Health inspection·March 26, 2021

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of the skilled nurses notes dated 3/20/21 revealed in section G. skin and wound, 1a. no new changes to skin integrity noted. Review of the skilled nurses notes dated 3/21/21 revealed in section G. skin and wound, 1a. no new changes to skin integrity noted. Residents Affected - Few Review of the skilled nurses notes dated 3/22/21 revealed in section G. skin and wound, 1a. no new changes to skin integrity noted. Review of the skilled nurses notes dated 3/23/21 revealed in section G. skin and wound, 1a. no new changes to skin integrity noted. Review of the skilled nurses notes dated 3/24/21 revealed in section G. skin and wound, 1a. no new changes to skin integrity noted. During an interview with Staff member H, RN (Registered Nurse) on 3/25/21 at 12:30 p.m. she stated she observed the resident to have right head steri strips, and oxygen which she did not see documented so she completed a full head to toe assessment and confirmed he should have been assessed thoroughly on admission. An interview with the Director of Nursing (DON) on 3/25/21 at 2:55 p.m. confirmed that the staff should ensure the admission assessment is accurate and complete. Review of facility policy 'skin assessment', undated, two pages, revealed: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Review of the facility policy 'physician orders' dated 12/19, two pages, revealed: Physician orders are obtained to provide a clear direction in the care of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 2 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of resident #55's medical record revealed that he was admitted to the facility on [DATE] and readmitted last on 9/10/2020. Review of the advance directives revealed he was his own decision maker. Review of the current Minimum Data Set (MDS) assessment 5 day, dated 3/11/2021, revealed the following: (Cognition/Brief Interview Mental Status BIMS - 15 of 15, which indicates no cognitive impairments); (Activities of Daily Living ADL - Eating: independent with set up only). Review of the current Physician's Order Sheet (POS) for the month 3/2021, revealed the following: Diet - Regular, Regular texture, Regular consistency CCHO. Review of the current care plans with next review date 5/19/2021 revealed the following: Resident is at a nutritional risk related to high Body Mass Index (BMI), has varied meal intake, Psychotropic meds and depression with interventions to include: provide and serve diet as ordered, monitor intake and record each meal. On 3/24/2021 at 8:20 a.m. resident #55 was visited while in his room. He was observed in bed and with his over the bed table placed in front of him with his breakfast meal tray. He was observed self feeding and was interviewable. He was asked how his meal was and he replied, I don't really like it, they give me things I don't like all the time. He further stated, they give me ham, bacon and I don't eat or like any ham products. His plate was observed with three slices of bacon and a bowl of hot oatmeal. There were small remnants of what appeared to be scrambled eggs. He also had a carton of whole milk which was not opened. He stated he could not open it and that he needs staff to open it. He also indicated he does not drink the milk, he puts it in his cold cereal frosted flakes, but he did not get any this a.m. Review of his meal ticket revealed he was to receive two boxes of frosted flakes and was ordered for a Regular diet, Regular consistency meal. Dislikes to include: eggs, french toast, ham, pancakes, oatmeal, sausage, waffles. It was found that resident #55 received bacon, oatmeal, eggs when it was on his dislikes list. He indicated he likes eggs and does not know why it shows as dislikes. Also, he did not receive the boxes of cold cereal (frosted flakes). Photographic evidence was taken. On 3/24/2021 at 12:00 p.m. resident #55 was observed in his room and seated upright in bed with his over the bed table in front of him and with his lunch meal tray placed on it. He had not touched anything on his plate. He was asked how his meal was today and he replied, they keep serving me things I don't like and it makes me not want to eat. He was asked what was on his tray that he did not like. Resident #55 replied, look, they gave me green beans, don't like them. He was asked if he could order something else. He replied, what's the use, they keep getting things wrong, and I don't want to keep complaining about it. Resident #55 was observed with the following food items on his plate; spiraled pasta with red meat sauce, garlic toast, mashed potatoes, a bowl of soup and a full serving of green beans. Review of the meal ticket clearly read, dislikes: greens. Photographic evidence was taken. On 3/25/2021 at 8:00 a.m. resident #55 was in his room with his breakfast meal placed in front of him. He was not eating. Interview with resident #55 revealed he received items he does not like and it just made him not hungry anymore. He was asked what things did he receive that he does not like. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 3 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 He pointed out on the plate of a slice of ham. He stated, I don't like ham or bacon. Review of the meal ticket again read; dislikes: ham. On 3/25/2021 at 9:00 a.m. an interview with a 300 hall Certified Nursing Assistant (CNA), Employee E revealed that she passed the resident his tray for breakfast and she did not know he received things that he disliked. She did say she does know him and that he does change his mind about food items but she should have reviewed the meal ticket prior to dropping off the tray. She confirmed she neglected to read the meal ticket after setting up his meal. On 3/25/2021 at 11:55 a.m. resident #55 was observed in his room and lying in bed upright and with his lunch meal placed on the over the bed table in front him. He was not eating and appeared to be a bit aggravated when asked if he was served what he wanted for lunch. Resident indicated he does not want to eat because they never give him things he likes. He was asked what he served today that he did not like. He pointed out the greens and carrots and indicated he does not like them. He also said he does not like ham as well. The kitchen did not provide him with the primary meal of ham slices because he doe s not like ham. However, there was a side plate on the table wrapped in clear plastic with ham sandwich. He said he likes hamburgers, but not ham or bacon. He confirmed he does not like ham of any kind. He said he did not want anything to eat now at all. Resident did not ask for alternate and did not eat any of his lunch meal today. Review of his current meal ticket revealed likes and dislikes to include: Ham, Greens, Carrots. He received all three. Photographic evidence was taken. Note, the same dislikes were reviewed on each ticket for the past three days 3/23/2021, 3/24/2021 and 3/25/2021. Photographic evidence was taken. On 3/25/2021 at 12:10 p.m. an interview with a Certified Nursing Assistant (CNA) Employee D, who had the resident on her assignment, was asked to show what the resident was served today. The tray had already been taken from his room and put on the tray cart to go back to the kitchen. She was asked to demonstrate what was on the tray. She pulled it out and lifted the top and she confirmed resident did not eat any of the scalloped potatoes, greens with carrots, ham sandwich, and or the dessert bar. Employee D revealed she believed the side sandwich was a ham sandwich. She was also asked who reviews the meal tickets to ensure the residents do not receive any documented dislikes. She said that kitchen is supposed to do that but staff on the floor review the ticket as well. She said she was the one who served the resident today and she must not have reviewed the ticket for lunch. She confirmed the meal ticket was documented with dislikes to include: carrots, ham, greens. She said she would go to the kitchen and talk to the Dietary Manager about it. She also indicated she is fairly new to the facility and does not know the resident too well. Further interview with the resident on 3/25/2021 at 12:00 p.m. revealed that he was not happy with the meals and meal service with regards to what he receives. He revealed that the kitchen gets his meal wrong so much that what's the bother to complain about it any more. He just does not eat his meal when its served things that he does not like. He confirmed he is not fine with it and would like for them to fix it. On 3/25/2021 at 11:45 a.m. during tray line observation and interview with the Kitchen Manager and a cook, Employee A, both revealed that when plating food there are three staff members that verify the meal ticket and audit to make sure residents receive what they choose and do not receive any of the dislikes that are on the ticket. The Kitchen Manager further revealed that staff out on the floor to include Certified Nursing Assistants are to review the meal ticket and look at what is on the plate as well. She revealed that if there is something that was served and the resident has as dislike, the tray should be brought back to the kitchen immediately so it can be fixed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 4 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 On 3/25/2021 at 1:00 p.m. another interview with the Kitchen Manager was conducted. She was made aware that resident #55 received food items on his plate in which he disliked and was also noted as dislike on his meal ticket. She was provided photographic evidence to show the plate of food and with the meal ticket. She confirmed that the resident received food items he disliked such as Greens/Green beans, Ham, Carrots, oatmeal. She did not know how he received those food items of dislike so many times and that her staff should be reviewing the meal tickets and what goes out on the plates. On 3/25/2021 at 1:40 p.m. an interview with the facility's Registered Dietician was conducted. She revealed that she followed up with the dietary staff related to resident #55 with his likes and dislikes. She revealed that her