Health inspection·August 11, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Staff D, LPN, Unit Manager (UM,) on 8/10/22 at 9:05 a.m. She stated, can't have personal cell phones period. She stated if a staff member needs to use the phone they should step outside and away from resident areas. She said when assisting a resident with eating, staff should be communicating with the resident. She said even if there is a language barrier with a resident, staff can communicate in other ways or get a translator if needed. She also stated staff should not have ear buds in place in the hallways. An interview was conducted with Staff E, CNA on 8/10/22 at 9:09 a.m. Staff E stated personal phones should be in the break room. She said if a CNA is helping at resident eat, they should sit down and have a conversation with the resident. She said they should definitely not be on their phone while helping. As far as having ear buds in while in the hallway, she stated nothing has ever been said about that, as long as you aren't on the phone or distracted. On 8/10/22 at 9:16 a.m. an interview was conducted with Staff H, CNA. She stated you should not have cell phones in resident rooms. When asked about her being observed on the phone multiple times while assisting Resident #222 with her meals, she stated she might have taken it out. She said she has kids at home. She added it's not an excuse. She stated she does not have any issues communicating with Resident #222. She said she knows she should be interacting with the resident, telling her what she is giving her, offering her drinks, and making sure she swallows. She agreed she shouldn't be on the phone and said she understood why there would be a distraction, but I was definitely aware of her. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 8/10/22 at 9:22 a.m. They confirmed personal cell phones are not allowed. They also stated ear pods (headphones) should not be in staff's ears in the hallway or resident areas. The NHA stated if they have ear pods in, they could miss hearing a resident calling or help or other things. She stated while assisting a resident with eating they should be engaging with resident. She said even if they can not communicate well with them, they should be engaging. The DON added beside all of this, it is against company policy. The DON provided a Nurse Aide Competency check list. She stated all CNAs at the facility had to do these items, including effective communication, resident rights and facility responsibilities, and person-centered care. This also includes nurse aids skills such as aspiration precautions and feeding a resident. A facility policy titled Personal Cell Phones was reviewed. The policy stated, It is the policy of this facility to provide quality care to our residents without interruption. Policy Explanations and Compliance Guidelines continued: 1. This facility prohibits employees from using personal cell phones including the use of wireless car phones/earbuds on the nursing units or in working areas of the facility. 4. Cell phones may be used by employees while on a scheduled break in break areas only. A facility policy titled Resident Rights was reviewed. The policy stated the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. It also stated, the resident has a right to be treated with respect and dignity and the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 2 of 26 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 08/11/2022 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage and the Center for Medicare and Medicaid Services form 10123-NOMNC was completed and provided to one (#273) out of three residents reviewed whose skilled services ended. Residents Affected - Few Findings included: On 08/09/2022, a record review was completed for three residents who had been discharged from a Medicare covered part A stay with benefits remaining in the last six months. The Nursing Home Administrator and the Social Services Director completed the Skilled Nursing Facility Beneficiary Protection Notification Review, which reflected Resident #273 last covered day of part A services was on 07/08/2022. It was noted on the document a notice of Medicare Non-Coverage, Center for Medicare and Medicaid Services (CMS) form 10123-NOMNC, and a Form CMS-10055, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) had not been completed for Resident #273. Resident #273 remained in the facility. On 08/09/2022 at 8:14 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated the facility was [NAME] Resident #273 because she had COVID-19 and was able to get Medicare A. She noted several people had COVID-19 and there was an outbreak in the facility. The NHA stated the social worker was not tracking when the resident was coming off quarantine to issue the Beneficiary Notice and NOMNC. She stated they did an education last night and changed the tracking mechanism to identify 48 hours prior to discharge from services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 3 of 26 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 08/11/2022 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide written notification of Transfer to Resident representative for one (Resident #26) of two sampled residents. Findings included: On 08/08/22 at 10:41 am Resident #26 was observed sitting in her wheelchair in the hallway. When spoken to the resident responded with words that were not understandable. A review of the admission Record indicated Resident #26 was admitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus without Complications. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. A review of a progress note dated 07/06/22 revealed Resident #26 was transferred to the hospital. Left in stable condition. Face sheet, medication list and bed hold policy signed. Report called into ER (emergency room). A review of a progress note dated 07/06/22 revealed writer was advised Resident #26 was admitted to the hospital. A review of a Hospital Transfer Summary dated 07/06/22 revealed Resident #26 had an emergency transfer to an acute care setting and the resident/resident representative was notified via telephone of the transfer. A review of Skilled Nursing Facility/Nursing Facility (SNF/NF) Hospital Transfer Form for Resident #26 dated 07/06/22 Resident #26 had an unplanned transfer to the medical center due to an altered mental status. The document revealed Resident #26 was alert, disoriented, but could follow simple instructions. In the section titled Resident Representative the document revealed her power of attorney (POA) was notified of the transfer and aware of the clinical status. On 08/10/22 at 1:02 pm an interview was conducted with the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the Regional Director of Operations. The DON stated Resident #26 was sent out on an emergency discharge on [DATE]. She noted Resident #26 had an altered mental status due to not being talkative or wanting to get out of bed that day. She stated her vitals were within normal limits. She stated the doctor was notified of the transfer to the hospital. The DON stated Resident #26 returned to the facility on [DATE] with antibiotic therapy (ABT) for a urinary tract infection (UTI). A review of the AHCA (Agency for Healthcare Administration) Nursing Home Transfer and Discharge Notice revealed the documents were not sent in writing to the resident representative. No signatures were present on the document indicating the resident representative had acknowledged the notice. An interview was conducted on 08/11/22 at 1:23 pm with the Social Services Director. She confirmed she did not send the AHCA Nursing Home Transfer and Discharge Notice, and Bed Hold Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 4 of 26 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 08/11/2022 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 0623 Level of Harm - Minimal harm or potential for actual harm Authorization to Resident #26's representative. She stated to her understanding it was not needed to be sent if it was sent with the resident to the hospital. She confirmed Resident #26 was not her own responsible party. A review of the policy entitled Transfer and Discharge (including AMA) revealed the following: Residents Affected - Few Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. 7. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident. i. Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 5 of 26 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 08/11/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide written notification of Bed Hold Policy to the resident representative for one (Resident #26) of two sampled residents. Findings included: On 08/08/22 at 10:41 am Resident #26 was observed sitting in her wheelchair in the hallway. When spoken to the resident responded with words that were not understandable. A review of the admission Record indicated Resident #26 was admitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus without Complications. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. A review of a progress note dated 07/06/22 revealed Resident #26 was transferred to the hospital. Left in stable condition. Face sheet, medication list and bed hold policy signed. Report called into ER (emergency room). A review of a progress note dated 07/06/22 revealed writer was advised Resident #26 was admitted to the hospital. A review of a Transfer Summary dated 07/06/22 revealed Resident#26 had an emergency transfer to an acute care setting and the resident/resident representative was notified via telephone of the transfer. A review of Skilled Nursing Facility/Nursing Facility (SNF/NF) Hospital Transfer Form for Resident #26 dated 07/06/22 Resident #26 had an unplanned transfer to the medical center due to an altered mental status. The document revealed Resident #26 was alert, disoriented, but could follow simple instructions. In the section titled Resident Representative the document revealed her power of attorney (POA) was notified of the transfer and aware of the clinical status. On 08/10/22 at 1:02 pm an interview was conducted with the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the Regional Director of Operations. The DON stated Resident #26 was sent out on an emergency discharge on [DATE]. She noted Resident #26 had an altered mental status due to not being talkative or wanting to get out of bed that day. She stated her vitals were within normal limits. She stated the doctor was notified of the transfer to the hospital. The DON stated Resident #26 returned to the facility on [DATE] with antibiotic therapy (ABT) for a urinary tract infection (UTI). A review of the Bed Hold Policy Authorization dated 7/6/22 revealed the document was not signed by a resident or a resident representative. An interview was conducted on 08/11/22 at 1:23 pm with the Social Services Director. She confirmed she did not send the AHCA Nursing Home Transfer and Discharge Notice, and Bed Hold Policy Authorization to Resident #26's representative in writing. She stated to her understanding it was not needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 6 of 26 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 08/11/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to be sent if it was sent with the resident to the hospital. She confirmed Resident #26 was not her own responsible party. A review of the policy entitled Exhibit B - Bed Hold Policy revealed the following: Before transferring a Resident to a hospital or allowing a Resident to go on therapeutic leave of absence, the Resident, family member, or Resident Representative will be notified in writing of this Resident Bed-Hold Policy .In the event a Resident requires emergency transfer to a hospital, where it is felt a delay may result in serious harm to the Resident's health, the Resident, family member or Resident Representative will be notified of the Bed-Hold Policy as soon as it is practicable following emergency transfer . Event ID: Facility ID: 106069 If continuation sheet Page 7 of 26 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 08/11/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and medical record review the facility failed to ensure appropriate restorative services were provided for one ( #55) out of two sampled residents with limited mobility and maintain independence with splint application. Findings Included: On 08/08/22 at 2:05 p.m. Resident #55 was receptive to an interview and said he had been at the facility longer than he wanted to be. He indicated he needed assistance with his care and services. His left hand was observed resting on top of his lap and presented with a clenched fist. Resident #65 confirmed his fingers were clenched and stated, it happened after my Cerebral Vascular Accident (CVA). The resident was able to move his left-hand fingers off the palm of his hand slightly with the assist of his right hand. When he removed his right-hand away from his left hand his fingers returned to a clenched state. He confirmed he had a splint for the hand. He opened the drawer to his bedside table and removed a splint. The custom-made splint contained Velcro straps. He denied not wanting to wear it and stated, I just can't put it on by myself. The resident said it had been a while since he had worn it last, stating maybe a day last week, I think. The resident denied staff were performing any range of motion to his left hand with activities of daily living. On 08/09/2022 at 12:15 p.m. Resident #55 was observed watching television in his bedroom. No splint was noted to his left hand. On 08/10/22 at 3:15 p.m. Resident #55 was noted asleep in his bed. His left hand was observed with no splint in place. A review of the medical record revealed Resident #55 had a Brief Interview for Mental Status (BIMS) dated 06/28/2022, with a score of 15, indicating no cognitive deficit. The admission Record form revealed the resident has resided at the facility for four years. Diagnosis information listed his primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting let dominant side. A review of Physician orders revealed an order for Restorative Nursing -Passive Range of Motion (PROM) to left hand, put on left resting hand splint- patient can remove splint encourage patient to wear splint daily up to 4 hours as tolerated. Alert therapy if splint is misplaced dated on 10/19/2021. A review of the Medication Administration Record (MAR) contained the order Restorative Nursing -Passive Range of Motion (PROM) to left hand, put on left resting hand splint- patient can remove splint encourage patient to wear splint daily up to 4 hours as tolerated. Alert therapy if splint is misplaced. The MAR revealed omitted documentation on the program. A review of the Care Plan Focus area revealed Resident #55 had left shoulder/elbow/wrist/thumb/index finger/middle finger/ring contractures. Interventions included: Patient will continue to wear splint L hand for two hours as tolerated for contracture maintenance. Patient can put on (don) and can remove splint daily. On 8/10/2022 at 4:00 p.m. the Regional Director of Clinical Reimbursement reviewed the MAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 8 of 26 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 08/11/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few restorative nursing program and confirmed the order was not put in accurately. As each day contained an 'X' not allowing documentation on the Physician ordered restorative program. On 08/10/2022 at 4:15 p.m. an interview was conducted with the Director of Rehabilitation she said Resident #55 was last seen in October 2021. She said he has active orders in place for restorative PROM to his left hand. She confirmed she was not able to find documentation on the restorative program. The