Inspection·February 4, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 2/1/22 at 2:16 p.m., revealed two (2) undated dressings, one tan-colored and one white-colored, attached to the right forearm of the Resident #294. The resident stated no she had not banged the arm as she looked at her left forearm. On 2/2/22 at 11:15 a.m., an observation of Resident #294 identified the two undated dressings continued to be attached to the residents right forearm, the tan-colored island dressing was located above the wrist and the white island dressing located between the tan dressing and the residents elbow. The observation also identified steri-strips were applied to the residents' left forearm. An observation, on 2/3/22 at 9:54 a.m., revealed the tan-colored dressing was not attached to the right forearm and the white-colored dressing had visual staining and continued to be undated. The observation and interview with the resident, on 2/4/22 at 11:03 a.m., revealed the right forearm did not have any dressings, the area had multiple skin tears without approximated edges, and the steri-strips were attached to the residents left forearm. The resident explained that she had gotten too close to the door frame. A review of Resident #294's physician orders, on 2/1/22 at 3:13 p.m., identified an order to cleanse left arm with Normal Saline, pat dry, apply Xeroform, cover with dry dressing every 3 days (q3days), every day shift every 3 days, dated 2/1/22 and to start on 2/2/22. The review of physician orders on 2/1/22 did not include physician orders related to the dressings observed on the resident's right forearm. The admission Data Collection, dated 1/28/22, identified tears to Resident #294's left antecubital. The admission Data did not identify any issue to the residents right forearm. The Skilled: Wound/Skin Assessment, dated 1/30/22 at 11:53 a.m., identified a skin tear to the residents left elbow, with no other skin issues. A review, on 2/4/22 at 10:42 a.m., of the Skin Check - Weekly or Other, dated 1/31/22 at 7:58 a.m., indicated the resident had a left arm skin tear treatment (tx) in place. The Skin Check - Weekly or Other, effective 1/31/22 at 7:58 a.m., identified a left arm skin tear with no new skin issues. A review of the Skilled: Medical Management Observation/Evaluations for Resident #294 identified: - Effective 2/1/22 at 3:00 p.m., No NEW Skin issues noted at this time and did not indicate that the resident suffered any other skin issues which included skin tear. - Effective 2/2/22 at 6:56 p.m., No NEW Skin issues noted at this time and did not indicate that the resident had any other skin issues which included skin tear. - Effective 2/3/22 at 2:47 p.m., No NEW Skin issues noted at this time and did not identify that the resident had any other skin issues including skin tear. The progress notes, indicated the following documentation: - 1/28/22 at 10:45 p.m., Resident was admitting via stretcher. The progress note did not identify that the resident had any skin issues. - 1/30/22 at 11:53 a.m., Late Entry Skilled: Wound/Skin note, did not include any further documentation. - 1/30/22 at 1:42 p.m., Skilled: Wound/Skin note, incorrect documentation. The note indicated this note was struck out at 11:57 a.m. on 2/4/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 2 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0684 Level of Harm - Minimal harm or potential for actual harm On 2/3/22 at 5:24 p.m., Staff Member J, Licensed Practical Nurse (LPN), stated she had changed the dressing on Resident #294's arm today and confirmed that the previous dressing was not dated. She stated the area on the right forearm was a skin tear that was unable to approximate the edges. The LPN reviewed the physician orders and confirmed the treatment was for the left arm and did not include an order for treatment for the right forearm. Residents Affected - Few During an interview on 2/4/22 at 8:22 a.m., the Director of Nursing (DON) stated she would expect documentation would describe how the Resident's skin conditions had happened and that the family and physician was notified. She stated if its not documented it wasn't done. The DON stated a dressing should be dated. A Situation, Background, Appearance, Review and Notify (SBAR) Summary note, dated 2/4/22 at 12:02 p.m., identified the Change in Condition (CIC) evaluation revealed a skin wound or ulcer. The nursing observations were Skin tear to right elbow/forearm area. Treatment order in place. The note indicated it was completed by