Health inspection·June 24, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #17 and was not able to state why the assessments were not completed timely because she was not working for the facility at the time. According to Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.18.1, the admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if this is the resident's first time in this facility, the resident has been admitted to this facility and was discharged return not anticipated, or the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. Prospective Payment System (PPS) Assessments for a Medicare Part A, stay including 5-Day assessments, must be completed within 14 days after the ARD (ARD + 14 days). Event ID: Facility ID: 106069 If continuation sheet Page 2 of 35 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 06/24/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one (#1) of thirty-two sampled residents. Residents Affected - Few Findings included: A review of Resident #1's admission Record revealed Resident #1 was admitted to the facility on [DATE] with a diagnosis of unspecified hearing loss. An observation was conducted on 6/22/2024 at 10:41 AM with Resident #1 in the resident's room. Resident #1 was observed in a wheelchair watching television. After attempting to conduct an interview, Resident #1 stated, You're going to have to write it down, I can't hear. He pointed to a dry erase board and dry erase marker on a nearby table. An interview was conducted with Resident #1 using the dry erase board and dry erase marker. Resident #1 stated he did not use any hearing devices and required an operation in order to use hearing aides. A review of Resident #1's care plan revealed a focus area, initiated 11/20/2023, [Resident #1] has difficulty hearing and will often misunderstand situations due to hearing impairment. Interventions included to use a dry erase board or writing pad and allow the resident time to respond. A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/16/2024, revealed under Section B - Hearing, Speech, and Vision, Resident #1's ability to hear (with hearing aid or hearing appliances if normally used) was adequate - no difficulty in normal conversation, social interaction, or listing to TV. The MDS assessment also revealed, under Section C Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #1 was cognitively intact. An interview was conducted on 6/24/2024 at 10:34 AM with Staff B, Registered Nurse (RN) and MDS Coordinator. Staff B, RN/MDS stated completion of the MDS assessments included reviewing the resident's administration records, pain assessments, physician's orders, and the charting completed by the nursing staff during the look back period. Staff B, RN/MDS also stated she will conduct interviews with the residents if they are able to communicate. Staff B, RN/MDS reviewed Resident #1's care plan and MDS assessment and addressed the information in Section B of the MDS assessment was incorrect because the resident was care planned for difficulty hearing. An interview was conducted on 6/24/2024 at 12:38 PM with the Director of Nursing (DON). The DON stated Resident #1 was not able to hear and staff used the dry erase board to communicate with the resident. The DON stated she would not agree Resident #1 had adequate hearing. A review of the policy titled, Comprehensive Care Plans, undated, revealed under the section titled Policy it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also revealed under the section titled Policy Explanation the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals or care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 3 of 35 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 06/24/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Review of the admission Record for Resident #42 revealed an admission to the facility on [DATE] with diagnoses to include depression, adjustment disorder with depressed mood and Non-Alzheimer's Dementia. Residents Affected - Some Review of the June 2024 Medication Administration Record (MAR) for Resident #42 revealed: -Depakote Oral tablet delayed release-Give 125 mg by mouth two times a day for mood disorder; start date: 06/11/2024, -FLUoxetine HCI Oral tablet 20 MG-Give 1 tablet by mouth one time a day for depression; start date: 09/21/2023, and -ABH Cream 1-25-1Mg/mL-Apply 1 mL topically to inner wrist or other hairless area three times a day for anxiety or restlessness; start date: 01/10/2024. Review of the Quarterly Minimum Data Set (MDS) for Resident #42, dated 06/02/2024, showed: -Section I Diagnosis: Depression checked; Non-Alzheimer's Dementia checked. -Section N Medications: Antipsychotic, Antianxiety, Antidepressant checked. -Antipsychotic Medication Review: Code 1 indicated Antipsychotics were received on a daily basis. Review of the Level I PASRR form located in the clinical record for Resident #42, dated 09/12/2023, revealed: -Section IA - Depressive Disorder checked, -Section II #2 C. Adaption to change -checked yes, -Section II #4- Has the individual exhibited actions or behaviors that may make them a danger to themselves or others was checked yes, -Section II #5-a primary diagnosis of Dementia -checked yes, -Section III: Not a provisional admission checked, -Section IV: PASRR Screen Completion- Serious Mental Illness checked. Verbal consent for a required Level II PASRR was given by Resident #42's spouse on 09/12/2023 at 9:54 a.m. Review of Resident #42's clinical record did not include a Level II PASRR as required. 11. Review of the admission Record for Resident #36 revealed an admission to the facility on [DATE] and a readmission on [DATE] with diagnoses to include major depressive disorder, generalized anxiety disorder (07/20/2023) and Alzheimer's Disease with late onset (07/18/2023). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 4 of 35 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 06/24/2024 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 0645 Review of the June 2024 MAR for Resident #36 revealed: Level of Harm - Minimal harm or potential for actual harm -Ativan Oral Tablet 0.5 MG *controlled drug* Give 0.25 mg by mouth every 12 hours as needed for anxiety; agitation for 14 days start: 06/20/2024 end: 07/04/2024, Residents Affected - Some -Setraline HCI Oral Tablet 100 mg Give 100 mg by mouth one time a day related to Major Depressive Disorder, recurrent, moderate start: 06/07/2024, -Buspirone HCI Oral tablet Give 1 tablet by mouth two times a day for treat anxiety start 06/07/2024. Review of the Quarterly MDS for Resident #36, dated 05/30/2024, showed: -Section I Diagnosis: Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety Disorder, Depression. -Section N Medications: Antianxiety, Antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #36, dated 07/10/2023, revealed: -Section IA - no diagnosis checked (07/20/2023), Alzheimer's not checked (07/18/2023), -Section II #7-checked yes-HX (history): Dementia. 12. Review of the admission Record for Resident #38 revealed an admission to the facility on [DATE] with diagnoses to include major depressive disorder recurrent severe without psychotic features, and adjustment disorder with anxiety (06/16/2020). Review of the June 2024 MAR for Resident #38 revealed: No medications related to a mental diagnosis were ordered. Review of the Quarterly MDS for Resident #38, dated 4/23/2024, showed: -Section I Diagnosis: Depression. Review of the Level I PASRR form located in the clinical record for Resident #38, dated 03/23/2020, revealed: -Section IA - no diagnosis checked (06/16/2020), -Section IB-nothing checked. 13. Review of the admission Record for Resident #29 revealed an admission to the facility on [DATE] with diagnoses to include major depressive disorder, recurrent, unspecified (01/31/2023). Review of the June 2024 MAR for Resident #29 revealed: Mirtazapine Oral Tablet 7.5 MG Give 1 tablet by mouth at bedtime for depression start: 10/26/2023. Review of the Quarterly MDS for Resident #29, dated 04/11/2024, showed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 5 of 35 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 06/24/2024 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 0645 -Section I Diagnosis: Depression. Level of Harm - Minimal harm or potential for actual harm -Section N Medications: Antianxiety checked. Residents Affected - Some Review of the Level I PASRR form located in the clinical record for Resident #29, dated 01/24/2022, revealed: -Section IA- no diagnosis checked (01/31/2023), -Section IB-nothing checked. Review of the policy titled, Resident Assessment - Coordination with PASRR Program, undated, revealed: This facility coordinates assessments with the preadmission and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. 5. The facility will have a designated staff member, such as Social Services Director or designee, responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. 8. Any resident who exhibits a newly evident behavioral or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II reviewed. 