interpretation and follow up with the Kitchen staff, revealed that greens on the dislikes section is only for collard greens and does not pertain to green beans. The Dietician also revealed that resident #55 changes his likes and dislikes routinely. She did not know how often the kitchen manager actually verifies likes and dislikes and makes the changes to reflect on the meal tickets. However, follow up interview with resident #55 on 3/25/2021 at 1:50 p.m., revealed that he does not like green beans at all and that is the reason he did not want to eat his lunch a couple of days earlier as he was served green beans. He again indicated that he does not ask for anything else because he has tried and tried to tell staff of things he does not like but keeps on receiving them. He again was asked by this surveyor if he likes green beans, oatmeal, carrots, ham, which are on his meal slip as dislikes. He confirmed and stated, I hate them, don't want them. On 3/26/2021 the Nursing Home Administrator provided the facility's Dietary Department Guidelines policy and procedure, not dated. The procedure did not reflect honoring food choices with regards to likes and dislikes. A review of the facility's Care Plans policy, undated, revealed the following: Aid in preventing or reducing declines in the resident's functional status and/or functional levels. CNA's are responsible for reporting to the nurse supervisor any changes in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. Based on observation, interviews and medical record reviews, the facility failed to ensure care plan interventions were followed related to falls (Resident #59) and food preferences (Resident #55) for two (2) out of thirty-seven (37) residents sampled. Findings included: 1. A review of the facility's Fall Incident Log revealed that Resident #59 had a witnessed fall on 1/14/21 at 7:20 AM. The resident had unwitnessed falls on 12/7/2020 at 5:57 PM, 12/16/2020 at 2:00 AM, 12/18/2020 at 10:00 AM, 12/25/2020 at 1:15 AM, 1/13/2021 at 4:06 AM, 1/17/2021 at 10:30 PM, and 1/19/2021 at 2:45 AM An observation on 3/24/21 at 9:30 AM, revealed the resident's call light was on the floor and out of reach. Resident's bed was in the lowest position with bolsters in place. No floor mats were in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 5 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 On 3/24/21 at 1:11 PM, Resident #59 was observed asleep in bed. Bed again in lowest position, head elevated, no fall mats at this time. The resident had bed bolsters on both sides. Resident's call light was on the floor, but the bed control remote was in reach. On 3/25/21 at 8:23 AM, a third observation revealed no floor mats, bed low, bolsters in place, call light on floor. A review of Resident #59's face sheet revealed that the resident was a Do Not Resuscitate (DNR) and the resident's daughter was the responsible party. The resident was initially admitted on [DATE] and readmitted on [DATE]. A review of the resident's 5-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating severe cognitive impairment. The resident was identified with displaying no behaviors in section E. Section G revealed the resident required extensive assistance for bed mobility, bed transfer, dressing, and personal hygiene. Section J revealed the resident had a fall within 2-6 months prior to entry. A review of the most recent completed care plan dated 3/17/2021 revealed a focus area for falls. Fall interventions included: bed bolsters in place, call light kept within reach and answered promptly with resident being checked frequently, educated on use of call bell for assistance with return demonstration of trying to assist roommate himself, fall risk assessment completed and review quarterly and PRN (as needed), floor mats (origin date of 12/28/2020 with no modifications made), keep areas of room clutter free, and keep bed in lowest position when resident in bed for safety. A review of Resident #59's progress notes revealed the following notes: -3/19/2021 Care Plan meeting with our team and daughter via conference call 3/18/21. Current care plans reviewed including cognition, poor safety awareness [and] risk for falls, skin condition, diet/weight, activity, (daughter gave much insight on his history for activities), code status to remain DNR. -3/19/21 Resident is resting with his eyes closed, will open eyes when his name is called. Bed in lowest position and call light is in reach. -3/17/21 Resting in bed with no complaint of pain at this [time]. Declining, refuse all medication and bed in the low position. Call light within reach. -3/15/21 Resident did not take any medication or eat dinner. Drink water, alert, no complaint of pain, no distress noted. Bed in low position. Call light within reach. On 3/24/21 at 10:41 AM, an interview with Resident #59's Representative stated the facility is very easy to contact and communicate with and that any issue is resolved efficiently. [Resident #59's Representative] had a care plan conference the week prior and the facility recommended fall mats be added to the resident's care