Director indicated if a restorative program is written it would be inputted into the TASK section. She then added she was not sure of the facility process on implementing the order for restorative nurse to follow. On 08/10/22 at 4:30 p.m. the Director of Rehabilitation asked Resident #55 if she could assist him with his splint application. He stated yes. You know when I roll over on my arm my wrist bends and I have pain that radiates up. After the splint was applied, he denied pain. The resident stated that it felt good. On 08/10/22 at 05:08 p.m. an interview with the Regional Director of Clinical Reimbursement she confirmed the restorative order had not been delegated as a task for restorative nurse to follow. Indicting the restorative nurse was unaware of the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 9 of 26 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 08/11/2022 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure pain management was provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one resident (#35) out of three residents sampled for pain. Residents Affected - Few Findings included: An interview was conducted with Resident #35 on 8/8/22 at 1:09 p.m. He stated he was in so much pain last night (8/7/22) at 11:00 p.m. He described his pain as 10/10 on the pain scale. Resident #35 stated he was not able to get his pain medication, because there wasn't any available. He stated this has happened to him four or five times. The resident began to get upset and cry explaining this and stated when this happens it hurts so bad, he feels like he could die. The resident stated he was given Tylenol and it doesn't do anything for his pain. He stated he was not able to get pain medication until lunchtime today (8/8/22). He stated at lunch the nurse was able to give him two tablets to combined to get his normal dose. The resident couldn't recall the name of the pain medication he normally receives. A review of admission records indicated Resident #35 was readmitted on [DATE] with an initial admission of 4/22/21. The resident had diagnoses including quadriplegia, chronic kidney disease, tracheostomy, pressure ulcer, atherosclerotic heart disease, and chest pain. A review of orders revealed the following: Fentanyl patch 75 micrograms (mcg)/hour (hr) 72 hour. Apply 1 patch transdermal every 72 hours for pain. Document site and remove per schedule. Order date was 8/9/22. Oxycodone HCL 10 milligrams (mg). Give 1 tablet by mouth every 3 hours as needed (PRN) for non-acute pain. Order date was 8/8/22. Acetaminophen tablet 650 mg. Give 1 tablet by mouth every 4 hours as needed for general discomfort. Order date was 8/4/22. Gabapentin capsule 100 mg. Give 1 capsule by mouth every 8 hours for never pain. Order date 8/4/22 (This was previously given via a feeding tube.) An order, dated 2/23/22, was in place to access and document pain level every shift using pain scale. A pain management evaluation was ordered for 8/8/22 A previous pain management evaluation was completed for Resident #35 on 1/8/22. The evaluation showed the resident has a terminal disease process and was able to verbalize his pain. The evaluation indicated the pain was chronic, occurring all the time at a severe level (7,8,9,10 on pain scale.) A care plan is in place for: risk for pain related to actual pain, quadriplegia, pressure areas, poor mobility and contractures. The care plan goal is for resident to be kept comfortable daily through next review. Interventions included: contact Medical Doctor (MD) for pain not relieved by current order, medications per MD order, pain assessment completed and reviewed quarterly and PRN, assist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 10 of 26 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 08/11/2022 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 0697 resident with re-positioning or other non-pharmacological aspect of pain relief. Level of Harm - Actual harm Resident #35's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C, Cognitive Patterns, indicated the resident has a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Residents Affected - Few Resident #35's electronic Medication Administration Record (eMAR) was reviewed. The eMAR indicated Resident #35 was given Oxycodone 10 mg on 8/7/22 at 3:45 a.m., 9:48 a.m., 1:25 p.m., and 5:25 p.m. The Oxycodone was not administered again until 8/8/22 at 11:53 a.m. This shows an 18.5 hour gap between administrations of Oxycodone that is ordered every 3 hours as needed. The eMAR indicated Resident #35 was administered Acetaminophen 8/7/22 at 11:17 p.m., noting it was ineffective. The resident was again given Acetaminophen on 8/8/22 at 3:19 a.m., again noting it was ineffective. On 8/8/22 at 11:00 a.m. a one-time order was entered for two 5 mg tablets of Oxycodone for pain, this was administered on 8/8/22 at 11:53 a.m. The resident resumed his normal ordered dosage of one 10 mg tablet on 8/8/22 at 2:20 p.m. A review of the July 2022 and August 2022 eMAR indicated Resident #35 takes his PRN (as needed) Oxycodone around the clock daily with Acetaminophen not being utilized. A review of Resident #35's progress notes did not indicate any additional nursing notes regarding ineffective pain control, notification of the doctor, or notification of the pharmacy. Resident #35's Controlled Drug Receipt/Record/Disposition Forms were reviewed. The forms revealed the delivery of Oxycodone to the facility on 7/26/22, with the medication card running out on 8/7/22 at 1:15 p.m. An interview was conducted with Staff B, Licensed Practical Nurse (LPN,) on 8/9/22 at 4:00 p.m. Staff B stated Resident #35 receives his pain medication routinely every 3 hours. Staff B stated he has never run out of the resident's Oxycodone on his shift. He stated some shifts may have issues due to waiting on the pharmacy to deliver, but if the card is empty, they should be able to get the medication from the medication dispensing machine on the north unit. He stated when the medication card is down to only have 5-6 pills left, the nurse is supposed to notify the pharmacy. He said he didn't have any way to confirm a nurse before him notified the pharmacy or not. An interview was conducted with Staff O, LPN on 8/9/22 at 4:06 p.m. She sated there is a medication dispensing machine in the medication room on the north unit. She said to access the Oxycodone the nurse would need an Emergency Drug Kit (EDK) code from the pharmacy. She stated the pharmacy can be reached in the middle of the night if needed. She also stated the pharmacy can tell the nurse if there is Oxycodone in the machine. She said she has never seen it out of Oxycodone. On 8/10/22 at 11:41 a.m. the west hall medication card was inspected with Staff C, LPN. Staff C confirmed Resident #35 currently had two cards of Oxycodone that were both delivered on 8/8/22. She stated one card now has 19 pills remaining and one card is full. Narcotics counts were verified in the narcotics book. Staff C stated the medication card shows the resident currently has 180 pills left on this prescription. Staff C stated as long as the resident has pills left on their prescription, the nurse can get an access code from the pharmacist at any time to get Oxycodone out of the medication dispensing machine. She stated the only reason a resident can run out of medication is because no one ordered it, or the nurse didn't follow up. Staff C explained when the medication card gets to the last row, indicated in red, the nurse knows to reorder the medication. She stated she would know if it was reordered because a small sicker on the top is pulled off and faxed to the pharmacy, if the sticker is gone the medication was ordered. She confirmed the pharmacy will deliver narcotics every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 11 of 26 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 08/11/2022 