the Assistant Director of Nursing and the Advanced Registered Nurse Practitioner (ARNP) was notified and a treatment (tx) order was in place. The SBAR evaluation, signed by the ADON, identified a skin wound or ulcer had occurred on Resident #294 on 2/3/22. The summarization of the SBAR identified Skin tear to right elbow/forearm area. Treatment order in place. The review and notify portion of the SBAR indicated the Primary Care Clinician was notified at 11:00 a.m. on 2/4/22 and the family of the resident was notified at the same time as the Primary Care Clinician. The Skin Check - Weekly or Other, effective 2/4/22 at 12:28 p.m., identified the following areas: - Vertebrae (upper-mid): scattered moles - Right elbow: 3 areas minor skin tears near outer elbow, 0.9 x 0.4 centimeter (cm), 2nd area - 2 outer below elbow, 0.5 x 0.4 cm, 3rd area 0.1 x 0.3 cm; no redness or drainage and no swollen treatment (tx) in place. - Left elbow: outer elbow dry skin; per patient psoriasis - Bilateral Lower Extremity (BLE) scattered bruises currently on blood thinner - right forearm scattered bruises The Order Summary Report, dated 2/4/22 at 12:21 p.m., included the following the physician orders: - Dated 2/4/22, Cleanse right arm skin tear with normal saline, pat dry. Apply Xeroform and cover with dry clean dressing every 2 days until resolved. May change as needed (prn) for dislodgement. As needed for dislodgement. - Dated 2/4/22, Start Date 2/5/22, Cleanse right arm skin tear with normal saline, pat dry. Apply Xeroform and cover with dry clean dressing every 2 days until resolved. May change as needed (prn) for dislodgement. Every day shift every 2 day(s) for Wound care. The care plan for Resident #294 indicated that the resident had impaired skin integrity which included a Left (L) antecubital skin tear which was resolved on 2/4/22 and a right forearm skin tear on 2/4/22. The interventions regarding the impaired skin integrity included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 3 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0684 - Administer skin treatment as ordered, initiated 1/31/22. Level of Harm - Minimal harm or potential for actual harm - Report any sign/symptom (s/s) skin breakdown to NP/wound team, initiated on 1/31/22. - Skin checks weekly and as indicated, initiated 1/31/22. Residents Affected - Few The DON reported, on 2/4/22 at 1:19 p.m., the skin tear to the residents' left arm was healed and the facility had determined that between the night shift on 1/31 and the day shift on 2/1/22 someone had put a dressing on the right forearm. The policy, Change in a Resident's Condition or Status, revised May 2017, identified Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The Interpretation included: - The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): b. discovery of injuries of an unknown source. - Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. - Unless otherwise instructed by the residnet, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. - the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a facility tour on 02/02/22 at 01:18p.m., Resident #69 was observed laying on her bed with a dressing noted on her right leg, dated 01/30/22. photographic evidence was obtained. A record review of Resident #69's physician orders on 02/2/22 showed Resident #69 did not have any orders for dressing change, or concerns documented related to the skin condition on the right shin. Review of an admission record printed on 02/03/22 showed Resident #69 was admitted to the facility on [DATE]. Resident #69 was admitted with diagnoses to include other fracture of upper and lower end of left fibula, subsequent encounter for closed fracture with routine healing, history of falling, type 2 diabetes, other idiopathic peripheral autonomic neuropathy, and generalized muscle weakness. A 5-day Minimum Data Set (MDS) dated [DATE] under section C, Cognitive patterns showed Resident #69 has a Brief Interview of Mental Status (BIMS) of 15, indicating intact cognition. Section G showed Resident #15 required extensive assistance with two + persons for activities of daily living. A care plan for Resident #69 with a revision date 01/18/22 showed a focus area indicating Resident # 69 was at risk for skin breakdown related to decreased mobility, anemia, and incontinence. Interventions included to administer skin treatment as ordered, complete [name of assessment] tool on admission and as indicated, report any signs and symptoms of skin breakdown to nurse practitioner or wound