6. Review of the admission Record for Resident #11 revealed an admission to the facility on [DATE], and a readmission on [DATE] with diagnoses to include Alzheimer's disease (05/06/2014), mood disorder due to known physiological condition with depressive features (04/25/2016), schizoaffective disorder, bipolar type (07/22/2019), anxiety disorder, unspecified (03/06/2016), other recurrent depressive disorders (10/01/2015), and unspecified psychosis not due to a substance or known physiological condition (05/06/2014). Review of the June 2024 Medication Administration Record (MAR) for Resident #11 revealed: -Trazondone HCI Oral Tablet 50 MG (milligrams) - Give 25 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 06/12/2024. - Trazondone HCI Oral Tablet 50 MG - Give 50 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 11/23/2023 and discontinued 06/12/24. - carBAMazepine Oral Suspension 100 MG/5ML (millileters) - Give 5 ml by mouth three times a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 6 of 35 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 06/24/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm related to Mood Disorder Due To Known Physiological Condition with Depressive Features; start date 12/05/2023. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #11, dated 04/21/2024, showed: Residents Affected - Some -Under Section I Diagnoses: Alzheimer's Disease, Anxiety Disorder, Depression, Psychotic Disorder and Schizophrenia checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR forms located in the clinical record for Resident #11, dated 09/04/2020 and 07/24/2020, revealed: -Section IA - no diagnoses were checked (09/04/2020 & 07/04/2020) and Alzheimer's was not checked (07/04/2020), -Section II #5 - Related Neurocognitive Disorder (including Alzheimer's disease) checked no. 7. Review of the admission Record for Resident #12 revealed an admission to the facility on [DATE] with diagnoses to include generalized anxiety disorder (11/21/23), other recurrent depressive disorders (7/18/22), and excoriation (skin-picking) disorder (5/10/22). Review of the June 2024 MAR for Resident #12 revealed: - FLUoxetine HCl Oral Tablet 10 MG - Give 10 mg by mouth one time a day for depression; start date of 12/20/2023, -Doxepin HCl Capsule 10 MG - Give 10 mg by mouth three times a day for depression with excessive skin picking, start date of 5/24/24. Review of the Quarterly MDS assessment for Resident #, dated 04/19/2024, showed: -Under Section I Diagnoses: anxiety disorder, depression and excoriation (skin-picking) disorder checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #12, dated 11/17/2023, revealed: -Section IA - depressive disorder checked, -Section IB - nothing checked. 8. Review of the admission Record for Resident #14 revealed an admission to the facility on [DATE], and a readmission on [DATE] with diagnoses to include depression (12/29/2023). Review of the June 2024 MAR for Resident #14 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 7 of 35 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 06/24/2024 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 0645 - Sertraline HCI Oral Tablet 50 MG - give 1 tablet by mouth one time a day for depression 4/13/24. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessments for Resident #14, dated 04/04/2024 and 05/02/2024, showed: -Under Section I Diagnoses (04/04/2024): depression checked. Residents Affected - Some -Under Section N Medications (05/02/2024): antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #14, dated 12/27/2023, revealed: -Section IA - anxiety order was checked and depressive disorder was not checked, -Section IB - nothing checked. 9. Review of the admission Record for Resident #64 revealed an admission to the facility on [DATE] with diagnoses to include other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions, bipolar disorder unspecified and bipolar disorder current episode depressed, moderate. Review of the June 2024 MAR for Resident #64 revealed: - DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG - Give 1 capsule by mouth one time a day for depression; start date 6/21/2024. - DULoxetine HCl Oral Capsule Delayed Release Particles 30 MG - Give 3 capsule by mouth one time a day for depression; start date 11/08/2023 and d/c date 6/20/2024. - Depakote Oral Tablet Delayed Release 250 MG - Give 3 tablet by mouth at bedtime for mood disorder; start date 6/6/2024. - Divalproex Sodium Oral Tablet Delayed Release 500 MG - Give 2 tablet by mouth at bedtime for mood disorder; start date 11/07/2023 and d/c date 6/6/2024. Review of the Quarterly MDS assessment for Resident #64, dated 05/15/2024, showed: -Under Section I Diagnoses: bipolar disorder and psychotic disorder checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #64, dated 10/30/2023, revealed: -Section IA - bipolar disorder, depressive disorder, other: adjustment disorder checked. substance abuse was not checked. -Section IB - nothing checked, -Section II - 3. A. Psychiatric treatment more intensive than outpatient care checked yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 8 of 35 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 06/24/2024 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 0645 The medical record was silent of any other PASRRs for Resident #64. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 06/24/24 at 12:04 PM with the Director of Nursing (DON). The DON stated if the PASRR Level I form was not correct, she would submit an updated version. The DON also confirmed if a resident had a new diagnoses added during their stay at the facility, a new PASRR Level I form should be completed. Residents Affected - Some Based on interview and record review, the facility failed to ensure the accuracy of admission diagnoses on the Level I Preadmission Screening and Resident Review (PASRR) and failed to update the Level I PASRR upon the addition of new diagnoses for thirteen (#43, #40, #6, #59, #37, #11, #12, #14, #64, #29, #42, #38 and #36) of sixteen residents reviewed for PASRR. Findings included: 1. Review of the admission Record for Resident #43 revealed an admission to the facility on [DATE] with diagnoses to include vascular dementia (02/20/2024), adjustment disorder with mixed anxiety and depressed mood (02/20/2024), and dementia (03/15/2024). Review of the June 2024 Medication Administration Record (MAR) for Resident #43 revealed: -Alprazolam Tablet 0.25 MG (milligrams) - Give 1 tablet by mouth one time a day for anxiety; start date 02/16/2024. -Aricept Tablet 10 MG - Give 1 tablet by mouth at bedtime for dementia; start date 11/18/2023. -Mirtazapine Tablet 7.5 MG - Give 1 tablet by mouth at bedtime related to major depressive disorder; start date 02/06/2024. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #43, dated 05/31/2024, showed: -Under Section I Diagnoses: non-Alzheimer's dementia checked. -Under Section N Medications: antianxiety and antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #43, dated 12/05/2023, revealed: -Section IA - anxiety and depressive disorder checked, -Section IB - none checked, -Section II #5 - primary diagnosis of dementia checked no, -Section II #6 - secondary diagnoses of dementia checked no. 2. Review of the admission Record for Resident #40 revealed an admission to the facility on [DATE], and a readmission on [DATE] with diagnoses to include unspecified dementia (08/18/2020), and major depressive disorder (01/12/2024). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 9 of 35 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 06/24/2024 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 0645 Review of the June 2024 MAR for Resident #40 revealed: Level of Harm - Minimal harm or potential for actual harm - Duloxetine HCl Oral Capsule Delayed Release Particles 20 MG - Give 20 mg capsule by mouth one time a day for depression; start date 04/09/2024. Residents Affected - Some Review of the Quarterly MDS assessment for Resident #40, dated 04/20/2024, showed: -Under Section I Diagnoses: non-Alzheimer's dementia and depression checked. -Under Section N Medications: antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #40, dated 01/17/2023, revealed: -Section IA - nothing checked, -Section IB - nothing checked, -Section II #5 - primary diagnosis of dementia checked no, -Section II #6 - secondary diagnoses of dementia checked no. 3. Review of the admission Record for Resident #6 revealed an admission to the facility on [DATE], and a readmission on [DATE] with diagnoses to include psychosis (03/17/2015), schizophrenia (08/20/2023), and anxiety (03/10/2015). Review of the June 2024 MAR for Resident #6 revealed: -Propranolol Oral Tablet 20 MG - Give 1 tablet via PEG Tube every morning and at bedtime for Anxiety; start date 08/20/2023. -Clonazepam Oral Tablet 1 MG - Give 1 tablet via PEG Tube three times a day for Anxiety; start date 11/15/2023. -Valproic Acid Oral Solution 250 MG/5 ML (milliliters) Give 10 ml via PEG Tube every 6 hours for bipolar disorder; start date 08/21/2023. Review of the Quarterly MDS assessment for Resident #6, dated 06/09/2024, showed: -Under Section I Diagnoses: anxiety, psychotic disorder, schizophrenia checked. -Under Section N Medications: antianxiety checked. Review of the Level I PASRR form located in the clinical record for Resident #6, dated 03/17/2015, revealed: -Section IA: nothing checked, and mental retardation written under other. -all other sections were checked no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 10 of 35 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 06/24/2024 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 0645 No additional PASRR forms were available in the clinical record for review. Level of Harm - Minimal harm or potential for actual harm 4. Review of the admission Record for Resident #59 revealed an admission to the facility on [DATE] with diagnoses to include major depressive disorder (04/01/2023) and anxiety (04/01/2023). Residents Affected - Some Review of the June 2024 