plan. [Resident #59's Representative] stated the resident had a history of falls while at home and that [Resident #59] can be stubborn and not ask for help or use the call light. On 3/25/21 at 9:36 AM, an interview with Staff F, Certified Nursing Aide (CNA), revealed that Resident #59 was indeed a fall risk and that after care was provided by CNAs, they verify that care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 6 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 interventions are in place. Staff F stated that Resident #59 was known for not using the call light and tended to yell out when in need of assistance. When asked specifically about Resident #59 related to falls, Staff F stated she was aware that Resident #59 did not have fall mats, but [Resident #59] had not had them since returning from the hospital. On 3/25/21 at 9:43 AM, an interview with Staff G, Licensed Practical Nurse (LPN), stated that care plan interventions are verified daily and if something was not in place the [CNAs] and residents are educated on the interventions. When asked specifically about Resident #59, Staff G stated that Resident #59 was totally a fall risk and was supposed to have fall mats in place. Staff G was unaware that the resident did not have fall mats in place. On 3/25/21 at 10:11 AM, an interview with Staff H, Registered Nurse (RN), revealed that Resident #59 was supposed to have fall mats in place. Staff H then stated the care plan intervention would be verified. On 3/25/21 at 10:25 AM Staff H confirmed that Resident #59 was supposed to have floor mats and that they were put in place. A review of a facility policy titled 'Accidents and Supervision', undated, revealed 3. Implementation of interventions - using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes e. ensuring that the interventions are put into action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 7 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 three Residents (#44, #376 & #378) were receiving oxygen according to professional standards of 3 residents observed. Residents Affected - Some Findings Included: 1. Observation of Resident #44 on 3/24/21 at 10:36 a.m. was observed wearing oxygen at 2.5 liters via nasal cannula. Observation on 3/24/21 at 2:40 p.m. revealed Resident #44 wearing oxygen via nasal cannula. Observation on 3/25/21 at 8:41 a.m. revealed Resident #44 wearing oxygen via nasal cannula at 2.5 liters. An interview with Staff member H, (Registered Nurse) RN on 3/25/21 at 12:45 p.m. confirmed Resident #44 did not have an order for oxygen. Staff member H stated the resident used to be on 2 liters of oxygen and stated she would add the orders. Staff member H, confirmed the oxygen setting on the concentrator was 3 liters of oxygen and adjusted the concentrator to 2 liters. Review of the physician orders revealed check oxygen saturation every shift and as needed if oxygen below 90%, encourage resident to cough and take a deep breath, then recheck oxygen saturation and apply oxygen per symptomatic protocol and notify doctor every shift dated 9/5/20 Review of the physician orders revealed to change respiratory tubing every night shift every 2 weeks on Sunday dated 3/25/21. Review of the oxygen therapy revealed 2 liters of oxygen via nasal cannula to maintain oxygen greater than 90% every shift for dyspnea dated 3/25/21. Review of the care plan revealed a focus area of oxygen therapy revised on 11/2/20. Interventions included to administer oxygen therapy initiated on 8/12/19, oxygen saturation as needed for dyspnea initiated on 8/12/19 and provide with humidification dated 8/12/19. Review of the admit/readmit assessment dated [DATE] revealed the resident on oxygen at 3 liters via mask. Review of the admission/readmission progress note revealed the resident on 3 liters oxygen with venti mask. Review of the oxygen vital summary revealed the resident was not having oxygen checked every shift on 3/17/21, 3/18/21, 3/20/21, 3/21/21 and 3/23/21. 2. Observation of Resident #376 on 3/23/21 at 10:20 a.m. revealed the resident wearing oxygen via nasal cannula. Observation of Resident #376 on 3/24/21 at 10:26 a.m. revealed the resident wearing oxygen via nasal cannula. Observation of Resident #376 on 3/25/21 at 8:34 a.m. wearing oxygen via nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 8 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 interview with Staff member K, LPN (Licensed Practical Nurse) on 3/25/21 at 12:25 p.m. stated the resident should have an order for continuous oxygen and that would have come from the hospital. During an interview with Staff member H, RN on 3/25/21 at 12:30 p.m. confirmed the resident did not have an order for oxygen and she added it to the record. Residents Affected - Some Review of physician orders revealed to check oxygen saturation every shift and as needed if below 90%, encourage resident to cough and take a deep breath, then recheck the oxygen saturation and apply oxygen per symptomatic protocol and notify the physician dated 3/20/21. Review of physician orders revealed change respiratory tubing every night shift every Sunday dated 3/24/21. Review of physician orders revealed 3 liters per minute via nasal cannula to maintain oxygen greater than 90% every shift for dyspnea dated 3/24/21. Review of the nursing progress notes dated 3/19/21 at 7:33 p.m. revealed the resident placed on 2 liters nasal cannula. Review of the nursing admit/readmit assessment dated [DATE] revealed the resident on oxygen 2 liters via nasal cannula. Review of the medical certification for Medicaid long-term care services and patient transfer form dated 3/19/21 revealed the resident on 2 liters continuous oxygen. 