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 0697 day of the week. Level of Harm - Actual harm An interview was conducted with the Director of Nursing (DON) on 8/1/22 at 2:03 p.m. She confirmed Resident #35 receives his PRN Oxycodone every 3 hours. She stated if the medication cards are out, staff should check the medication dispensing machine to see if it is in and get a code from the pharmacy. She stated, if the machine was out of the medication, the doctor would be notified. She stated he should never go without his pain medication. She confirmed the process is to reorder medication when the card has 7 pills remaining. After hearing the situation from the night of 8/7/22 and the morning of 8/8/22, she stated on Sunday night, 8/7/22, the doctor should have been notified or the pharmacy should have been called. The DON also stated, if [Acetaminophen} gave multiple times and it's ineffective should have notified the doctor. She stated the nurse taking care of Resident #35 on Sunday night was an agency nurse, but she should have still had access to the medication dispensing machine. She said all agency nurses are orientated to the building and where things are. She confirmed the nurse should have been able to get the Oxycodone. Residents Affected - Few An interview was conducted with facility's Consultant Pharmacist on 8/11/22 at 2:58 p.m. She stated there is no reason Resident #35 shouldn't have been able to receive pain medication on the weekend. She stated the pharmacy does stat runs if there is something needed that can not wait until the next delivery. An interview was conducted with Staff T, Pharmacist currently working in the pharmacy. Staff T reviewed Resident #35's medication orders and deliveries. She stated there was a refill requested on 7/26/22 and 60 pills were delivered the same day. She also stated she can see where a new Oxycodone prescription for Resident #35 was sent in from a doctor on 8/8/22 at 10:45 a.m. She stated the resident was due for a new prescription. Staff T stated the card on 7/26/22 indicated to the facility there were no refills remaining and a new prescription was needed. She stated the facility should have requested a new prescription at that time. She stated this request was not put in until Sunday, 8/7/22. Staff T said the pharmacy received the request on Sunday and it was delivered Monday. She confirmed it is the facility's responsibility to follow-up and get new prescriptions. Staff T reviewed the stock of the facility's medication dispensing machine. She stated the machine had 5 mg tablets in stock and the resident's prescription was for 10 mg. She stated the doctor could have been called at any time for a prescription for two 5 mg tablets to be given. Staff T stated there would have been no issue with the nurse being able to access the Oxycodone in the middle of the night on 8/7/22. Staff T stated she is able to see Monday morning (8/8/22) an order was put in for two 5 mg tablets of Oxycodone and access to the medication was provided by the pharmacy. An interview was conducted with the Nursing Home Administrator on 8/11/22 at 3:50 p.m. The NHA stated they are looking for a Pain Management doctor to come to the facility. She agreed Resident #35 should never have to go without pain medication. She confirmed nurses are responsible for tracking medication and requesting refills. A facility policy titled, Pain Management Program, was reviewed. The policy stated, Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. It also stated, If resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for appropriate pain management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 12 of 26 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 08/11/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure daily monitoring of resident behaviors was conducted in order to ensure the appropriateness and continuation of the psychotropic medication regime for two residents (#56 and #57) of five sampled residents for unnecessary medications. Finding Included: On 08/09/22 at 12:52 p.m. Resident #56 was in his bedroom watching the television. He looked up when approached and appeared comfortable. He shrugged his shoulders in the I don't know gesture when asked how long he had resided at the facility. He then turned back in the direction of the television. On 08/10/22 at 12:19 p.m. Resident #56's nurse said the resident had a scheduled outside appointment today and had declined to attend. She said he needs to go to his dialysis appointment. She added she had attempted several times and called his family member as she is involved with his care but continued to decline. The resident was observed lying in bed with his eyes closed. On 08/11/2022 at 1:30 p.m. Resident #56 was observed sitting by the front door of the facility looking outside. He was asked if he was waiting for his family member and he responded with a flat affect and without eye contact I like to sit here. A review of Resident #56's admission Record form indicated he has resided at the facility for two years and considered middle aged. The diagnosis information description listed anxiety disorder and major depressive disorder. A review of Physician orders revealed medication orders for Mirtazapine 15 mg (milligrams) give 1 tablet by mouth at bedtime related to major depressive disorder dated 03/31/2022. Behavioral monitoring was not in place for the use of the anti-depressant. Further review of Physician orders included Buspirone HCL tablet 7.5 mg give 1 tablet by mouth two times a day for anxiety dated 03/02/2022, and Lorazepam tablet 0.5 mg give 1 tablet by mouth two times a day for anxiety disorder dated 03/14/2022. Behavioral monitoring was did not reflect a specific behavior for either anxiety medication. Only one behavioral monitoring was in place for two separate antianxiety medications. On 08/10/2022 at 11:32 p.m. an interview was conducted with the Director of Nursing she confirmed only one monitoring was in place for two different antianxiety medications. She additionally confirmed no behavioral monitoring was in place for the anti-depression (Mirtazapine) medication. Review of the Medication Regimen Review Activity between 07/01/2022 and 07/26/2022 did not contain any recommendations for Resident #56. On 08/10/2022 at 10:30 a.m. a phone interview was conducted with the Pharmacist Consultant she said she provides a psychoactive medication report that recommends when gradual dose reductions (GDRs) are due. The Pharmacist confirmed it would be her responsibility to bring to the facility's attention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 13 of 26 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 08/11/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm if behavior monitoring was not in place. When informed the behavior monitoring forms in the medication administration record list several behaviors but no specific medication. She said most probably it would be the last medication that was added which affected the behavior. The Pharmacist reported she does not attend any meetings at the facility that would discuss changes in medications, including psychotropic medications. Residents Affected - Few A review of the admission Record indicated Resident #67 was admitted on [DATE] with the diagnosis' including unspecified Dementia without Behavioral Disturbance, unspecified Psychosis not due to a substance or known physiological condition, and hallucinations. A review of orders revealed an order for Risperidone tablet. Give 1 milligram (mg) by mouth at bedtime for psychosis. Start date: 07/08/22. An order for Donepezil HCI Tablet 5 mg. Give 5 mg by mouth at bedtime for dementia. Start date: 07/08/22. A review of the electronic Medication Adminsitration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for months of July of 2022 did not include any behavior or side effects monitoring for specific psychotropic medications. Resident #67's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C: Cognitive Patterns revealed Resident #67 has a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Section N. (Medications) of the MDS indicated Yes-Antipsychotics were received on a routine basis. A review of the care plan with a focus area dated 07/12/22 revealed Resident #67 to have a diagnosis (dx) of insomnia, dementia, and psychosis. Recent history (hx) of hallucinations in the hospital. He is taking antianxiety and antipsychotic medication; he is at risk for adverse effects. The goal dated 07/12/22 stated the resident will not experience complications related to (r/t) antipsychotic and antianxiety medications .The interventions dated 07/12/22 include medications per orders, observe for effectiveness, notify primary care provider (pcp) of any changes in behavior or status, observe for signs of adverse effects such as agitation/changes in behavior, increased confusion/lethargy, and psych consult as needed (prn). A focus area dated 07/21/22 revealed resident has altered behavior patterns r/t verbally aggressive at times, becomes combative at times, declines to allow staff to render care at times r/t dx dementia, recent hospitalization for delirium and hallucinations. The goal dated 07/21/22 revealed the resident will have fewer episodes of behaviors .The interventions dated 07/21/22 include to administer medications as ordered and monitor/document for side effects and effectiveness . A review of the facility policy on Psychoactive Medication Management Program that did not contain a date indicated the following: Upon noting an order for psychoactive medication on admission or initiation of therapy: 3. Implement the behavior monitoring/side effects monitoring form from psychoactive medications with targeted behavior on the form or why the resident is receiving the medication ordered. Initial appropriate observed behaviors or no behaviors observed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 14 of 26 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 08/11/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review the facility did not ensure the medication error rate was below 5 % for two (# 56 & 174) of 5 sampled residents who were administered medications. This resulted in 2 errors from 28 medication administration opportunities for a medication error rate of 7.14%. Residents Affected - Few Findings Included: 1. On 08/09/22 at 5:19 p.m. medication administration observation task was conducted alongside Staff Member K, a Licensed Practical Nurse as he performed a blood glucose test on Resident #56. The blood sugar level reflected a reading of 184. Staff K returned to the medication cart and removed a Novolog Flex Pen 100 unit/ml solution pen -injector. He dosage selector was set to 2 units. When asked what the resident blood sugar level was, he looked back at the computer screen and stated oh, it's supposed to be 4 units. He then dialed the pen to four units. Staff K then entered Resident #56 bedroom and administered the insulin to his right lower abdomen. On 08/09/2022 at 5:40 p.m. an interview was conducted with the Director of Nursing (DON) she confirmed the insulin pen should be primed to ensure the accurate amount of insulin is given. On 08/11/2022 at 11:15 a.m. the DON provided a copy of the directions for preparing the insulin pen. She said she could not find a facility policy nor procedure on preparing an insulin pen. The DON stated staff refer to the direction sheet. Each pen one comes with directions. She denied training had been provided to the licensed staff on the use of the pen. Review of directions for preparing the insulin pen Give the air shot before each injection Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose select 2 units. Hold your Novolog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few ties to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. 2. On 08/10/22 at 8:35 a.m. a medication administration observation task was conducted alongside staff member L, Licensed Practical Nurse as she prepared Resident #174's oral medications. The following medications were prepared: Lisinopril 10 mg (milligrams), Metoprolol 50 mg, Ferrous Sulfate 325 mg, Vitamin C 500 mg, Cetirizine 10 mg, and Metamucil. Staff L said the ordered for the Metamucil says one cap full. The container of Metamucil was observed with a large cover not a cap. She stated, I'll just give a teaspoon. Staff L placed approximately 2.5 to 3 milliliters (ml) of Metamucil inside of a souffle cup. Then transferred it into a 5-ounce cup with 4 ounces of water and mixed it together. The medications were taken to Resident #174 and administered. A record review of Resident #174 Physician orders read Metamucil powder give 1 cap full with water twice daily two times a day for irritable bowel syndrome (IBS) start date 06/02/2022. On 08/11/2022 at 10:10 a.m. an interview was conducted with Staff Member S, Licensed Practical Nurse she read the order for Resident #174's Metamucil its about 20 cc that would be considered a 1 cap full and added its mixed in cold water or juice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 15 of 26 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 08/11/2022 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the directions on the container How to take Metamucil 1. Put 1-2 rounded teaspoons in an empty glass. 2. Mix briskly with 8 ounces or more of cool liquid. Dosing of medicine, a teaspoonful is defined as 5 ml. https://en.wikipedia.org/wiki/Teaspoon. On 08/11/22 at 10:30 a.m. a phone interview was conducted with the facility pharmacist she said there was a Pharmacy Book, either in the medication room or on the medication cart that gives lots of information, including measurements and equivalents. The Pharmacist stated a cap full is not a quantitative amount. They should have clarified that order. She added that it seemed some education was needed. A review of the facility policy titled Medication Administration policy indicated the following: Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state as order by the physician and in accordance with professional standards of practice. 14. Administer medications as ordered in accordance with manufacturer's specifications. A Provide appropriate amount of food and fluid. 20. Correct any discrepancies and report to nurse manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 16 of 26 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 08/11/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review the facility failed to maintain proper storage of medication for one resident (#30) out of 39 sampled residents, in two out of four medication carts, and one out of two medication storage rooms. Findings included: On 8/9/22 at 5:39 p.m. an observation was made of an unlocked medication cart of the west hallway. The computer was open with resident health information on the screen and a personal cell phone was on top of the medication cart. No nurses were in the hallway. After two minutes of observation, Staff B, Licensed Practical Nurse (LPN,) came out of a resident room just past the medication cart. (Photographic evidence obtained.) Staff B was interviewed on 8/9/22 at 5:41 p.m. He stated he knew the cart had to be locked and the screen off but I forgot. On 8/9/22 at 5:45 p.m. an observation was made in the soiled utility room on the west unit. There was a trash can in the soiled utility room that contained plastic bags used for medication. Staff D, LPN, Unit Manager (UM) assisted with looking at the plastic bags after they were discovered. Staff D confirmed there was medication and resident information in the regular trash. There was a plastic bag with the name of Resident #30, her room number, and two medication names (Hyoscyamine SL tab 0.125 milligram(mg) and Metoclopramide tab 5 mg.) The Hyoscyamine SL tablet was still in a plastic package