MAR for Resident #59 revealed: -Amitriptyline HCl Tablet 50 MG - Give 1 tablet by mouth one time a day for depression; start date 06/13/2024. -Duloxetine HCl Capsule Delayed Release Particles 60 MG - Give 1 capsule by mouth two times a day for depression; start date 03/28/2024. Review of the Annual MDS assessment for Resident #59, dated 03/30/2024, showed: -Under Section I Diagnoses: anxiety and depression checked. -Under Section N Medications: hypnotic and antidepressant checked. Review of the Level I PASRR form located in the clinical record for Resident #59, dated 03/18/2023, revealed: -Section IA - nothing checked, -Section IB - nothing checked, -Section II all sections are checked no. 5. Review of the admission Record for Resident #37 revealed an admission to the facility on [DATE] and a readmission on [DATE] with diagnoses to include unspecified dementia (01/21/2020 and major depressive disorder (09/01/2020). Review of the Quarterly MDS assessment for Resident #37, dated 04/09/2024, showed: -Under Section I Diagnoses: non-Alzheimer's dementia and depression checked. Review of the Level I PASRR form located in the clinical record for Resident #37, dated 01/20/2020, revealed: -Section IA - nothing checked, -Section IB - nothing checked, -Section II #5 - primary diagnosis of dementia checked no, -Section II #6 - secondary diagnoses of dementia checked no. An interview was conducted on 06/24/24 at 12:14 PM with the Director of Nursing (DON) and Staff D, Social Services Director (SSD). The DON said it was her, and the previous SSD's responsibility to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 11 of 35 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 06/24/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm ensure PASRR Level I forms were accurate upon the resident's admission to the facility. She stated if the PASRR Level I form was not correct, she would submit an updated version. The DON also confirmed if a resident had a new diagnoses added during their stay at the facility, a new PASRR Level I form should be completed. The DON confirmed the residents listed above had inaccurate/incorrect PASRR Level I forms related to diagnoses. Residents Affected - Some During an interview on 06/24/24 at 02:02 PM, the Nursing Home Administrator (NHA) confirmed PASRR Level I forms should have an accurate and complete diagnoses listed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 12 of 35 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 06/24/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the baseline care plan in a timely manner for one (#274) of thirty-two sampled residents. Findings included: A review of Resident #274's admission Record revealed Resident #274 was admitted to the facility on [DATE]. A review of Resident #274's baseline care plan revealed a completion date of 6/17/2024. An interview was conducted on 6/24/2024 at 12:32 PM with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated unit managers would normally initiate the baseline care plan and the care plan should be completed as soon as possible. Staff C, LPN was not able to state when the baseline care plan should be completed. An interview was conducted on 6/24/2024 at 12:49 PM with the Director of Nursing (DON). The DON stated baseline care plans were to be completed by the resident's admitting nurse and should be completed within 48 hours. A request for a facility policy for baseline care plans was requested on 6/24/2024 at 11:28 AM. Then at 1:25 PM, the DON stated the facility did not have a policy for baseline care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 13 of 35 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 06/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 06/22/2024 at 11:49 AM during an observation of the lunch service for fourteen residents in the main dining room, Resident #11 was sitting at a table in her wheelchair by herself having sporadic outbursts of laughing. Review of the admission Record for Resident #11 revealed an admission to the facility on [DATE], and a readmission on [DATE] with diagnoses to include Alzheimer's disease, mood disorder due to known physiological condition with depressive features, schizoaffective disorder, bipolar type, anxiety disorder, unspecified, other recurrent depressive disorders, and unspecified psychosis not due to a substance or known physiological condition. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #11, dated 04/21/2024, showed: - Section C - Cognitive Patterns - the resident was rarely/never understood. - Section I Diagnoses: Alzheimer's Disease, Anxiety Disorder, Depression, Psychotic Disorder and Schizophrenia checked. Review of the care plan, initiated 09/30/20, for Resident #11 revealed: - Focus: She has dx (diagnoses) of dementia, schizoaffective disorder, and mood disorder. She is at risk for her psychosocial well-being needs not being met. She takes psychotropic medication, she is at risk for adverse reactions and complications. Goal: She will not experience any adverse reactions secondary to antidepressant medication through review. Interventions included: meds (medications) per orders, observe for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion, Provide calm environment as needed, observe for non-verbal signs of distress/discomfort/anxiety such as insomnia, fidgeting, restlessness, psych consult prn (as needed). -Focus: Behaviors: [Resident #11] has a behavior problem r/t (related to) refuses medications at times. Goal: Encourage resident to take medications however, staff will honor resident's right to refuse; The resident will have fewer episodes of unwanted behavior through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. -Focus: Cognition: [Resident #11] has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 14 of 35 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 06/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Goal: Staff will anticipate resident's needs, if she is unable to make them known. The resident will be able to communicate basic needs on a daily basis through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding residents capabilities and needs. COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Cue, reorient and supervise as needed. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. Provide the resident with a homelike environment. Reminisce with the resident using photos of family and friends. The resident needs [sic] with all decision making. The active care plan was silent of a focus, goal or intervention related to the behavior of laughing outbursts. Review of a Psychotropic Medication Interdisciplinary Review, dated 06/05/2024, revealed, Patient presents with involuntary, sudden and frequent episodes of laughing and/or crying. The episodes are consistent with PBA [pseudobulbar affect], and typically occur out of proportion or incongruent to the underlying emotional state. ,[sic] trialing nudexta at this time. Documented in the DX (diagnoses) section was the following: 5: Pseudobulbar affect - start Nuedexta 20 mg (milligrams) qd (once a day) for 7 days then q (once) 12 hours when the medication comes for [vendor name] pharmacy. Review of the June 2024 Medication Administration Record (MAR) for Resident #11 revealed: -Trazondone HCI Oral Tablet 50 MG (milligrams) - Give 25 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 06/12/2024. - Trazondone HCI Oral Tablet 50 MG - Give 50 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date 11/23/2023 and discontinued 06/12/24. - carBAMazepine Oral Suspension 100 MG/5ML (milliliters) - Give 5 ml by mouth three times a day related to Mood Disorder Due To Known Physiological Condition with Depressive Features; start date 12/05/2023. The June 2024 MAR was silent of any administration for Nudexta. During an interview on 06/23/2024 at 12:12 PM Staff J, Certified Nursing Assistant (CNA) stated normally she crawls out of bed, but for the noise thing; she does it a lot. It is between a laugh and cry. She confirmed she has doing this for a few months. Staff J stated she will ask Resident #11 if she is crying, but Resident #11 will say no I'm laughing. She will make the same noise all the time and you just ask her what is wrong. During an interview on 06/23/2024 at 1:07 PM Staff I, Licensed Practical Nurse (LPN) confirmed there were no orders for Nuedexta in Resident #11's record. She reviewed the progress notes for Resident #11 and confirmed there were no notes related to the outbursts of laughing or administration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 15 of 35 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 06/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nuedexta. Staff I stated if you ask her if she is laughing, crying, hurting or in pain; she will answer appropriately and she will acknowledge if she is in pain. Staff I stated they do not know what triggers the laughing. She stated it was sporadic. She stated we start asking her to rule out what it is. She stated that most of the time it is laughing and we ask her what she is laughing at and she will tell you she doesn't know. Staff I stated Resident #11 has been doing this for a little over a month and that it comes and goes. She reviewed the current care plan to see if this was addressed and she stated, I don't see it anywhere in here, but aware of what to do. During an interview on 06/23/0204 at 1:25 PM Staff B, RN/MDS confirmed Resident #11's care plan did not include information related to the outbursts of laughing and stated that nursing would