3. Observation of Resident #378 on 3/24/21 at 2:25 p.m. revealed the resident lying in bed on 3 liters of oxygen via nasal cannula. Observation of Resident #378 on 3/25/21 at 8:37 a.m. revealed the resident sitting up in bed getting oxygen at 3 liters via nasal cannula. Observation of Resident #378 on 3/25/21 at 2:30 p.m. revealed the resident observed lying in bed asleep with oxygen at 2 liters via nasal cannula. During an interview with Staff member L, RN on 3/25/21 at 9:18 a.m. she confirmed Resident #378 was receiving oxygen at 3 liters via nasal cannula and put it back to 2 liters. Review of the admit/readmit assessment on 3/11/21 revealed the resident on 2 liters of oxygen via nasal cannula. Review of Physician orders revealed change respiratory tubing every night shift every Saturday for wheezing dated 3/16/21. Review of physician orders revealed check oxygen saturation every shift as needed if less than 90%, encourage resident to cough and take a deep breath then recheck oxygen saturation and apply oxygen per symptomatic protocol and notify physician dated 3/11/21 and 3/13/21. Review of physician orders revealed oxygen at 2 liters per minute via nasal cannula to keep oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 9 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 saturation above 90% if below 90% encourage resident to cough and take a deep breath, then recheck oxygen saturation and notify physician dated 3/11/21. Review of physician orders revealed oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation above 90% if below 90% encourage resident to cough and take a deep breath, then recheck oxygen saturation and notify physician every shift dated 3/25/21. An interview with Staff member H, RN/unit manager on 3/25/21 at 12:50 p.m. confirmed an order for oxygen should be on record for a resident on oxygen and confirmed she did see discrepancies and would fix the records. An interview with the Director of Nursing (DON) on 3/25/21 at 2:50 p.m. confirmed that the staff should ensure the orders for oxygen are reviewed and complete. Review of the facility policy 'Oxygen Safety' without a date, two pages revealed: The purposes of this procedure are to provide general information concerning oxygen safety and to promote safety precautions during oxygen administration. A.1. Oxygen therapy is administered to the resident only upon the written order of a licensed physician. Review of the facility policy 'physician orders' dated 12/19, two pages, revealed: Physician orders are obtained to provide a clear direction in the care of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 10 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record review, the facility failed to honor resident food item preferences during meal services for one of thirty-one sampled residents, (#55), and during two of four days observed (3/24/2021, and 3/25/2021). It was found that resident #55 received multiple food items that were on his dislike list. Findings included: On 3/24/2021 at 8:20 a.m. resident #55 was visited while in his room. He was observed in bed and with his over the bed table placed in front of him with his breakfast meal tray. He was observed self feeding and was interviewable. He was asked how his meal was and he replied, I don't really like it, they give me things I don't like all the time. He further stated, they give me ham, bacon and I don't eat or like any ham products. His plate was observed with three slices of bacon and a bowl of hot oatmeal. There were small remnants of what appeared to be scrambled eggs. He also had a carton of whole milk which was not opened. He stated he could not open it and that he needs staff to open it. He also indicated he does not drink the milk, he puts it in his cold cereal frosted flakes, but he did not get any this a.m. Review of his meal ticket revealed he was to receive two boxes of frosted flakes and was ordered for a Regular diet, Regular consistency meal. Dislikes to include: eggs, french toast, ham, pancakes, oatmeal, sausage, waffles. It was found that resident #55 received bacon, oatmeal, eggs when it was on his dislikes list. He indicated he likes eggs and does not know why it shows as dislikes. Also, he did not receive the boxes of cold cereal (frosted flakes). Photographic evidence was taken. On 3/24/2021 at 12:00 p.m. resident #55 was observed in his room and seated upright in bed with his over the bed table in front of him and with his lunch meal tray placed on it. He had not touched