inside the bag that was found in the trash can. (Photographic evidence obtained.) The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were called to the utility room. The DON and NHA confirmed these plastic bags should not go out with the normal trash. The DON confirmed medication carts should always be locked when unattended. Regarding the unsecured medication and resident's personal health information in the trash, the NHA stated so many bad decisions on so many levels. A review of admission records indicated Resident #30 was admitted on [DATE] with diagnoses including gastro-esophageal reflux disease, gastrostomy status, gastroduodenitis, and adult hypertrophic pyloric stenosis. A review of her order revealed an order, dated 10/28/21, for Hyoscyamine Sulfate tablet 0.125 mg. Give 1 tablet via peg-tube three times a day for secretions. On 8/11/22 at 9:50 a.m. an observation was made with the DON in the northwest medication storage room. The refrigerator contained a 5 milliliter (ml) vial of influenza vaccine that expired on June 30, 2022. Inside of a cabinet there was a bottle of GeriCare Mucous Relief Guaifenesin 400 mg that expired 7/22. (Photographic evidence obtained.) The DON was interviewed immediately. She stated both medications are house medication not assigned to a particular resident. She stated the unit managers are in charge of checking at least weekly for expired medications but try to go through the medication room daily for a quick check. The DON stated she would not expect to see any expired medications in the medication storage room. On 8/11/22 at 4:43 p.m. a medication cart was observed to be unlocked on the north hall. No nursing staff were in sight and residents were moving in the hallway. (Photographic evidence obtained.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 17 of 26 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 08/11/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm A facility policy titled Medication Storage was reviewed. The policy stated, It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy and/or mediation rooms, according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines continue: Residents Affected - Few 1a. All drugs and biologicals will be stored in locked compartments . 2c. During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 8. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 18 of 26 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 08/11/2022 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 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. Based on observation, interview, and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 the facility 1) failed to maintain protected health information (PHI) for two residents (#56 and 174), and 2) failed to maintain the security of a computer screen with PHI information displayed for multiple residents out of 75 residents sampled during the survey. Findings Included: On 08/09/2002 at 5:30 p.m. medication administration observation task was conducted alongside Staff K, Licensed Practical Nurse. Staff K removed a white plastic pouch from the medication cart. The pouch indicated it was for Resident #56 and resident name, room number, unit number the facility name, the Physician name, medication names that were due at that time, and the prescription (RX) number were all listed on the pouch. Staff K removed the medications from the pouch and then disposed the pouch into a clear colored plastic trash bag. Staff K was asked where the trash bag is placed after his shift. He stated, down there as he pointed down the hallway two rooms down from the nursing station. Two rooms down from the west hall nursing station revealed a soiled utility room. At 5:40 p.m. the soiled utility room was entered that contained a large yellow trash can. Inside of the can revealed a clear colored plastic bag which contained large quantities of white plastic pouches. Resident #174 pouch was noted inside and near the top opening of plastic bag. The pouch reflected her name, room number, current unit she was residing, facility name, Physician name, prescription (RX) number. Staff U was present during the observation and stated the pouches are perforated so the resident name can be torn off. She indicated the resident name should not be attached to the pouch when it is disposed of (photographic evidence obtained). The Director of Nursing (DON) was outside of the room and confirmed the top portion of the pouch (that contained the resident PHI) is to be torn off and placed in the shredder. The DON stated they (licensed nurses) were trained on that. The Nursing Home administrator appeared and confirmed it was a breach of resident personal health information. Review of the facility policy titled Health Insurance Portability and Accountability Act (HIPPA) 18. All Protected Health Information (PHI) for destruction, will be placed in shred bins and shredded. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule. https://www.cdc.gov/phlp/publications/topic/hipaa.html 2) An observation was made on 8/9/22 at 5:39 p.m. in the west hallway of an unlocked medication cart The computer on top of the cart was open, displaying multiple resident's personal health information on the screen. (Photographic evidence obtained.) There were no staff members in the vicinity of the computer. After two minutes of observation, Staff B, Licensed Practical Nurse (LPN,) came out of a resident room just past the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 19 of 26 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 08/11/2022 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Staff B was interviewed on 8/9/22 at 5:41 p.m. He stated he knew the cart had to be locked and the screen off but I forgot. An interview was conducted with the Director of Nursing (DON) on 08/09/22 05:45 PM. The DON confirmed the computer screen should not be left with resident information open and the staff know they are supposed to hit the lock button on the screen before they walk off. Event ID: Facility ID: 106069 If continuation sheet Page 20 of 26 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 08/11/2022 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** Based on observation, interview and policy review the facility 1) failed to maintain proper infection control standards to provide a safe, sanitary environment regarding COVID-19 precautions for three residents (#5 , #175, and #222) on two days (8/8 and 8/9/22) out of four days surveyed , 2) failed to maintain infection control policies related to staff's personal items in resident care areas on two days (8/8 and 8/10/22) of four days surveyed, and 3) failed to maintain sanitary conditions for the facility ice machine on two days (8/8 and 8/10/22) of four days surveyed. Residents Affected - Few Findings included: 1) An observation was made on 8/8/22 at 8:57 a.m. of Resident #5 being on droplet precautions. The resident had a droplet precaution sign on the door and a personal protective equipment (PPE) cart outside the door. Resident #5 was identified by the facility as being COVID positive. An observation on 8/9/22 at 9:14 a.m. showed Resident #5 had been removed from droplet precautions. There was no longer a sign or PPE cart at the door to the resident's room. A review of admission records indicated Resident #5 was admitted on [DATE]. Lab results revealed a positive COVID-19 test on 8/1/22. A review of resident orders indicated a discontinued order, dated 7/31/22, for droplet and isolation precautions related to COVID-19 secondary to new onset of symptoms of COVID-19. Every shift for 14 days isolation precautions related to containment of potential transmission. There was an active order for droplet precautions related to COVID-19 every shift for 10 days isolation precautions related to containment of potential transmission. The order start date was 8/1/22 with precautions