transitioned to the floor staff in October 2021. The DON said the resident had contractures of bilateral hands and bilateral roll with finger separator should have been applied by the floor staff. She recalled the resident had refused splints in the past but the DON acknowledged no documentation could be identified regarding the placement or refusal of the splints. On 2/17/22 at 1:45 PM, the resident's EMR was reviewed with the South Wing Unit Manager (UM). She verified orders for hand rolls with finger separators were active in the previous EMR and were not transcribed to the new EMR until 2/15/22. Review of the clinical records revealed no documentation to address any attempt to apply the hand rolls with finger separator, or any refusal of the application by resident #11. The UM stated the resident's CNA or nurse would apply the splint, and it was the responsibility of the resident's nurse to ensure the splints were in place as ordered, along with documentation of the resident's tolerance to the device, skin assessment prior to donning and after doffing, and any refusal. The UM verbalized she could not identify any documentation in the resident's clinical records to address the hand rolls. Review of the resident's care plan self-care deficit requires assistance with bed mobility and ADL care .have limited ROM to bilateral hands edited on 11/09/21, revealed a handwritten date of 1/25/22 advising to continue with plan of care. Approaches included, hand rolls with finger separators or carrot to left and right hands all times as tolerated, Monitor for pain/discomfort, hand hygiene, splint hygiene, nail care and skin integrity every shift. Documentation indicated the task was changed from Restorative to nursing on 10/14/21. Review of the resident's clinical record revealed no documentation regarding application of the resident's hand roll with finger separator. There was no documentation regarding skin integrity, until a progress note dated 2/16/22 which read, left palm of hand and in between fingers reddened with white creamy build up in the palm of hand. Foul smelling odor noted .ARNP (Advance Registered Nurse Practitioner) new orders for Diflucan 200 mg(milligram) po (by mouth) daily x 10 days . Based on observation, interview and record review, the facility failed to follow plan of care for splint application for 2 of 5 residents reviewed for mobility of a total sample of 44 residents, (#104, #11). Findings: 1. Resident #104 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, dementia, quadriplegia and osteoporosis. The annual Minimum Data Set (MDS) assessment with reference date 01/10/22 revealed resident #104 had moderately impaired cognition and required extensive assistance of 1 person for bed mobility, dressing, personal hygiene and bathing. She was totally dependent on 1 staff for toilet use. A physician order dated 7/20/21 read Apply resting hand splint to right hand, ON in AM and OFF in PM as tolerated. Monitor for pain, discomfort, hand hygiene, splint hygiene, nail care and skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 4 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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 0688 integrity every shift. Level of Harm - Minimal harm or potential for actual harm A care plan initiated on 10/02/20, and revised on 12/24/21 noted resident #104 had self-care performance deficit which required assistance with bed mobility, toileting and Activities of Daily Living (ADL) care. She also had limited range of motion (ROM) to bilateral hands (contractures) and bilateral feet (foot drop). Residents Affected - Some On 02/14/22 at 12:30 PM, resident #104 was in bed, and had limited responses to simple questions. Her right hand was on top of her chest area observed to be contracted without any splint or cushion. On 02/15/22 at 5:24 PM, the resident was alert, able to answer simple questions by nodding her head upwards or sideways. Her right hand did not have any splint or any kind of support while resting on her upper chest. On 02/16/22 at 10:35 AM, the resident was resting in bed and her right hand did not have any splint. On 02/17/22 at 10:32 AM, the resident was alert, able to whisper single word responses to questions. Her right hand was placed on top of her upper chest without splint/cushion. When asked if her right hand had been contracted, she whispered yes. When asked if she ever had a splint on her right hand, she whispered yes, but long time ago. When asked if the staff had been applying splint to her right hand, she replied no. On 02/17/22 at 10:48 AM, Certified Nursing Assistant (CNA) E explained the resident required extensive assistance of 1 staff for most of her ADLs. She added the resident never refused care during her shift. She recalled she had never seen the resident with a right hand splint ever since she started working with her around August of 2021. On 02/17/22 at 11:00 AM, Registered Nurse, (RN) F said she had never been informed of the resident refusing care. RN F explained the resident could not move her arms and hands at all and acknowledged there was an order for splint to be applied to right hand and was not done. RN F said there were times the splint was there and other times it was gone. She stated it was difficult to monitor and ensure splints were being applied due to workload. She did not explain why the splint was not applied. A review of the progress notes reviewed from 02/01/22 to 02/16/22 did not show any documentation that resident #104 refused to wear the right hand splint. On 02/17/22 at 5:05 PM, the Director of Nursing (DON) explained when a resident was discharged from restorative nursing program, the restorative staff would relay the splinting plan to the nurse. The nurse then would notify the assigned CNA of the splint to be applied. She stated nurses were supposed to have a list of residents with splints. She did not explain why the splint was not applied for resident #104. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 5 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for tube feedings (TF) for 1 of 4 residents reviewed for tube feedings of a total sample of 44 residents, (#90). Findings: Resident #90 was admitted to the facility on [DATE] with his most recent readmission on [DATE]. His diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, dementia, aphasia, dysphagia emphysema, severe protein-calorie malnutrition, depression, and atrial fibrillation. Review of the resident's clinical records showed a physician's order dated 2/01/22 which read, every night shift Enteral: Closed system container- Change feeding administration set with each new bottle; label the formula container, syringe, and administration set with resident's name, date, time, and nurse's initials. The Medicare 5-day Minimum Data Set (MDS) assessment with assessment reference date of 1/02/22 indicated the resident was rarely/never understood and required extensive assistance for most ADLs including eating, and personal hygiene, and was totally dependent on staff for transfers, and bathing. Resident #90 was assessed as having a feeding tube. On 2/14/22 at 10:06 AM, and on 2/15/22 at 1:15 PM, resident #90's TF formula was in a bag hanging from the feeding pump. The bag was labeled with the name of the formula, flow rate and was dated 2/13/22. The label did not have the time the formula was hung and was not initialed. On 2/15/22 at 11:08 AM, the TF formula bag was dated 2/13/22, no time or initial was documented on the label. There was 400 milliliters (ml) of formula in the bag, and the water flush bag was also dated 2/13/22 with 300 ml remaining in the bag. The system was hanging from the feeding pump, not connected to the resident. A large syringe was in a plastic bag on the resident's over bed table and was not dated. On 2/15/22 at 1:31 PM, the North Wing UM stated resident #90 was on tube feeding daily, and the system/ TF formula/flush bag was to be changed on the 11 PM-7 AM shift and should be checked by the resident's nurse every shift. Observation of the resident's TF was conducted with the UM. She verbalized date on the bag containing the TF formula, and the water flush bag were 2/13/22. On 2/15/22 at 1:38 PM, Licensed Practical Nurse (LPN) K stated the resident was on TF at 75 ml/hours, to be off at 10 AM and on at 2 PM. LPN K stated she disconnected the TF from the resident at 10 AM, but did not check the date on the TF formula bag. She stated she assumed the system was changed as required on the 11 PM-7 AM shift. In an interview with the Director of Nursing (DON) on 2/16/22 at 9:32 AM, she stated the system should be changed on the 11 PM-7 AM shift daily. The DON verbalized that nurses were educated to change the system once the bag was completed, and were educated to label, date, time and initial the formula prior to administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 6 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the feeding tube care plan noted that the resident was at risk for altered hydration related to receiving 100% of nutrition via feeding tube. An approach read, Feeding and flush as ordered. The facility's policy Enteral Tube Feeding via Continuous Pump read, Check the enteral nutrition label against the order before administration On the formula label document initials, date and time formula was hung/administered, and initial that the label was checked against the order. Event ID: Facility ID: 105967 If continuation sheet Page 7 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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 oxygen (O2) therapy was administered per the physician's order for 1 of 3 residents (#51) and failed to obtain physician orders for O2 therapy for 1 of 3 residents reviewed for oxygen therapy, (#90) of a total sample of 44 residents. Residents Affected - Few Findings: 1. Resident #51 was admitted to the facility on [DATE] with a recent readmission of 2/12/22. Her diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, acute and chronic respiratory failure with hypercapnia, chronic diastolic (Congestive) heart failure, and Coronavirus Disease 2019. The resident's physician orders dated 2/13/22 noted oxygen at 2 Liters via nasal cannula (N/C) continuously. The resident's admission Minimum Data Set (MDS) assessment with assessment reference date of 12/20/21 revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 15/15, and indicated the resident used O2. Observations on 2/14/22 at 1:10 PM, and 2/15/22 at 10:49 AM showed resident # 51 received O2 via N/C at 3 Liter/Minute (L/M). On 2/15/22 at 5:20 PM, Licensed Practical Nurses (LPN) M stated after report from off going nurse, she performed a head-to-toe assessment of the resident, and usually checked on the resident's O2 setting. LPN M stated the resident had physician orders for O2 at 2 L/M. An observation of the resident's O2 was conducted with LPN M and she verbalized the O2 setting was on 3 L/M. The physician's orders were reviewed with LPN M, and she acknowledged the order was for 2 L/M. On 2/16/22 at 9:32 AM, the Director of Nursing (DON) stated O2 administration was by physician orders, and O2 therapy should have been administered as ordered for resident #51. The resident's care plan for Risk for ineffective tissue perfusion related to acute/chronic respiratory failure with hypoxia created on 12/20/21 and revised on 2/12/22 included, Oxygen per order. 