team, and to perform skin checks weekly, and as indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 4 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A second focus area in the care plan showed Resident #69 had impaired skin integrity issues with bruise to right upper extremities /left (RUE/L) shoulder. Interventions included to perform skin checks weekly and as indicated and to report any signs and symptoms of breakdown to the nurse practitioner or wound team. Review of Resident #69's most recent [name of assessment tool] scale for predicting pressure sores or risk assessment dated , 01/30/22 showed there were no apparent problems with friction and shear. A skilled medical management evaluation / observation note dated 01/30/22, scribed by Staff F, LPN showed no documented concerns related to Resident #69's right leg injuries. Review of Resident #69's skin assessments dated 01/08/22, 01/24/22, and 01/31/22 did not show any documentation related to the injury on the right leg or the reason for the dressing applied on the right shin. During a facility tour on 02/03/22 at 10:12 a.m., the same dressing was noted on Resident #69's right shin with the previously observed date, 01/30/22. Review of a medication administration record and treatment administration record for Resident #69 dated 01/01/22 - 01/31/22 showed no orders or treatment documentation related to the right leg injury. Review of a medication administration record and treatment administration record for Resident #69 dated 02/01/22 - 02/28/22 showed new orders to treat right lower leg every shift with a start date of 02/03/22. On 02/03/22 at 12:05 p.m. an interview was conducted with Resident #69. she was observed in her room, noted without the dressing previously observed on the right shin. An abrasion approximately 15 cm long was noted with dark scabbing, indicating a healing process. Resident #69 stated she has had the injury for a while, but she could not say how long. Resident #69 stated she thought she might have scratched herself with her left boot. Resident #69 stated a nurse had looked at it 3 or 4 days earlier, applied some ointment and applied a bandage. Resident #69 stated the same nurse had removed the dressing today, [02/03/22] to allow the wound to air. An interview was conducted with Staff F, RN on 02/03/22 at 12:22 p.m., Staff F stated she did not know if there were orders to treat the injury on Resident #69's right shin. Staff F confirmed there were no orders for treatment when she first applied the dressing on 01/30/22. Staff F stated she did not know what caused the injury. Staff F stated she did not report the incident and did not contact the physician per facility policy. Staff F stated she did not complete a skin assessment related to the injury. Staff F said, It's my fault. There was no order treat the right leg. Staff F stated an order had just been put in, to apply a topical cream, BLE (bilateral lower extremities) twice daily. On 02/03/22 at 12:30 p.m., a follow - up interview was conducted with the Director of Nursing (DON.) The DON stated she became aware in the morning that Resident #69 had received treatment without an order. The DON confirmed the injury was unknown and unreported. The DON stated the expectation would be to report the incident, notify the physician to obtain orders for skin prep. 02/03/22 12:35 p.m., an interview was conducted with Staff G, LPN, Unit Manager. Staff G stated she had educated the nurse involved related to providing care without an order. Staff G stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 5 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed Resident's #69 chart and there were no orders related to the right leg injury. Staff G stated their expectation is to notify family and the physician whenever there is an injury of unknown origin. Staff G stated they would investigate to try and figure out what caused the injury. Staff G stated she had spoken to the Advanced Registered Nurse Practitioner (ARNP), and she had stated to start skin prep and monitor. Staff G stated the resident did not know what had happened. Staff G stated she had reviewed the skin assessments since Resident #69's admission date of 01/07/22 and there was no indication of injury on her right leg. Staff G stated they conduct weekly skin checks per facility policy. Staff G said, someone should have caught the injury by now. It looked more than 7 days old. Staff G confirmed a skin assessment should have been documented and the physician should have been