Health inspection·June 19, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her wheelchair towards her. At that point, Staff H said she told Resident #2 that she owed her an ass whooping. 0n 6/19/2023 at 11:30 a.m. an interview was conducted with Staff I, Speech Therapist. Staff I while she was at the vending machine, she heard Staff H yelling at Resident #2, and telling her she owed her an ass whooping and she would slap the piss out of her. Staff I said she went to the director of nursing's (DON) office to report Staff H. On 6/19/2023 at 12:38 p.m., an interview was conducted with Staff J, Certified Nursing Assistant (CNA). Staff J said she witnessed both incidences with Staff H and Resident #2. She said the first incidence happened when Staff H was bringing out the trash in the afternoon and Resident #2 was attempting to maneuver her wheelchair out of Staff H's way. Staff J said Staff F was yelling at the resident to leave the dining area. Staff F said the NHA overheard the commotion and had to separate the resident and Staff H. Staff J said the second incident was not long after and she overheard Staff H telling Resident #2 that she will slap the dog piss out of her and that she owed her an ass whooping. Staff J said the resident wheeled herself out of the dining room she watched to make sure that the resident returned to her room. Staff J said she the reported the incident to the DON. On 6/19/2023 at 1:00 p.m., an interview was conducted with Resident #2's, Nurse Practitioner (NP). The NP said Resident #2 was demented and had episodes of sundowning (confusion in the evenings). She said she was not aware of the incident between Staff H and Resident # 2 and that no Staff member should speak to any resident in that way. On 6/19/2023 at 1:55 p.m., an interview was conducted with the DON. The DON said she was aware of the way Staff F had spoken to Resident #2. She said she gathered testimony from the staff members who overheard the incident and Staff H had been suspended pending an investigation. The DON said Staff F received training in communication, and then was allowed to resume work. The DON said that DCF (Department of Children and Families) and law enforcement was informed. A review of the facility policy's titled, Freedom from Abuse, Neglect and Exploitation, dated 11/28/2017, showed to comply with Federal regulation 483.12, The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. Definitions per 483. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Staff to Resident Abuse of Any Type (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 2 of 6 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 06/19/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility has diverse populations including, among others, residents with dementia, mental disorders, intellectual disabilities, ethnic/cultural differences, speech/language challenges, and generational differences. Once a resident is accepted for admission, the facility assume the responsibility of ensuring the safety and well-being of the resident. It is the facility's responsibility to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to resident behaviors. All staff are expected to be in control of their own behaviors, are to behave professionally, and should appropriately understand how to work with the nursing home population. III. Prevention of Abuse , Neglect and Exploitation The facility has implemented this policy and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: b) Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient number to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; h) Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. XVIII. Protection of Resident The facility will make effects to ensure all residents are protected from physical and psychological harm during and after the investigation. Examples include but not limited to: C. Increase supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident (s) from the alleged perpetrator F. Providing emotional support and counseling to the resident during and after the investigation, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 3 of 6 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 06/19/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policies and medical records, the facility failed to ensure supervision was provided to prevent a fall which resulted in injuries for one resident (#1) of two residents sampled. Findings included: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include displaced unspecified condyle fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, unspecified lack of coordination, other abnormalities of gait and mobility, unspecified fracture of right wrist and hand, subsequent encounter for fracture with routine healing, unspecified fall, subsequent encounter, unspecified osteoarthritis, unspecified site. On 06/19/23 at 10:20 a.m., an interview was conducted with Resident #1. She was observed in her room, lying on the bed. The resident recalled the fall and stated she had mobility limitations prior to the fall. The resident stated on the day she fell, the certified nursing aide (CNA) [Staff A] was standing on the right side of the bed assisting her with toileting. Resident #1 said, I don't know what happened, I remember rolling over and fell on the window side to my left. The CNA could not catch me. I am almost 300 pounds. The problem was gravity. I could not catch myself. The resident stated the CNA was providing care by herself and confirmed she usually gets care from one CNA. Resident #1 stated she does not get out of bed because of her weight and her limited mobility. On 06/19/23 at 11:53 a.m., an interview was conducted with Staff A, CNA assigned to Resident #1 the day she fell. Staff A said, the resident was a one person assist, I went into the room to toilet her. She likes to lay on her side. After toileting I asked her to turn toward me so I could clean her up, but she turned the opposite way. The CNA confirmed the resident was a one personal assist, stating that was what her [NAME] [an informational filing system that is used for quick reference for nursing staff] said. Continuing, the CNA said Since the fall, she has been a two-person assist. I had assisted her multiple times before. I was always able to care for her by myself. I got the nurse right away and stayed in the room with the resident. Staff A stated she had not experienced any problems prior to this, and the Resident #1 could assist in turning herself. A review of a progress note dated 05/27/23 showed a late entry, Resident is sent out to ER for further evaluations for post fall. The resident was discharged to ER (Emergency Room) via stretcher with 4 paramedics and the Responsible Party .Pain level is 10. A review of a progress note dated 06/8/23 showed, Resident sitting up in bed with eyes closed. This nurse spoke with the resident regarding past medical history. Resident was readmitted to facility on 06/5/23 under [name of doctor] services. Resident has a fracture of left distal femur and tibia/fibula. Resident has orders to follow up with orthopedic. Resident informed this nurse that she has history of fractures, right foot, right wrist and hand, osteoarthritis to bilateral knees and hips, left knee meniscus tear. Resident informed nurse that she was to follow up for bilateral knee braces. Resident is NWB (Non-Weight Bearing) to left lower extremity and WBAT (Weight Bearing As Tolerated) to right lower extremity. Resident has pain in her right foot and states that she was informed in hospital that she had fractured toes on left foot. Medical Doctor (MD) in today for visit, new orders in place to x-ray both feet . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 4 of 6 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 06/19/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Minimum Data Set (MDS) dated [DATE], section C showed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15. Section G showed: Bed mobility, dressing, toilet use, bathing, Total dependence, one-person physical assist. An undated Care plan showed a focus on ADLs (Activities of Daily Living)/Mobility which indicated Resident #1 required assistance with ADLS related to weakness, decreased mobility, and wrist fracture. The Resident will have ADL needs met daily with appropriate assist through next review. Interventions included activities as tolerated, anticipate, and meet residents needs as necessary, observe for signs/symptoms of fatigue during tasks and allow resident rest breaks as needed, Oral care BID (twice daily) and PRN (as needed) and Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) to screen and if indicated eval and treat per MD orders. A focus in the undated care plan showed Resident #1 is at risk for falls related to weakness and decreased mobility. The goal indicated the resident would have no problems or negative implications. Interventions included to anticipate and meet the residents need if unable to voice needs, fall risk assessment completed and reviewed quarterly and PRN, keep room clutter free and PT/OT to screen PRN and if indicated to treat per MD orders. On 06/19/23 at 12:25 p.m., a telephone interview was conducted with Staff E, LPN (Licensed Practical Nurse) weekend supervisor. She confirmed she worked the day Resident #1 fell. Staff E said, I am familiar with the resident. The resident fell on [DATE]. When I came on the shift her call light was on. It was around 10:30 a.m. I answered her call light. The resident told me she needed to use the bathroom. I asked her to wait so I could get the CNA which I did. [Resident #1] was heavy, and she does not walk. At the time she was in a bariatric bed. It was about 20-30 minutes later when the CNA came and got me and said the resident had fallen. I went to the room and saw her on the floor. She was lying on the floor facing the window, on the left side of the bed. She was talking to the CNA, [Staff A]. She was conscious. Her nurse was already in the room cleaning her up and assessing her. EMS (Emergency Medical Service) was called. A family member happened to arrive for his usual visit and was present during the transfer. It took the EMS a long time to get her off the floor, they had to use a Hoyer lift. She was gone for a week. Staff E said the incident was unusual because the CNA was familiar with the resident and her bed mobility status. She had taken care of her before, and she was comfortable. On 06/19/23 at 11:20 a.m. an interview was conducted with the Advanced Registered Nurse Practitioner (ARNP). She stated she was not on call but became aware that Resident #1 fell and was sent out to the ER. She stated the resident has been back and has resumed regular care and therapy. She stated their goal was to manage her pain so the resident can resume full therapy. She stated she was not aware if this resident was receiving psych services. She stated Resident #1 might be depressed because she was not moving up to her goal of weight loss. The ARNP stated, it does not help that she does not get out of bed. On 06/19/23 at 11:35 a.m., an interview was conducted with Staff C, CNA. She stated she did not remember specifically how Resident #1 fell. She said, I don't know how she may have fallen. When I assist the resident, I always pull curtain, get what I need, and then tell her which way to turn. I show them with my hand in case they are not sure. I make sure the resident is not too far in the bed. On 06/19/23 at 11:40 a.m. an interview was conducted with Staff D, Staffing coordinator. She confirmed the facility did not have any staffing shortages around the time Resident #1 fell. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 5 of 6 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 06/19/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/19/23 at 2:12 p.m., an interview was conducted with the Director of Rehab, (DOR). She stated Resident #1 had been assessed by physical therapy (PT) for mobility. She said, the resident was able to roll to her left side facing the window, most of the time. She was not noted to roll to her right. She has a limited range of motion due to a pre-existing injury. On 06/19/23 at 2:29 p.m., an interview was conducted with the Director of Nursing (DON). She stated it was reported to her Resident #1 had a fallen when a CNA [Staff A] was giving care on 5/27/23. She stated one CNA was providing care by herself because the resident was a one person assist. The DON said, The CNA had reported the resident was lying on her side facing the window. The CNA said she told the resident to roll to her right, but the resident rolled to her left and fell. The DON stated after the fall, the resident was complaining of pain in her left knee and was sent out to the emergency room (ER). The DON said, the following Monday we received hospital paperwork showing she had suffered a Tibia fracture. She was hospitalized from [DATE] to 6/5/23. I conducted a full investigation, received statements from staff, and I asked the CNA to explain what happened and she did. She demonstrated what happened. We did not anticipate that she would fall and break her leg. The CNA reported gravity took hold of her and she rolled off bed. I did not consider the incident as abuse or neglect because the CNA was working with a patient who was alert and oriented and was previously able to follow commands. I reported the incident because the resident suffered injuries. The DON stated since the fall her transfer status was adjusted to a two person assist. The DON stated they had discussed the fall in their QAPI and had initiated an improvement plan. A review of an undated facility policy titled, Activities of Daily Living (ADLs), showing, the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to transfer and ambulate. Under policy explanation and compliance guidelines, the facility will maintain individual objectives of the care plan and periodic review and evaluation. A review of an undated facility policy titled, Fall Prevention Program, showed each resident will be assessed for the risk of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level but not as a result of an overwhelming external force e.g., (resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Under policy explanation and compliance guidelines, (1) the facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. (2) Upon admission the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. (3) The nurse will indicate the resident's fall risk in the medical record and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. (4.) Facilities standards to prevent falls includes implementing universal interventions that decrease the risk of resident falling, implement routine rounding schedule, monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed. When any resident experiences a fall, the facility will assess the resident, complete a fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 6 of 6