to end on 8/12/22. No progress notes had been entered into the medical record since 8/6/22. An interview was conducted on 8/9/22 at 11:19 a.m. with the DON, Nursing Home Administrator (NHA) and Staff F, Infection Control Director. The NHA stated a resident should be on isolation for 10 days after testing positive for COVID-19. She continued saying if the resident is fully vaccinated, they may retest them after 7 days and if negative, the resident could be removed from precautions. Staff F confirmed Resident #5 was not fully vaccinated. The DON, NHA and Staff F reviewed the orders for Resident #5 and confirmed the order stated droplet precautions should be in place from 8/2 to 8/12/22. The NHA stated the order is incorrect. They all reviewed the COVID positive test results from Resident #5. The NHA stated the day of testing counts so the resident should be under precautions until 8/10/22. The DON confirmed the resident had not been retested for COVID-19. The NHA stated they try to staff employees who have recently had COVID-19 to the positive residents, but now staff have been potentially exposed with the resident coming off precautions too soon. The NHA stated the prior DON had a spreadsheet to track transmission-based precaution (TBP) days. She stated she will educate staff and the resident will go back on isolation immediately. Staff F left to put precautions back in place. The NHA stated Staff F would have been the one to take the resident off precautions this morning. The NHA stated, this is so disconcerting. She said, because the doctor order says the 12th, the resident will stay there until the 12th. An interview was conducted with Staff F, LPN at 8/9/22 at 11:29 a.m. She confirmed she was the one who took Resident #5 off precautions that morning. She said she did not double check the spreadsheet. She stated she was talking about the patient coming off precautions yesterday and was thinking it was today the resident came off precautions. She said it was an oversight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 21 of 26 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 08/11/2022 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 Residents Affected - Few An interview was conducted with Staff H, CNA on 8/9/2 at 12:05 p.m. She stated she had been in Resident #5's room this morning without PPE. She said she noticed the precautions had been removed. She confirmed she was just notified of the potential exposure to COVID-19. A record review indicated Resident #222 was admitted on [DATE]. Observations on 8/8/22 and 8/9/22 revealed Resident #222 was not on isolation precautions. Staff and visitors were observed entering and exiting the resident's room multiple times. There was no isolation precaution sign posted or PPE cart at the resident's door. An interview was conducted with the DON, Nursing Home Administrator (NHA) and Staff F, LPN on 8/10/22 at 6:04 p.m. They stated when a resident is admitted they must have a COVID-19 test within 48 hours of admission. The newly admitted resident is placed on quarantine for a period of 10 days. They said the resident then goes into the regular testing schedule for the facility. They stated the facility is currently doing outbreak testing which is twice a week, every Monday and Thursday. The NHA stated the company made the decision to keep everyone on quarantine for 10 days as this was the safest decision for the facility. They stated this applies to newly admitted residents and residents who are out of the facility for 24 hours or more. The NHA reviewed Resident #222's orders and confirmed the resident was admitted on [DATE] and there are no precaution orders in place. The DON stated they are just monitoring them, not putting them on droplet or any particular precautions. The NHA questioned the DON about when that started because she didn't know anything had changed. The DON stated they don't place a sign stating precautions or put a PPE cart in place, they just monitor them. When asked what quarantine meant to her, the DON didn't answer. The NHA wanted to know who said to stop doing a PPE set up kit with precautions for new admissions because they should be on quarantine. Staff F, the Infection Control Director stated she would put them on standard isolation precautions. The NHA stated anyone coming from the hospital is considered presumptive positive and should be on quarantine for 10 days. She said they should be on droplet precautions with a sign and PPE cart in place. She stated staff should follow exactly what is on the sign. The NHA stated the company doesn't update the policy every time new guidance comes out. Per the NHA, Resident #222 is going on droplet precautions. On 8/11/22 at 11:57 a.m. an observation was made of Staff M, LPN entering Resident #175's room without donning PPE. The room was posted with contact precaution signs and a PPE cart was at the door. The LPN entered the room, gave the resident medication and exited the room. A provider was also observed in the resident's room with no gown or gloves in place. A blue fan was also observed to be sitting just outside the resident's partially open door, blowing down the hallway toward the front of the building. An interview was conducted with Staff M upon her exiting the precautions room. She said, I just handed medication and added, they aren't positive, just a new admission. She wore no gown, gloves, or face shield as stated was required on the door sign. 08/11/22 at 12:42 p.m. the fan was observed to continue to run outside of Resident #175's room the door is now closed. A review of admission records indicated Resident #175 was admitted on [DATE]. A physician order review revealed an order, dated 8/10/22, for droplet and contact isolation precautions every shift for 10 days related to containment of potential transmission. An interview was conducted with Staff F, LPN on 8/11/22 at 12:45 p.m. She stated all staff and visitors should be wearing additional PPE when going into droplet/contact isolation rooms. She also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 22 of 26 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 08/11/2022 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 Residents Affected - Few stated having the blue fan plugged in and running outside of the room was definitely a concern. She stated having a fan blowing air from the door of a COVID-19 precaution room down the hallway is a problem and it will be removed immediately. 2) On 8/8/22 at 9:37 a.m. an observation was made of a medication cart with a stainless-steel drinking container with straw in it sitting on top of the medication cart. No staff member was observed near the medication cart at the time. Photographic evidence obtained. On 8/8/22 at 9:45 a.m. the drink remained on the medication cart being utilized by Staff A, Licensed Practical Nurse (LPN). An interview was conducted with Staff A who said, that's mine. She stated she had not been told about any policy regarding drinks or personal items on the medication cart, but it's only my second day here. On 8/9/22 at 5:39 p.m. on observation was made of a cell phone on a medication cart on the west hallway. There was no staff observed near the medication cart at the time. Two minutes later, Staff B, LPN, returned to the cart from passing medication to a resident. Staff B confirmed it was his personal cell phone on the cart. When asked about it being on top of the medication cart, he removed it and continued to pass medication. An observation was made on 8/10/22 at 8:08 a.m. of Staff H, Certified Nursing Assistant (CNA.) Staff H was assisting Resident #222 with eating her breakfast. The CNA had ear buds in her ears and her personal cell phone was observed on the resident's lunch tray. A review of Resident #222's admission records indicated she was admitted on [DATE] with diagnoses including cerebral infarction due to thrombosis of right posterior