notified prior to treating the resident. A second review of physician orders for Resident #69 with a print date 02/03/22 at 12:40 p.m. showed new orders had been initiated to apply house cream to BLE (bilateral lower extremity) twice daily every day and evening, and to apply skin prep to the right lower extremity scab every shift. On 02/04/22 at 11:33 a.m., an interview was conducted with the DON and the Regional Nurse. The DON confirmed there were 3 skin checks documented, without indication of injury on right shin. The DON stated the nurse was completing a new skin assessment today [02/04/22]. The DON confirmed it should have been noted during the last assessment. The Regional nurse said, a skin assessment should have been completed when the injury was first noted, and the doctor should have been notified. A follow-up interview with the ARNP on 02/04/22 at 12:09 p.m. The ARNP stated the nurse should have called the doctor upon discovery of new skin conditions. The ARNP said, nurses should not treat a resident without orders. The physician should be notified first. The ARNP stated skin assessments should be completed per facility protocol weekly, and upon indication of new conditions. The ARNP stated she would expect to see documentation related to the injury or new skin concerns. Review of facility's nurse's meeting minutes dated 01/26/22 showed on-going concerns related to completion of weekly skin assessments. Review of a facility policy titled, Accidents and incidents - investigating and reporting, revised July 2017, showed all accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the administrator. (#2.) (b.) the nature of the injury / illness e.g., bruise shall be included on the report of incident or accident form. Review of a facility policy titled, Physician services, revised April 2013, showed the medical care of each resident is under the supervision of a licensed physician. (#1.) stated that the resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 6 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure weight variances were addressed for two (#4 and #40) out of thirty-eight sampled residents. Residents Affected - Few Findings included: Resident #4 was admitted on [DATE]. The admission Record for the resident identified diagnoses not limited to unspecified systolic (congestive) heart failure, unspecified viral hepatitis without hepatic coma, and hypertensive heart disease with heart failure. An observation and interview was conducted, on 2/3/22 at 12:57 p.m., with Resident #4. The resident reported a weight loss and that no one from the facility had talked to her about it. The resident stated, don't worry about it, I have enough. A review of Resident #4's Annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS Section K Swallowing/Nutritional Status indicated the resident weighed 152 pounds and a loss or gain of 5% or more in the last month and the loss or gain of 10% or more in the last 6 months was no or unknown. The review of Resident #4's AHCA form 3008, dated 1/15/21 indicated the resident weighed 83 kilogram (kg), 182.984 pounds (#). The electronic record included one NUTRITION - Dietary Profile that was completed on 1/19/21 and one NUTRITION -Comprehensive Assessment that was completed on 1/22/21. The documentation identified one Nutrition At Risk progress note on 3/10/21 that indicated the resident weighed 175# and was noted to have significant gain in 30 days. The record identified one Quarterly Nutrition Assessment, dated 4/27/21, had been completed for the resident. A Nutrition Full Assessment, dated 2/3/22 at 4:53 p.m., was in progress. The review of the clinical record for Resident #4 did not include any further nutritional assessments had been completed for the resident. A review of Resident #4's weights included the following: - 1/16/21, 187.0# struck out as incorrect documentation on 2/9/21. Struck out after the Dietary Profile dated on 1/19 and the Comprehensive assessment dated on 1/22/21. - 1/20/21, 160.8# (did not indicate type of scale used). - 1/27/21, 163.1# (did not indicate type of scale) - 2/3/21, 160# via hoyer lift - 2/9/21, 173.8# via wheelchair, indicated a 13.8# weight gain in 6 days. - 3/10/21, 175# via wheelchair - 4/28/21, 177# via wheelchair - 7/26/21, 168.5# via sitting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 7 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0692 - 8/1/21, 155.8# (did not indicate type of scale) - loss of 7.54% of body weight in 6 days. Level of Harm - Minimal harm or potential