tell her if there was a new diagnosis to be added. She stated, I would add that new diagnosis and a care plan. She stated she was not made aware of the PBA diagnosis. She stated nursing attends the psych meetings and they communicate that in the meetings the next day they talk about new orders and new diagnosis. During an interview on 06/23/2024 at 1:47 PM the Director of Nursing (DON) stated the ARNP (advanced practice registered nurse) was trying to get the Nuedexta from another pharmacy the facility doesn't use. She stated that it was her understanding they would start the medication once they received it. She confirmed there was no documentation of communication between the pharmacy and the facility to follow up on the status of the medication. She confirmed the outbursts of laughing and diagnosis of PBA should have been in Resident #11's care plan. She confirmed someone should have told Staff B, RN/MDS. On 06/23/2024 at 4:30 PM Resident #11 was observed in her wheelchair in the hall and having sporadic outbursts of laughing. Two staff members were with her and one was trying to straighten Resident #11's jacket. Resident #11 shouted, Don't touch me. The staff member stopped and walked away. Another staff member yelled from the other end of the hall asking what was wrong, and the staff member standing next to Resident #11 stated, She is just being [Resident #11]. Resident #11 continued with sporadic laughing outbursts. 3. On 06/22/2024 at 10:02 AM Resident #12 was observed in bed with a red ulcer on her right lower shin and crusted discharge on the corner of her toenail on her big toe, a dressing was not observed on either location. Resident #12 stated they were taking care of her open sore. She stated, They had it (toe) wrapped so tight. I pulled it off and it had all this junk oozing. I need them to do something about that toe. Review of the admission Record for Resident #12 revealed an admission to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; acquired absence of left leg above knee; excoriation (skin-picking) disorder, and peripheral vascular disease. Review of the June 2024 MAR for Resident #12 revealed: -Doxepin HCl Capsule 10 MG - Give 10 mg by mouth three times a day for depression with excessive skin picking, start date of 5/24/24. This medication was administered as ordered. - Podiatrist, Audiologist, Vision and Dental Consult; start date of 3/18/22. - BEHAVIORS - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 16 of 35 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 06/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift document yes for active behaviors this shift, no if not actively having behaviors this shift. document type of behavior document number of times noted this shift, Start date of 9/10/22. NO was documented for each shift from 06/01/2024 to 06/23/2024 except for the evening shift on 06/21/2024 there was no behavior documented. Review of the June 2024 Treatment Administration Record (TAR) on 06/23/2024 at 2:20 PM for Resident #12 revealed: - PO cleanse right shin with nss (normal saline solution) pat dry apply hydrophilic ointment wrap with gauze wrap and coban every two days and as needed - every day shift every 2 days (s) for wound care, start date 5/18/24. Review of the June 2024 TAR provided by facility on 06/24/2024 revealed and additional physician order for: -cleanse right great toe with nss, pat dry apply TAO and Band Aid daily until resolved - every evening shift for wound care, start date, [sic]/25/2024 1500 (3:00 p.m.) - with no documentation of administration. Review of the Quarterly MDS assessment for Resident #12, dated 04/19/2024, showed in Section C Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section I Diagnoses showed anxiety disorder, depression and excoriation (skin-picking) disorder were checked. Section M - Skin Conditions showed Resident #12 had other open lesion(s) on the foot and application of dressings to feet (with or without topical medications). Review of the active care plan for Resident #12 revealed: - Focus: Venous Ulcer to Right shin, Left leg r/t (related to) DX (diagnosis) of PVD. Goal and Interventions were blank. -Focus: Behaviors: [Resident #12] has a behavior problem r/t picking at skin and pulling scabs of healed areas. Goal: The resident will have fewer episodes of behavior by review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Staff to keep nails trimmed and cleaned as she allows. When staff observe resident picking at skin attempt to redirect the behavior. -Focus: Impaired skin integrity with risk for further decline r/t Hx (history) of picking at skin. Incontinence and impaired mobility, she frequently picks at her skin, venous ulcer (R)leg, (L)leg. Goal: No problems or negative complications r/t impaired skin integrity with skin integrity with skin being kept intact daily through next review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 17 of 35 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 06/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interventions included: head to toe skin check weekly, observe skin during care for any s/s (signs/symptoms) of redness and report to nurse immediately and wound care consult/weekly visit treatment as ordered. The active care plan was silent of a focus, goal or intervention related to the behavior of pulling off gauze/dressings to open wounds and care for the right big toe. In addition, the care plan did not document a goal or interventions for the focus related to the venous ulcers. During an interview on 06/23/2024 at 4:31 PM Staff A, LPN stated Resident #12 picks at her skin. She stated Resident #12 receives an ointment for the ulcer and it is wrapped with gauze. Staff A stated Resident #12 refuses it (gauze) and she takes it off. She stated Resident #12 doesn't like the compression. Staff A placed this information in an observed progress note. She stated, today Resident #12 refused for me to wrap it. She stated the toe is scabbed and a CNA came to me today to tell me about the resident's concern with the toe. She stated, I am looking into it. She stated Resident #12 takes the gauze off using her grabber. During an interview on 06/24/2024 at 11:13 AM Staff B, RN/MDS stated she was not aware of Resident #12's toe and that she removes the gauze placed on her wounds. She stated, I would think that would be a behavior. She stated no one had brought this up. She stated there was nothing about the toe in the nurses' notes. She said, I don't see a note about taking the gauze off. She reviewed and read aloud part of the general nurse note, dated 5/24/2024, Resident alert and verbal . Facility MD here for visit . continue current wound care treatment and discussed importance of leaving dressing on and not taking them off and picking at skin. She stated this was addressing pulling off gauze as a behavior. She stated nursing would have to bring that to my attention and social services. She stated care plans should have the behaviors. She confirmed the current care plan did not have anything referencing care for Resident #12's big toe. During an interview on 06/24/2024 at 1:26 PM Staff K, RN stated Resident #12 picks. She stated the podiatrist trimmed her nails. She stated a wrap is put on it and she pulls it and picks it. She confirmed Resident #12 pulls the gauze by nodding her head up and down. She stated that wound care was there on Friday and there was a dressing on her toe then. During an interview on 06/24/2024 at 12:27 PM the DON stated the behavior of taking off the gauze was new to her. She stated nurses should inform her and she would let Staff B, RN/MDS Coordinator know. She confirmed she hadn't seen anything about Resident #12's toe and staff should have informed her. 4. Resident #14 was observed on 06/22/2024 at 9:50 AM in bed sleeping and received oxygen via a nasal cannula. Resident #14 was observed on 06/22/2024 at 11:52 AM in bed receiving oxygen at 4 LPM (liters per minute). She stated she sleeps a lot and was not having any concern with her oxygen. Review of the admission Record for Resident #14 revealed a readmission date of 12/28/2023 and 04/09/2024 and an original admission date of 09/12/2023 with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, type 2 diabetes mellitus with diabetic neuropathy, dysphagia oropharyngeal phase, and dysphagia following cerebral infarction Review of the June 2024 Physician Orders revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 18 of 35 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 06/24/2024 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 0657 - Oxygen @ 2L (liters) via nasal cannula as needed for SOB (shortness of breath); start date of 04/05/2024, Level of Harm - Minimal harm or potential for actual harm - Check Oxygen Saturation Q (every) Shift and Document every shift for Covid Monitor; start date of 12/28/2023, Residents Affected - Few - Increase o2 to keep 02sat>92%, order date of 5/9/24, - Ipratropium-albuterol solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters)- 3 ml inhale orally every 4 hours as needed for SOB or wheezing via nebulizer, start date of 5/9/24, - HOB is elevated to prevent of SOB while lying flat r/t (related to) chronic lung disease (bed or pillows), every shift for COPD; start date of 04/10/2024, - Fast Blood Glucose - one time a day for DM (diabetes mellitus); start date of 12/30/2023, - Bydureon BCise Subcutaneous Auto-injector 2 MG/0.85ML (Exenatide) - Inject 2 mg subcutaneously one time a day every Fri for DM; start date of 4/19/2024, - Glucagon (rDNA) Kit 1 MG - Inject 1 mg intramuscularly every 15 minutes as needed for blood sugar less than 60 give 1 mg IM (intramuscular) if blood sugar less than 60 and resident unable to swallow without risk of aspiration due to lethargy. Recheck blood sugar in 15 minutes if still less than 60 notify medical provider; start date 3/18/2024, - metFORMIN HCl Oral Tablet 1000 MG (Metformin HCl) - Give 1000 mg by mouth two times a day related to Type 2 Diabetes Mellitus Without Complications; start date of 04/12/2024, - Insulin Glargine Solution 100 UNIT/ML Inject 98 unit subcutaneously one time a day for diabetes; start date of 6/17/2024, - Insulin Glargine Solution 100 UNIT/ML Inject 57 unit subcutaneously at bedtime for diabetes; start date of 06/21/2024. Review of the MDS assessment for Resident #14, dated 05/02/2024, showed: -Under Section N Medications: hypoglycemic checked. Review of the MDS assessment for Resident #14, dated 09/17/2023, showed: -Under Section I Active Diagnoses: diabetes mellitus, COPD, and dysphagia as checked. Review of the O2 (oxygen) sats (saturation) Summary for the dates of 05/31/2024 to 06/24/2024 showed Resident #14 received oxygen via a nasal cannula everyday. Review of the active care plan, initiated on 12/29/2023 revealed it was silent of focuses related to oxygen therapy, and the diagnoses and care related to dysphagia and diabetes. The care plan only had diabetes mentioned as part of the focuses for the resident being at risk for pain, skin breakdown and incontinence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 19 of 35 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 06/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/23/2024 at 12:20 PM Staff J, CNA stated Resident #14 always wears it (nasal cannula). She stated confirmed she was aware Resident #14 had diabetes and if she wasn't feeling good she would get a nurse. She didn't think there was anything on the Kardex related to diabetes for Resident #14. During an interview on 06/23/2024 at 12:34 PM Staff I, LPN confirmed the oxygen order for Resident #12 and the care plan did not include anything related to the oxygen she received. She stated Resident #14 received snacks when requested and the care plan did not include diabetes care. During an interview on 06/23/2024 at 1:21 PM Staff B, RN/MDS Coordinator confirmed Resident #12 did not have a care plan for oxygen, diabetes or dysphagia. She said, Yes, it should be. She stated if Resident #14 had a care plan it would trigger on the Kardex. Review of a policy titled, Comprehensive Care Plans, undated, revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team . Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for four (#55, #11, #12, and #14) of 32 residents reviewed. Findings included: 1. Review of the admission Record for Resident #55 revealed admission to the facility on [DATE] and a readmission on [DATE] with diagnoses to include congestive heart failure, acute kidney failure, chronic kidney disease, and ESBL (extended-spectrum beta- lactamases). Review of the care plan for Resident #55 on 06/22/2024 revealed: Focus: -[Resident #55] requires Isolation Precautions r/t [related to] ESBL in urine. Goals: -No problems or negative complications r/t Isolation Precautions until infection is resolved. Interventions: -Don proper PPE [personal protective equipment] when providing care. -Observe Isolation Precautions Date initiated: 05/24/2024; a resolved or completed date was not present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 20 of 35 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 06/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2024 and June 2024 revealed: - contact isolation related to ESBL start date on 5/24/24 and discontinue on 6/3/24 (10 days). On 06/23/2024 at 12:30 PM, Resident #55 was observed in room and laying on the bed, dressed and groomed. The resident was not interviewable at that time. Further observation revealed no contact isolation signage or PPE caddy at the room door entrance. During an interview on 06/23/2024 at 12:32 PM, with Staff A, Licensed Practical Nurse (LPN), she confirmed Resident #55 had been treated for a urine infection several weeks ago, and said at that time she was on transmission-based precautions (TBP). Staff A said the precautions were discontinued but she could not recall the date. On 06/23/2024 at 12:56 PM an interview was conducted with Staff B, Minimum Data Set (MDS) Coordinator, Registered Nurse (RN). The RN/MDS Coordinator confirmed she was responsible for the MDS assessments and the care plans. Staff B stated the care plan focus should be resolved when it was no longer an issue for the resident/staff. Reviewing the resident's care plan, the RN/MDS Coordinator confirmed the care plan should have been updated to remove the TBP focus when the TBP were discontinued and stated, I missed that. The RN/MDS Coordinator continued, saying the focus was resolved yesterday (06/22/2024). Review of a printed care plan, provided by the RN/MDS Coordinator, showed the TBP focus had a resolved dated on 06/22/2024 (after the survey team entered the facility and reviewed the care plan). During an interview with the Director of Nursing (DON) on 06/24/2023 at 12:10 PM, she said it would be her expectation that care plans are updated and revised to reflect the resident's current care needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 21 of 35 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 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the admission Record for Resident #29 revealed an admission to the facility on [DATE] with a diagnoses not limited to: chronic obstructive pulmonary disease (COPD), unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral. Residents Affected - Few Review of Resident #29's active physician orders, dated 6/24/2024, revealed: -Oxygen @ 2LPM (liters per minute) via nasal cannula PRN as needed for SOB (shortness of breath) start: 02/21/2024. -HOB (head of bed) is elevated to prevent SOB while laying flat for chronic lung disease (COPD) every shift for COPD start: 10/27/2023. -change oxygen tubing weekly. Review of the June 2024 MAR for Resident #29 revealed: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for shortness of breath or wheezing. -Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/ACT 2 puff inhale orally one time a day for COPD. Review of the care plan for Resident #29, dated 10/20/2023, revealed: Focus: Resident is at risk for shortness of breath and/or respiratory distress. Goal: No problems or negative complications r/t shortness of breath and /or respiratory distress through next review. Interventions included: -change oxygen tubing weekly, -Elevate HOB as needed for ease of breathing, -Observe respiratory status and report difficulty breathing immediately, -oxygen per MD (medical doctor) order, -oxygen sats per MD order and as needed. On 06/22/2024 at 10:41 a.m. Resident #29 was observed sleeping in bed wearing a nasal cannula with oxygen flowing from an oxygen concentrator and set at 1L (liter). On 06/23/2024 at 11:18 a.m. Resident #29 was observed resting in bed wearing a nasal cannula with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 22 of 35 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 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 oxygen flowing from an oxygen concentrator and set at 1L. Level of Harm - Minimal harm or potential for actual harm On 06/24/2024 at 12:47 p.m. Resident #29 was observed resting in bed wearing a nasal cannula with oxygen flowing from an oxygen concentrator and set at 1L. Residents Affected - Few During an interview with Resident #29 on 6/24/2024 at 12:47 p.m., she stated she did not know how many liters of oxygen she should be getting, and she was not sure if she felt like she was getting enough oxygen. During an interview with Staff I, Licensed Practical Nurse (LPN) on 06/24/2024 at 2:04 p.m., she stated Resident #29 was supposed to be on 2L of oxygen. She stated the nurse is responsible for it, but they usually keep it at the level it is set at or the level it is supposed to be set at. They keep it on her and the tubing is changed every Sunday night. During an interview with Staff H, Certified Nursing Assistant (CNA) on 06/24/2024 at 2:06 p.m., she stated Resident #29 was on 1 or 2 liters of oxygen and the nurse is responsible for checking it. 3. Resident #14 was observed on 06/22/2024 at 9:50 AM in bed sleeping and received oxygen via a nasal cannula. No signage was observed outside of Resident #14's room indicating the oxygen was in use. Resident #14 was observed on 06/22/2024 at 11:52 AM in bed receiving oxygen at 4 LPM (liters per minute) via a nasal cannula. She stated she sleeps a lot and was not having any concern with her oxygen. No signage was observed outside of Resident #14's room indicating the oxygen was in use. Review of the admission Record for Resident #14 revealed a readmission date of 12/28/2023 and 04/09/2024 and an original admission date of 09/12/2023 with diagnoses to include chronic obstructive pulmonary disease (COPD). Review of the June 2024 Physician Orders revealed: - Oxygen @ 2L (liters) via nasal cannula as needed for SOB (shortness of breath); start date of 04/05/2024, - Check Oxygen Saturation Q (every) Shift and Document every shift for Covid Monitor; start date of 12/28/2023, - Increase o2 to keep 02sat>92%, order date of 5/9/24. Review of the O2 (oxygen) sats (saturation) Summary for the dates of 05/31/2024 to 06/24/2024 showed Resident #14 received oxygen