anything on his plate. He was asked how his meal was today and he replied, they keep serving me things I don't like and it makes me not want to eat. He was asked what was on his tray that he did not like. Resident #55 replied, look, they gave me green beans, don't like them. He was asked if he could order something else. He replied, what's the use, they keep getting things wrong, and I don't want to keep complaining about it. Resident #55 was observed with the following food items on his plate; spiraled pasta with red meat sauce, garlic toast, mashed potatoes, a bowl of soup and a full serving of green beans. Review of the meal ticket clearly read, dislikes: greens. Photographic evidence was taken. On 3/25/2021 at 8:00 a.m. resident #55 was in his room with his breakfast meal placed in front of him. He was not eating. Interview with resident #55 revealed he received items he does not like and it just made him not hungry anymore. He was asked what things did he receive that he does not like. He pointed out on the plate of a slice of ham. He stated, I don't like ham or bacon. Review of the meal ticket again read; dislikes: ham. On 3/25/2021 at 9:00 a.m. an interview with a 300 hall Certified Nursing Assistant (CNA), Employee E revealed that she passed the resident his tray for breakfast and she did not know he received things that he disliked. She did say she does know him and that he does change his mind about food items but she should have reviewed the meal ticket prior to dropping off the tray. She confirmed she neglected to read the meal ticket after setting up his meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 11 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/25/2021 at 11:55 a.m. resident #55 was observed in his room and lying in bed upright and with his lunch meal placed on the over the bed table in front him. He was not eating and appeared to be a bit aggravated when asked if he was served what he wanted for lunch. Resident indicated he does not want to eat because they never give him things he likes. He was asked what he served today that he did not like. He pointed out the greens and carrots and indicated he does not like them. He also said he does not like ham as well. The kitchen did not provide him with the primary meal of ham slices because he doe s not like ham. However, there was a side plate on the table wrapped in clear plastic with ham sandwich. He said he likes hamburgers, but not ham or bacon. He confirmed he does not like ham of any kind. He said he did not want anything to eat now at all. Resident did not ask for alternate and did not eat any of his lunch meal today. Review of his current meal ticket revealed likes and dislikes to include: Ham, Greens, Carrots. He received all three. Photographic evidence was taken. Note, the same dislikes were reviewed on each ticket for the past three days 3/23/2021, 3/24/2021 and 3/25/2021. Photographic evidence was taken. On 3/25/2021 at 12:10 p.m. an interview with a Certified Nursing Assistant (CNA) Employee D, who had the resident on her assignment, was asked to show what the resident was served today. The tray had already been taken from his room and put on the tray cart to go back to the kitchen. She was asked to demonstrate what was on the tray. She pulled it out and lifted the top and she confirmed resident did not eat any of the scalloped potatoes, greens with carrots, ham sandwich, and or the dessert bar. Employee D revealed she believed the side sandwich was a ham sandwich. She was also asked who reviews the meal tickets to ensure the residents do not receive any documented dislikes. She said that kitchen is supposed to do that but staff on the floor review the ticket as well. She said she was the one who served the resident today and she must not have reviewed the ticket for lunch. She confirmed the meal ticket was documented with dislikes to include: carrots, ham, greens. She said she would go to the kitchen and talk to the Dietary Manager about it. She also indicated she is fairly new to the facility and does not know the resident too well. Review of resident #55's medical record revealed that he was admitted to the facility on [DATE] and readmitted last on 9/10/2020. Review of the advance directives revealed he was his own decision maker. Review of the current Minimum Data Set (MDS) assessment 5 day, dated 3/11/2021, revealed the following: (Cognition/Brief Interview Mental Status BIMS - 15 of 15, which indicates no cognitive impairments); (Activities of Daily Living ADL - Eating: independent with set up only). Review of the current Physician's Order Sheet (POS) for the month 3/2021, revealed the following: Diet Regular, Regular texture, Regular consistency CCHO. Review of the current care plans with next review date 5/19/2021 revealed the following: Resident is at a nutritional risk related to high Body Mass Index (BMI), has varied meal intake, Psychotropic meds and depression with interventions to include: provide and serve diet as ordered, monitor intake and record each meal. Further interview with the resident on 3/25/2021 at 12:00 