2. Resident #90 was admitted to the facility on [DATE] with his most recent readmission on [DATE]. His diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, dementia, aphasia, emphysema, depression, and atrial fibrillation. Observations on 2/14/22 at 10:06 AM, 2/15/22 at 4:46 PM showed resident # 90 received O2 via N/C at 2 L/M, and 2.5 L/M. Review of the resident's physician orders revealed no order for O2 therapy. A nursing progress note dated 2/01/22, read, .O2 sats (saturation) 89% on RA (room air), 2 L of O2 applied with improvement of O2 sats 95% . On 2/15/22 at 4:49 PM, LPN K stated the resident had an order for O2, and flow rate was probably 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 8 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few L/M. The resident's O2 settings were observed with LPN K She verbalized the O2 was infusing at 2.5 L/M. The resident's clinical records were reviewed with the LPN and showed no order for O2. LPN K stated the facility just switched to a new electronic medical record (EMR) system. A review of the prior EMR was also conducted and LPN K acknowledged she did not see an order for O2. She verbalized nurses could place O2 as a preventative measure, but needed to follow up, and obtain a physician's order for the therapy. LPN K confirmed that a physician's order could not be identified for O2 therapy for resident #90. On 2/15/22 at 4:56 PM, the North Wing UM stated resident #90 was on O2, but she was not sure of the settings. Observation of the resident's O2 settings was conducted with the UM and she verbalized the O2 was infusing via n/c at 2.5 L/M. The UM stated the resident had orders for 2 L/M, however, a review of the resident's clinical records did not show an order for O2. The UM verbalized that O2 was considered a medication and was to be administered per physician's order. On 2/16/22 at 9:32 AM, the DON stated O2 administration was by physician orders. She stated administration of O2 could be a nursing judgement in an emergency, but nurses should follow up and obtain a physician's order for continued therapy. The DON verbalized O2 order should have been in place for resident #90 and should have been administered as ordered for resident #51. She verbalized the expectation was that nurses should ensure an order was in place, if not they were to follow-up with the physician, and obtain an order. On 2/16/22 at 11:29 AM, LPN L stated it could be a nursing judgement to initiate O2 in an emergency, but nurses needed to follow up and obtain a physician's order for continued therapy. LPN L stated resident #90 should have had an order in place for O2 therapy. The facility's policy Oxygen Administration revised 1/18/2018 read, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .start the flow of oxygen at ordered rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 9 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medication was not left at the bedside unattended for 1 of 17 residents on the 200 unit, out of a total sample of 44 residents, (#124). Findings: Resident #124 was admitted to the facility on [DATE] with diagnoses including gastric ulcer, diverticulosis and cognitive communication deficit. Review of the medical record revealed a Brief Interview for Mental Status assessment dated [DATE] which indicated the resident was cognitively intact with a score of 15/15. Review of the physician orders for February 2022 revealed resident #124 had an order for Carafate (Sucralfate) Tablet 1 gram (gm) to be given three times a day for stomach acid. Sucralfate is a prescription medication used to treat ulcers by sticking to the ulcer sites and protecting them from acids, enzymes and bile salts (retrieved on 2/18/22 from www.drugs.com). On 2/16/22 at 9:28 AM, resident #124 was observed sitting on the edge of her bed with her overbed table in front of her. An oval white tablet was observed in a disposable medicine cup on the overbed table. Resident #124 stated it was Tylenol and she was going to take it later. On 2/16/22 at 9:32 AM, Licensed Practical Nurse (LPN) B confirmed there was an oval white tablet in a medicine cup on resident #124's overbed table. LPN B stated the tablet was not Tylenol but could not identify the tablet. On 2/16/22 at 9:35 AM, resident #124 stated she thought the tablet was Tylenol but wasn't sure. The resident stated dietary brought the tablet to her and then stated the night nurse dropped it off. On 2/16/22 at 9:37 AM, LPN B removed the medicine cup with the oval white tablet from the resident's room and took it to the medication cart. Observation of the tablet revealed it was an oval white tablet imprinted with the letters TEVA on one side and 22/10 on the opposite side. LPN B compared the tablet to resident #124's medication cards and identified the tablet as Sucralfate 1 gram. LPN B stated she administered Sucralfate to resident #124 earlier in the morning. LPN B confirmed the nurse should ensure the resident took the medication and no medications should be left at bedside. She explained, if left