via a nasal cannula everyday. A review of Resident #14's medication administration record for June 2024 did not reveal oxygen at 2 liters per minute via nasal cannula was being administered. Review of the active care plan, initiated on 12/29/2023 revealed it was silent of focuses related to oxygen therapy. Resident #14 was observed on 06/23/2024 at 09:34 AM in bed receiving oxygen at 4 LPM (liters per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 23 of 35 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 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm minute) via a nasal cannula. She stated she sleeps a lot and was not having any concern with her oxygen. No signage was observed outside of Resident #14's room indicating the oxygen was in use. During an interview on 06/23/2024 at 12:20 PM Staff J, Certified Nursing Assistant (CNA) stated Resident #14 always wears it (nasal cannula). Residents Affected - Few During an interview on 06/23/2024 at 12:34 PM Staff I, LPN confirmed the oxygen order was for 2L for Resident #12 and then on 5/5/24 it was increased based on sats (saturation). She stated when she checks the oxygen level she would not turn it to 2L if at 4L the resident was stable. Based on observations, interviews, and record reviews, the facility failed to provide oxygen therapy in accordance with professional standards for four (#14, #274, #47 and #29) of four residents sampled for oxygen therapy. Findings included: 1. A review of Resident #47's medical record revealed Resident #47 was admitted to the facility on [DATE]. An observation was conducted on 06/22/2024 at 9:49 AM of Resident #47 in the unit hallway. Resident #47 was observed wearing an oxygen nasal cannula with oxygen flowing from a portable tank hanging from the back of the wheelchair. A review of Resident #47's physician orders revealed an order, dated 5/23/2024, for oxygen at 2 liters per minute via nasal cannula as needed (PRN). An observation was conducted on 6/23/2024 at 1:58 PM of Resident #47 in the resident's room. Resident #47 was observed resting in bed wearing an oxygen nasal cannula with oxygen flowing from an oxygen concentrator. No signage was observed outside of Resident #47's room indicating the oxygen was in use. A review of Resident #47's medication administration record for June 2024 did not reveal oxygen at 2 liters per minute via nasal cannula was being administered. 2. A review of Resident #274 medical record revealed Resident #274 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and dependence on supplemental oxygen. An interview was conducted on 6/22/2024 at 1:45 PM with Resident #274 in the residents room. Resident #274 stated wears oxygen continuously and used oxygen at home prior to her admission to the facility. Resident #274 was observed resting in bed wearing an oxygen nasal cannula with oxygen flowing from an oxygen concentrator at 3 liters per minute. No signage was observed outside of Resident #274's room indicating the oxygen was in use. A review of Resident #274's physician orders did not reveal an order for oxygen. A review of Resident #274's admission assessment dated [DATE] revealed the resident used oxygen at 3 liters per minute via nasal cannula and reported shortness of breath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 24 of 35 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 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Wales Health and Rehabilitation Center 730 N Scenic Hwy Lake Wales, FL 33853 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation was conducted on 6/23/2024 at 2:55 PM of Resident #274 in the resident's room. Resident #274 was observed resting in bed wearing an oxygen nasal cannula with oxygen flowing from an oxygen concentrator. No signage was observed outside of Resident #274's room indicating the oxygen was in use. An interview was conducted on 6/24/2024 at 11:52 AM with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated when a resident is admitted to the facility, they review with resident's transfer documentation to check if the resident is using supplemental oxygen. Staff C, LPN also stated if a resident uses oxygen, a physician order should be in the resident's chart for the oxygen use. Staff C, LPN reviewed Resident #274's physician orders and addressed the resident did not have an order for oxygen. Staff C, LPN stated she was not sure if the facility utilized signage related to oxygen usage in the resident's rooms. Staff C, LPN was not able to state if a PRN oxygen order should be documented on the administration record when it's in use. An interview was conducted on 6/24/2024 at 12:41 PM with the facility's Director of Nursing (DON). The DON stated if a resident used oxygen, a physician order should be in place. The DON reviewed Resident #274's physician orders and addressed the resident did not have an order for oxygen. The DON also stated if a resident used oxygen on a PRN basis, it should be documented in the resident's medication administration record. The DON stated resident's using oxygen should have signage displayed on the outside of the room indicating oxygen is in use. A review of the facility policy Oxygen Administration, with no effective date, revealed under the section titled Policy oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. A review of the facility policy Provider Orders, with no effective date, revealed under the section titled Policy Explanation and Compliance Guidelines each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the medication administration record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 25 of 35 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 06/24/2024 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** 2. On 6/22/2024 at 11:49 AM during an observation of the lunch service for fourteen residents in the main dining room, Resident #11 was in her wheelchair sitting at a table by herself, and having sporadic outbursts of laughing. Review of the medical record for Resident #11 revealed an admission to the facility on 9/03/2020, and a readmission on [DATE] with diagnoses to include Alzheimer's disease, mood disorder due to known physiological condition with depressive features, schizoaffective disorder, bipolar type, anxiety disorder, unspecified, other recurrent depressive disorders, and unspecified psychosis not due to a substance or known physiological condition. Review of the June 2024 Medication Administration Record (MAR) for Resident #11 revealed: -Trazondone HCI Oral Tablet 50 MG (milligrams) - Give 25 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date of 6/12/2024. - Trazondone HCI Oral Tablet 50 MG - Give 50 mg by mouth at bedtime for insomnia related to other recurrent depressive disorders; start date of 11/23/2023 and discontinued on 6/12/2024. - carBAMazepine Oral Suspension 100 MG/5ML (milliliters) - Give 5 ml by mouth three times a day related to Mood Disorder Due To Known Physiological Condition with Depressive Features; start date of 12/05/2023. - Sedative/Hypnotic Medication - Monitor or burning or tingling in hands/feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, weakness. Document: 'Y' if monitored and above observed. 'N' if monitored and none of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every day and night shift; start date of 11/30/2023. For the month of June 2024 (06/01/2024 to 06/22/2024) each day and night shift was marked with a check mark not a Y or N. - Behaviors - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift; start date of 12/22/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. Review of the care plan, initiated 9/30/2020, for Resident #11 revealed: - Focus: She has dx (diagnoses) of dementia, schizoaffective disorder, and mood disorder. She is at risk for her psychosocial well-being needs not being met. She takes psychotropic medication, she is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 26 of 35 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 06/24/2024 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 at risk for adverse reactions and complications. Level of Harm - Minimal harm or potential for actual harm Goal: She will not experience any adverse reactions secondary to antidepressant medication through review. Interventions included: meds (medications) per orders, observe for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion, observe for non-verbal signs of distress/discomfort/anxiety such as insomnia, fidgeting, restlessness, psych consult prn (as needed). Residents Affected - Few -Focus: Behaviors: [Resident #11] has a behavior problem r/t (related to) refuses medications at times. Goal: Encourage resident to take medications however, staff will honor resident's right to refuse; The resident will have fewer episodes of unwanted behavior through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. -Focus: Cognition: [Resident #11] has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's. Goal: Staff will anticipate resident's needs, if she is unable to make them known. The resident will be able to communicate basic needs on a daily basis through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of a Psychotropic Medication Interdisciplinary Review, dated 6/05/2024, revealed, Patient presents with involuntary, sudden and frequent episodes of laughing and/or crying. The episodes are consistent with PBA [pseudobulbar affect], and typically occur out of proportion or incongruent to the underlying emotional state. ,[sic] trialing Nuedexta at this time. Documented in the