p.m. revealed that he was not happy with the meals and meal service with regards to what he receives. He revealed that the kitchen gets his meal wrong so much that what's the bother to complain about it any more. He just does not eat his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 12 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal when its served things that he does not like. He confirmed he is not fine with it and would like for them to fix it. On 3/25/2021 at 11:45 a.m. during tray line observation and interview with the Kitchen Manager and a cook, Employee A, both revealed that when plating food there are three staff members that verify the meal ticket and audit to make sure residents receive what they choose and do not receive any of the dislikes that are on the ticket. The Kitchen Manager further revealed that staff out on the floor to include Certified Nursing Assistants are to review the meal ticket and look at what is on the plate as well. She revealed that if there is something that was served and the resident has as dislike, the tray should be brought back to the kitchen immediately so it can be fixed. On 3/25/2021 at 1:00 p.m. another interview with the Kitchen Manager was conducted. She was made aware that resident #55 received food items on his plate in which he disliked and was also noted as dislike on his meal ticket. She was provided photographic evidence to show the plate of food and with the meal ticket. She confirmed that the resident received food items he disliked such as Greens/Green beans, Ham, Carrots, oatmeal. She did not know how he received those food items of dislike so many times and that her staff should be reviewing the meal tickets and what goes out on the plates. On 3/25/2021 at 1:40 p.m. an interview with the facility's Registered Dietician was conducted. She revealed that she followed up with the dietary staff related to resident #55 with his likes and dislikes. She revealed that her interpretation and follow up with the Kitchen staff, revealed that greens on the dislikes section is only for collard greens and does not pertain to green beans. The Dietician also revealed that resident #55 changes his likes and dislikes routinely. She did not know how often the kitchen manager actually verifies likes and dislikes and makes the changes to reflect on the meal tickets. However, follow up interview with resident #55 on 3/25/2021 at 1:50 p.m., revealed that he does not like green beans at all and that is the reason he did not want to eat his lunch a couple of days earlier as he was served green beans. He again indicated that he does not ask for anything else because he has tried and tried to tell staff of things he does not like but keeps on receiving them. He again was asked by this surveyor if he likes green beans, oatmeal, carrots, ham, which are on his meal slip as dislikes. He confirmed and stated, I hate them, don't want them. On 3/26/2021 the Nursing Home Administrator provided the facility's Dietary Department Guidelines policy and procedure, not dated. The procedure did not reflect honoring food choices with regards to likes and dislikes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 13 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/25/2021 at 7:02 a.m. a Certified Nursing Assistant (CNA), Employee N was observed in the 100 new admissions unit. All rooms on the 100 new admissions unit were on droplet precautions with directions to wear full PPE when going inside; PPE signage included wearing of N95 or regular surgical masks. Employee N was wearing a black colored fabric mask with a white plastic corrugated tube leading from mask and attached to a device strapped on her arm. Employee N was assisting nursing staff with a resident emergency so she could not be interviewed at the time of the observation. Residents Affected - Few On 3/25/2021 at 7:30 a.m. an interview was conducted with the DON, and Employee N, Employee N stated she had a medical condition that required wearing a breathing filter apparatus, ordered by her physician. She indicated she had a breathing difficulty and always needed a portable air purifier when wearing a mask. She stated the device came with N95 masks which had special cut outs for the tubing, but the mask was too big, and she chose to wear a fabric cloth mask. She further stated she fashioned a hole in the fabric mask to insert the tubing. She indicated she cleaned the fabric cloth mask with disinfectant spray (did not specify what kind) and wiped the tubing with bleach wipes after use. She further stated the filter was good for five hundred hours and she stated she kept track of that in my head. Employee N stated she had used the device on her past shifts (3/25/2021 and 3/24/2021). Employee N stated she did not discuss the use of the device with the DON. During the interview, the DON revealed she did not know Employee N was wearing a fabric cloth mask with an air purifying device. Employee N confirmed she did not wear any other type of mask over the fabric cloth mask. The DON confirmed Employee N should be wearing a surgical mask over her fabric mask to ensure compliance with Personal Protective Equipment (PPE). Employee N confirmed she had no training to modify the fabric cloth mask and she further confirmed that she felt the fabric masks were a better fit for her than the masks supplied with the device. Review of guidance from the CDC dated 02/10/2021 and accessible at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#anchor_1604360679150 revealed Cloth mask: Textile (cloth) covers that are intended primarily for source control in the community. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel as the degree to which cloth masks protect the wearer might vary. Based on observation, interview, record review and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to maintain an effective infection prevention program to mitigate the spread of COVID-19 as evidenced by 1) failing to ensure staff performed hand hygiene after doffing personal protective equipment (PPE) for one staff (#K), and 2) failing to ensure staff used PPE according to accepted national standards for 2 staff (#K and #N) on one of four days observed. Findings Included: 1. Observation of medication administration on 3/25/21 at 8:49 a.m. for room [ROOM NUMBER] revealed an isolation caddy on the door with a sign to the left of the door outlining the PPE required. Staff member K, Licensed Practical Nurse (LPN) was observed doffing her surgical mask and placing it in her right front pocket, then removing an N95 mask from a brown paper bag and donning it with the nose piece on her chin and one strap to secure it. Staff member K, then took the surgical mask out of her pocket and placed it over her N95 mask below the valve and donned a blue gown and gloves. Staff K entered the room and provided the resident with an inhaler and medication. Staff member K then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 14 of 15 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 106069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 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 doffed the blue gown, gloves and N95 mask, placed the gown and gloves in the garbage and the N95 back in the brown paper bag. She did not perform hand hygiene prior to leaving the room. In a subsequent interview, conducted immediately after the observation, Staff member K, stated she was told when she gave any breathing treatments, she needed to wear the N95 mask, and confirmed she had the mask on upside down. Residents Affected - Few Review of facility policy for hand hygiene, undated, 3 pages reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 4.b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. Review of page 3 revealed the staff to use either soap and water or alcohol-based hand rub before applying and after removing personal protective equipment and before and after providing care to residents in isolation. Review of facility policy for personal protective equipment, undated three pages, revealed: 4.a. Indications for considerations for PPE use: ii. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. During an interview with the Director of Nursing (DON) on 3/25/21 at 3:46 p.m. she stated she would expect the staff to hand sanitize before donning and after doffing gloves. On 3/25/21 at 9:34 a.m. during an observation on the new admission observation unit, Staff K, LPN was observed wearing a vented N95 mask, without a surgical mask covering. Staff K, LPN entered room [ROOM NUMBER]; she was not wearing any gloves or eye protection. A sign was observed outside the door indicating instructions for donning PPE (photographic evidence obtained). There was no signage indicating the type of precautions for room [ROOM NUMBER]. An interview was conducted with Staff K, LPN immediately following the observation. Staff K, LPN said she gets her mask from the front desk. She said staff can wear surgical masks or N95's; eye wear was optional unless they were doing a nebulizer. She stated These residents are new admissions. A couple had COVID a few weeks ago before they were admitted . Staff K, LPN said she was not aware that she needed a surgical mask over the vented mask. Review of guidance from the CDC website dated 02/23/2021 and accessible at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html revealed the CDC does not recommend using masks with exhalation valves or vents. The hole in the material may allow your respiratory droplets to escape and reach others. Research on the effectiveness of these types of masks is ongoing. On 3/26/21 at 10:19 a.m. an interview was conducted with the facility Infection Preventionist. She stated she did hear about the cloth masks and vented N95 masks, and they started in-servicing. She further said, We will follow our policy for the yellow zone (new admission hall); a gown, mask and gloves for direct patient care. Review of the facility policy for personal protective equipment, undated three pages, revealed it did not address the use of fabric face coverings/masks or the use of mask with inhalation/exhalation valves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 15 of 15