unattended, another resident could ingest it, choke on it or have an adverse reaction to the medication. Review of resident #124's medical record on 2/16/22 revealed no physician order and no care plan for self-administration of medication. On 2/16/22 at 1:17 PM, the North Wing Unit Manager (UM) validated the medication observed in resident #124's room was identified as Sucralfate. She explained the process for medication administration was to administer the medications and to observe the resident took all of their medications. She said, Medications should never be left unattended at a resident's bedside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 10 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm On 2/16/22 at 4:03 PM, the Director of Nursing (DON) stated the standard of practice for medication administration was for the nurse to ensure the resident took the medication prior to leaving the bedside. She clarified if medications were left at bedside, there was a risk of another resident taking the medication. The DON acknowledged the nurse should not have left the medication at the resident's bedside on the overbed table. Residents Affected - Few Review of the facility's Policy and Procedure for 6.0 General Dose Preparation and Medication Administration dated 12/01/17 included procedures to observe the resident's consumption of the medication(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 11 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician order was obtained for advanced directive/code status for 1 of 2 residents reviewed for advanced directives of a total sample of 44 residents, (#363). Findings: Review of resident #363's medical record documented she was admitted to the facility on [DATE] with diagnoses of thoracic fracture, and and spinal stenosis lumbar region. On 02/15/22 at 11:24 AM, a review of the resident's medical record did not reveal an order for advanced directive/Code Status. 02/15/22 at 1:33 PM, a review the Advance Directives book for the 100 hall revealed no physician order for resident #363's code status, Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (3008) from the hospital documented the resident's wishes for full code status. Review of the Social Service note dated 02/10/22 at 3:06 PM, noted the resident wishes for full code. On 02/16/22 at 9:30 AM, the North Wing Unit Manager (UM) stated the process for new admission was to review all hospital paperwork and advanced directives. She said, we then call the resident's physician to verify the orders and then enter those orders into the electronic medical record. A copy of the resident's code status order is placed in the advanced directive book on each wing. The UM confirmed resident #363 did not have a physician's order for full code status and the advanced directive book contained no order for the resident's code status. On 02/16/22 at 10:01 AM, Licensed Practical Nurse (LPN) B explained if a resident did not have a pulse or was not breathing, she would immediately look in the electronic medical record to check for code status. She added, every resident has a copy of their code status order in the Advanced Directives book but I don't know who is responsible for putting the form in book. On 02/16/22 at 11:35 AM, the Director of Nursing (DON) explained resident #363's physician orders for advance directive/full code was not entered in the medical record until 02/16/21. The DON noted the resident was admitted to the facility on [DATE] and the admitting nurse had not obtained a physician's order for code status at admission. Not having an order for advance directive/full code could have caused a serious situation. The DON reported the admitting nurse was required to call the physician for advance directive order which was part of the admission process. She said if a resident had a medical emergency, the nurse would check the physician orders for the resident's code status. She added that all nursing units also had an advanced directive book which contained a copy of each resident's code status order. On 02/17/22 at 4:57 PM, LPN N acknowledged she had admitted resident #363 on 02/09/22. She said she made an error in entering the resident's physician orders into the electronic medical record and as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 12 of 13 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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 a result, the code status did not show up. I recall she was a full code. I put the order into a cue but did not activate the order so it did not show up. On 02/18/22 at 9:13 AM, the Administrator and DON confirmed that a physician order for code status was required for each resident. Residents Affected - Few Review of the facility's Nursing - Admitting/Readmitting a Resident Policy, not dated, read, Policy . admission orders will be obtained from the attending physician either just prior to admission or soon after admission . Procedure: The Admission/readmission Procedure is initiated upon the residents arrival to the facility. The nursing department, at minimum will complete the following: . 2. Physician orders, 3008 form . Code status/Advance Directives . 6. Obtain additional physician orders as indicated and verify the following: . Code Status/Advanced Directives. 7. Accurately and completely transcribe verified physician orders onto the physician order sheet (POS) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105967 If continuation sheet Page 13 of 13