cerebral artery, dementia, and diverticulitis of intestine. Resident #222 had a care plan in place for requiring assistance with activities of daily living (ADL.) An observation was made on 8/10/22 at 10:10 a.m. of Staff J, LPN at the west hall medication cart. Staff J was dispensing medication for a resident while talking on the phone with ear buds in her ear. Her personal cell phone was sitting on the top of the medication cart. Staff J was interviewed immediately after she hung up from her call. She stated she knows she isn't supposed to be on the phone but it is the first day of school and I needed to answer. When asked about the policy for having personal items on the medication cart she didn't respond. Staff J put her cell phone in her pocked and continued passing medications. An interview was conducted with the Director of Nursing (DON) on 8/9/22 at 5:42 p.m. The DON stated a personal cell phone should not be on the medication cart at all. An interview was conducted with Staff D, LPN, Unit Manager (UM,) on 8/10/22 at 9:05 a.m. She stated, can't have personal cell phones period. She stated if a staff member needs to use the phone they should step outside and away from resident areas. On 8/10/22 at 9:16 a.m. an interview was conducted with Staff H, CNA. She stated you should not have cell phones in resident rooms. When asked about her being observed on the phone multiple times while assisting Resident #222 with her meals, she stated she might have taken it out. She said she has kids at home. She added it's not an excuse. 3) An observation was made of the west hallway ice machine on 8/8/22 at 9:56 a.m. The ice machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 23 of 26 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 08/11/2022 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 Residents Affected - Few was locked and there was a plastic container attached to the wall to hold the ice scoop. The ice scoop was propped in the top of the container with the opening to the scoop facing up, uncovered. (Photographic evidence obtained.) The ice scoop was observed to remain uncovered at 12:39 pm. And 3:45 p.m. on 8/8/22. On 8/10/22 at 9:00 a.m. the ice machine was observed to be unlocked. There is a sign on the ice machine stating, Lock after each use. The ice machine is located on a resident hallway just inside the facility's front door. The ice scoop remained uncovered, with the scoop facing up. (Photographic evidence obtained.) On 8/10/22 at 10:10 a.m. Staff G, Registered Nurse (RN,) was observed using the uncovered ice scoop in the west hallway to fill a cooler with ice. When finishing with the scoop, the RN attempted to fit the ice scoop into the plastic container attached to the wall. She was unable to get the ice scoop to fit, she propped it back on the container uncovered and left. The RN was interviewed at this time. Staff G stated the ice she put in the cooler was being used for resident's lunch drinks. She stated the scoop should be covered but it would not fit in the container that is intended to cover it. An interview was conducted with the Staff F, LPN and Director of Infection Control, on 8/10/22 at 10:18 a.m. Regarding staff's personal cell phones she stated, should not have in work area period. Staff F explained there are bugs on the phone from everyday use and having the phones in a medication area would be breaking precaution barriers. She also stated company policy is cell phones are not allowed. She stated the ice scoop should always be bagged/covered and dated. She stated the ice scoop should not be exposed to air and facing up out of the bag. She was observed going to the ice machine and attempting to place the scoop in the provided plastic container and unable to make it fit. She removed the ice scoop and stated it will be fixed. An interview was conducted with the DON on 8/10/22 at 11:30 a.m. The DON stated the ice scoop should be placed upside down in the covered plastic bin attached to the wall. She also confirmed the ice machine must be locked. The DON also confirmed no staff member drinks or phones should be on the medication carts because it could cause contamination. A facility policy titled Novel Coronavirus Prevention and Response, dated 2/7/22, was reviewed. The policy stated, This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus. The policy explanation continues: 6. Procedure when COVID-19 is suspected or confirmed: b. Place a resident in a private room (containing a private bathroom) with the door closed. Follow current CDC guidance for quarantine timeframes. f. Implement standard, contract, and droplet precautions Wear gloves, gowns, goggles/face shields, and a NIOSH-approved N95 or equivalent or higher-level respirator upon entering room and when caring for the resident. 9. Managing a resident who has been treated for COVID-19 illness: b. Utilize symptom-based strategy for discontinuing transmission-based precautions based on severity of illness except in rare situations where the test-based strategy is to be considered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 24 of 26 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 08/11/2022 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 Discontinuation of transmission-based precautions on COVID-19 positive residents is as follows: Level of Harm - Minimal harm or potential for actual harm b.i.A. Residents with mild to moderate illness who are not severely immunocompromised: a. At least 10 days have passed since symptoms first appeared and Residents Affected - Few b.i.B. Residents who are not severely immunocompromised and who are asymptomatic throughout their infection: a. At least 10 days have passed since date of their first positive viral diagnostic test. 10. Considerations for admitting or readmitting residents or residents who may have left the facility for 24 hours or longer: b. newly admitted residents and residents who have left the facility for >24 hours, regardless of vaccination status, should have a series of two viral test for SARS-CoV-2 infection; immediately and, if negative, again 5-7 days after their admission. c. All residents who are not up to date with all recommended COVID-19 vaccine doses and are new admission and readmission should be placed in quarantine, even if they have a negative test upon admission; COVID-19 vaccination should also be offered. The Center for Disease Control and Prevention (CDC) article titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, offers current guidance stating, Empiric use of Transmission-Based Precautions (quarantine) is recommended for residents who are newly admitted to the facility and for residents who have had close contact with someone with SARS-CoV-2 infection if they are not up to date with all recommended COVID-19 vaccine doses. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) The CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, stated: In general, patients should continue to wear source control until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation below. Then they should revert to usual facility source control policies for patients. Patients with mild to moderate illness who are not moderately to severely immunocompromised: -At least 10 days have passed since symptoms first appeared and -At least 24 hours have passed since last fever without the use of fever-reducing medications and -Symptoms (e.g., cough, shortness of breath) have improved Patients who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: -At least 10 days have passed since the date of their first positive viral test. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 25 of 26 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 08/11/2022 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 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#:~:text=HCP%20who%20enter% Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 26 of 26