DX (diagnoses) section was the following: 5: Pseudobulbar affect - start Nuedexta 20 mg (milligrams) qd (once a day) for 7 days then q (once) 12 hours when the medication comes for [vendor name] pharmacy. During an interview on 06/23/2024 at 12:12 PM Staff J, Certified Nursing Assistant (CNA) stated normally she crawls out of bed, but for the noise thing; she does it a lot. It is between a laugh and cry. She confirmed she has been doing this for a few months. Staff J stated she will ask Resident #11 if she is crying, but Resident #11 will say no I'm laughing. She will make the same noise all the time and you just ask her what is wrong. During an interview on 6/23/2024 starting at 1:00 PM Staff I, Licensed Practical Nurse (LPN) reviewed the June 2024 MAR for Resident #11. In reviewing the behavior monitoring she acknowledged the checkmarks entered, and stated, It doesn't drop open. She confirmed there were no orders for Nuedexta in Resident #11's record. She reviewed the progress notes for Resident #11 and confirmed there were no notes related to the outbursts of laughing or administration of Nuedexta. Staff I stated if you ask her if she is laughing, crying, hurting or in pain; she will answer appropriately and she will acknowledge if she is in pain. Staff I stated they do not know what triggers the laughing. She stated it was sporadic. During an interview on 6/23/2024 at 1:47 PM the DON explained the Nuedexta was coming from another pharmacy the facility doesn't use. She stated that it was her understanding they would start the medication once they received it. She confirmed there was no documentation of communication between the pharmacy and the facility to follow up on the status of the medication. In review of the MAR, she stated if there aren't any behaviors then there will just be a checkmark, and if there are behaviors it will have a number. The check mark means they are monitoring behaviors. If there are behaviors we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 27 of 35 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 06/24/2024 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 would notate it. It is how they put in the order. She acknowledged the physician order instructed the documentation should be a Y or N, or a Yes or No. On 6/23/2024 at 4:30 PM Resident #11 was observed in her wheelchair in the hall and having sporadic outbursts of laughing. Two staff members were with her and one was trying to straighten Resident #11's jacket. Resident #11 shouted, Don't touch me. The staff member stopped and walked away. Another staff member yelled from the other end of the hall asking what was wrong, and the staff member standing next to Resident #11 stated, She is just being [Resident #11]. Resident #11 continued with sporadic laughing outbursts. 3. Resident #14 was observed on 6/22/2024 at 9:50 AM in bed sleeping and received oxygen via a nasal cannula. Resident #14 was observed on 6/22/2024 at 11:52 AM in bed receiving oxygen via a nasal cannula. She stated she sleeps a lot and was not having any concern with her oxygen. Review of the admission Record for Resident #14 revealed a readmission date of 12/28/2023 and 4/09/2024 and an original admission date of 9/12/2023 with diagnoses to include depression. Review of the June 2024 MAR revealed: - Sertraline HCI Oral Tablet 50 MG - give 1 tablet by mouth one time a day for depression, start date of 4/13/2024. - Antidepressant: Monitor for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion. Type yes when adverse effects are present. Type No when adverse effects absent every shift for depression. Type yes if having adverse side effects, type no if no adverse side effects; start date of 4/10/2024. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. -BEHAVIORS - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present. Document number of times per shift every shift document yes for active behaviors this shift, no if not actively having behaviors this shift. Document type of behavior document number of times noted this shift.; start date of 12/29/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. Review of Resident #14's care plan, initiated 12/29/2023, revealed: Focus: [Resident #14] is at risk for potential adverse reactions to psychotropic medications r/t DX (Depression). Interventions included to observe for behaviors and report immediately, observe for s/s (signs/symptoms) of increased, (depression, anxiousness, sleeplessness) and report immediately to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 28 of 35 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 06/24/2024 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 nurse and MD (medical doctor) if needed, psych services to eval and treat per md order. Level of Harm - Minimal harm or potential for actual harm 4. Review of the Administration Record for Resident #64 revealed an admission date of 11/06/2023 with diagnoses to include other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions, bipolar disorder unspecified and bipolar disorder current episode depressed. Residents Affected - Few Review of the June 2024 MAR for Resident #64 revealed: - DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG - Give 1 capsule by mouth one time a day for depression; start date of 6/21/2024. - DULoxetine HCl Oral Capsule Delayed Release Particles 30 MG - Give 3 capsule by mouth one time a day for depression; start date 11/08/2023 and discontinued on 6/20/2024. - Depakote Oral Tablet Delayed Release 250 MG - Give 3 tablet by mouth at bedtime for mood disorder; start date of 6/06/2024. - Divalproex Sodium Oral Tablet Delayed Release 500 MG - Give 2 tablet by mouth at bedtime for mood disorder; start date 11/07/2023 and discontinued on 6/06/2024. - Sedative/Hypnotic Medication - Monitor or burning or tingling in hands/feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, weakness. Document: 'Y' if monitored and above observed. 'N' if monitored and none of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every day and night shift; start date of 11/07/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, and night shift was marked with a check mark and not a Y or N. - Behaviors - Monitor for: (1)itching, (2)picking at skin, (3)restless (agitation), (4)hitting,(5)increase in complaints, (6)biting, (7)kicking, (8)spitting, (9)cussing, (10)racial slurs, (11)elopement, (12)stealing, (13)delusions, (14)hallucinations, (15)psychosis, (16)aggression, (17)refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift; start date of 11/07/2023. For the month of June 2024 (6/01/2024 to 6/24/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. - Antidepressant: Monitor for adverse side effects: fatigue, drowsiness, insomnia, orthostatic hypotension, anticholinergic effects, extrapyramidal symptoms, and syndrome of inappropriate antidiuretic hormone secretion. Type yes when adverse effects are present. Type No when adverse effects absent every shift for depression. Type yes if having adverse side effects, type no if no adverse side effects; start date of 11/07/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. 5. Review of the medical record for Resident #24 revealed a readmission date of 11/20/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 29 of 35 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 06/24/2024 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 Resident #24's diagnoses included unspecified dementia, unspecified severity with other behavioral disturbance, Alzheimer's disease with late onset, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, vascular dementia moderate with other behavioral disturbance, major depressive disorder severe with psychotic symptoms, schizoaffective disorder, mood disorder due to known physiological condition with depressive features and paranoid schizophrenia. Residents Affected - Few Review of the June 2024 MAR revealed the following: - Citalopram Hydrobromide Tablet 10 MG Give 1 tablet by mouth one time a day for depression; start date of 5/09/2024. - Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 125 mg by mouth two times a day related to Mood Disorder Due To Known Physiological Condition With Depressive Features; start date of 4/29/2024. - busPIRone HCl Oral Tablet 7.5 MG (Buspirone HCl) Give 7.5 mg by mouth two times a day for anxiety; start date of 1/10/2024. - Aricept Tablet 10 MG (Donepezil HCl) Give 1 tablet by mouth one time a day for dementia; start date of 12/07/2023. - ABH Gel 2mg-25mg-2mg per 1 ml Apply one ml to wrist BID two times a day for Anxiety; start date of 7/19/2023. - Namenda Tablet 10 MG (Memantine HCl) Give 1 tablet by mouth two times a day for Dementia; start date of 4/19/2023. - BEHAVIORS - Monitor for: itching, picking at skin, restless (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document: Yes if any behaviors are observed, No if none present Document number of times per shift every shift, document yes for active behaviors this shift, no if not actively having behaviors this shift. document type of behavior document number of times noted this shift; start date of 4/18/2023. For the month of June 2024 (6/01/2024 to 6/24/2024) each day, evening and night shift was marked with a check mark and not a Yes or No. - Monitor resident for NEW onset Covid symptoms: (New Onset cough, New Onset Shortness of breath, New Onset Diarrhea) Document Y if new onset symptom is present or N if no new symptoms present every shift for Covid Monitor; Start date of 12/28/2023. For the month of June 2024 (6/01/2024 to 6/24/2024) each day, evening and night shift was marked with a check mark and not a Y or N. - Short of Breath - Did the Resident have shortness of breath? Every shift Answer Yes or No on the appropriate answer. EX = exertion, Ly=lying, Res=resting; start date of 04/18/2023. For the month of June 2024 (6/01/2024 to 6/22/2024) each day, evening and night shift was marked with a check mark and not a Y or N. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 30 of 35 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 06/24/2024 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 During an interview with on 6/24/2024 at 11:32 AM Staff C, LPN reviewed the process for behavior monitoring documentation in the MAR. She stated when you acknowledge; it should have supplementary information. During an interview on 6/24/2024 starting at 12:13 PM the DON stated she (Resident #24) has had medication changes due to her recent falls and psych is following her and confirmed interventions are reviewed and implemented. In review of the MAR and behavior monitoring she stated that it is the way the order was put in. It doesn't have the supplemental documentation. It wasn't put in correctly. A review of the facility policy titled, Use of Psychotropic Drugs, implemented 10/21/2022, revealed under the section titled Policy residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy also revealed under the section titled Policy Explanation and Compliance Guidelines, .12. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation routine and as needed, .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. Based on interview, observation and record review, the facility failed to ensure physician ordered psychotropic medications used on an as needed basis were limited to 14 days use for one (#273) of five residents sampled for unnecessary medication use, and failed to ensure behavior and side effect monitoring of psychotropic medication use was completed in accordance with physician orders for four (#11, #14, #24, and #64) of eight residents sampled for medication monitoring. Findings included: 1. A review of Resident #273's admission Record revealed Resident #273 was admitted to the facility on [DATE] with diagnoses of mood disorder and dementia. A review of Resident #273's physician orders revealed an order, dated 6/13/2024, for Lorazepam 0.5 milligrams (mg). Give 0.25 mg by mouth every 12 hours as needed (PRN) for agitation/anxiety. The order did not have an end date. An interview was conducted on 6/24/2024 at 11:52 AM with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated when a resident is admitted to the facility, the admitting nurse will review with resident's admission packet and review the discharge medication list. The nurse will enter the order into the electronic health record how they are written and the order will be reviewed with the resident's physician. Staff C, LPN also stated if a resident is ordered a psychotropic medication, a batch order is included for monitoring of side effects and behaviors related to the use of the medication. An interview was conducted on 6/24/2024 at 12:46 PM with the Director of Nursing (DON). The DON stated psychotropic medications used on an as-needed basis should be limited to 14 days. The DON reviewed Resident #273's physician orders and addressed the order for Lorazepam should be limited to 14 days. The DON stated if a resident still needs the psychotropic medication after the 14 day duration, it will be reviewed by the resident's physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 31 of 35 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 06/24/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility policy titled, Use of Psychotropic Drugs, implemented 10/21/2022, revealed under the section titled Policy residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy also revealed under the section titled Policy Explanation and Compliance Guidelines, PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days) or as physician prescribes. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Event ID: Facility ID: 106069 If continuation sheet Page 32 of 35 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 06/24/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, record review and observation, the facility failed to ensure the reach-in cooler was maintained in a sanitary manner in one of one kitchen. Residents Affected - Many Findings included: During an observation of the kitchen on 06/23/2024 at 9:38 a.m. the reach-in cooler was observed with a variety of food items to include: a container of prepared food covered with plastic wrap, an open carton of eggs, container of turkey, half a head of lettuce with plastic wrap, a cucumber with plastic wrap, a package of meat, a silver pan of corn with plastic wrap. In addition, the multiple white racks, in the reach-in cooler holding the food and containers, were observed to have the white coating peeling and exposing the brown rusted individual bars on each rack. There was also a brownish yellow staining collected on each rack. (Photographic Evidence Obtained) During an interview with the Dietary Director on 6/23/2024 at 11:11 a.m., she stated she knew the racks needed to be replaced and would like to replace the whole cooler. Additionally, she stated they use an on-line system for work orders but did not know when it was put in. During an interview with the Maintenance Director on 6/24/2024 at 3:44 p.m., he stated he had not received any work orders for the reach-in cooler. On 06/24/2024 a report listing the facility work orders was reviewed for the months of May 2024 and June 2024 and revealed the report was silent of work orders for the reach-in cooler. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 33 of 35 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 06/24/2024 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure the facility had an Infection Control Preventionist (ICP), who had specialized training in Infection Control and Prevention. Residents Affected - Many Findings included: An interview was conducted on 06/24/2024 at 11:29 PM with the Director of Nursing (DON). The DON stated she was in training to be the facility's ICP as well as Staff C, Licensed Practical Nurse (LPN), who was also in training. The DON confirmed neither herself nor Staff C had completed specialized training related to infection control and prevention. The DON also stated she and Staff C were assisted in their training by the Regional Nurse Consultant (RNC), who comes to the facility once a month. During an interview on 06/24/2024 at 1:53 PM, the Nursing Home Administrator (NHA) confirmed the previous ICP left in May 2024 and currently Staff C, LPN and the DON are in training with assistance from the RNC. Review of the policy titled, Infection Preventionist, dated 10/18/2022, showed: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. 2. The facility will ensure the Infection Preventionist (IP) is qualified by education, training, experience or certification. 6. The IP must be employed at least part-time . 8. The IP will physically work onsite in the facility. 10. The IP must have obtained specialized IPC [infection prevention and control] training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate(s) of completion or equivalent documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 34 of 35 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 06/24/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and observation, the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition in one of one kitchen. Residents Affected - Many Findings included: During an observation of the kitchen on 06/22/2024 at 9:44 a.m. the reach-in cooler had a wet towel under it and puddles of water were pooling from underneath and into the floor. In addition, the steam table was observed with wet towels and buckets on the lower shelf catching water dripping from the upper shelf that contained the food storage compartments. (Photographic Evidence Obtained) During an interview with Staff E, Dietary [NAME] on 6/22/2024 at 10:00 a.m., she stated, Yes, it leaks. I am not gonna lie. It has been a while. We put in a maintenance request. She also stated the drain was missing on the steam table, so they used buckets to catch the water. During an interview with the Dietary Director on 6/23/2024 at 9:40 a.m. she stated, The reach-in has been temporarily fixed by on-site maintenance, he is trying to fix it first. The steam table does not leak all the time. Maintenance is working on it too. During an interview with the Dietary Director on 06/23/2024 at 11:11 a.m. she stated they use an on-line system for work orders but did not know when it was put in. She stated, I know I had told them about the steam table. He has worked on it a few times. He is responsive to work orders, they work on it right away unless they need parts from an outside source. During an interview with the Maintenance Director on 6/24/2024 at 3:44 p.m., he stated he had not received any work orders for the reach-in cooler or the steam table. He also stated, I was told by the kitchen staff since you have been here; asking me to look at the reach in cooler. No one has mentioned the steam table. On 06/24/2024 a report listing the facility work orders was reviewed for the months of May 2024 and June 2024 and revealed the report was silent of work orders for the reach-in cooler or steam table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106069 If continuation sheet Page 35 of 35