for actual harm - 9/6/21, 153.9# via wheelchair - 9/27/21, 186.0 via hoyer, struck out as incorrect documentation on 9/30/31. Residents Affected - Few - 10/27/21, 187.1# (did not indicate type of scale) - struck out as incorrect documentation on 10/28/21. - Weights taken on 9/27/21 and 10/27/21 were struck out as incorrect documentation without any weights retaken, identifying that no corrected weights had been obtained from 9/6 to 11/29/21. - 11/29/21, 152.7# via mechanical lift - 12/6/21, 182.6# via hoyer. Struck out as incorrect documentation on 12/9/21. No corrected weight was obtained on 12/9/21. - 12/27/21, 152.6# via wheelchair. - 1/3/22, 175.4# via wheelchair. Struck out as incorrect documentation on 1/13/22. No weight was obtained on 1/13/22. - 1/24/22, 151.2# via mechanical lift. - 1/27/22, 176.8# via mechanical lift. (gain of 25.6# in three days) - 1/31/22, 175.6# via mechanical lift. - 2/4/22 at 9:27 a.m., 176.4# via hoyer. An interview was conducted on 2/3/22 at 4:32 p.m., with the Director of Dietary - Dietician. The Dietician reported being at the facility since May 2021. She stated the aides (Certified Nursing Assistants, CNA) obtain weights and the nurses enter them into the computer. She reported running two reports weekly: monthly weights and weight variances. She stated at the beginning of the month she would look at 30-90 day and 6 month weights. The Dietician stated the weights are crazy, they are all over the place, reported weights are discussed during morning meetings, and one day a resident will weigh 150 pounds the next day (will weigh) 250. She stated if there are discrepancies she would ask for re-weighs. She stated she has attempted to address variances with weights and one time resident would be weighed with a Hoyer lift, the next time with a wheelchair scale. The Dietician stated an admission, quarterly, as needed, and annual nutritional assessments are done. She reported she has brought up the variances of weights at different meetings and has requested a weight meeting. The Dietician reviewed Resident #4's weights and stated the 25 pound weight gain in three days, from 1/24 to 1/27/22 was not realistic. She reported speaking with the previous Administrator, the Director of Nursing (DON), and during the nursing meetings regarding the discrepancies. She stated her expectation would be that the nurse entering the weights look at the previous weight before entering, obtain another weight if not realistic, and to use the same scale, if able. The Dietician reviewed the Nutritional Assessments for Resident #4 located in the clinical record and stated the ones available were old ones and after reviewing the clinical chart she was unable to locate any documentation that she had completed for the resident. She confirmed the last assessment completed for the resident was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 8 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/27/21, prior to her arrival to the facility. The Dietician stated she was going to do an annual assessment on the resident tomorrow. During an interview on 2/3/22 at 5:24 p.m. Staff Member J, Licensed Practical Nurse (LPN), reported that Certified Nursing Assistants (aides) and nurses weigh the residents and the nurses and concierges enter weights into the computer. The staff member stated she does look at previous weights and if there is a discrepancy, she has the resident re-weighed. The Director of Nursing reviewed the documented weights of Resident #4 on 2/4/22 at 8:15 a.m., and stated that a 25# weight gain in three days was not possible. She stated during the Standard of Care (SOC) meetings, the facility discusses weight changes, increase and/or decreases. She stated her expectation was that the residents be re-weighed and the physician be notified of the weight gain. A review of Resident #4's progress notes from 1/20 to 2/4/22 did not indicate that the physician was notified of the residents 25# weight gain. A review of the clinical record for Resident #4, on 2/4/22 indicated that the Dietician was not offered as an author, when attempting to filter results by author. An interview was conducted, on 2/4/22 at 1:27 p.m., with the Regional Director of Nursing (RDON), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON). The RDON stated the facility had an issue with the current Dietician and there was a discrepancy in the communication regarding weight changes. The DON stated prior to 2/4/22, nurses were entering weights into the record and that critical thinking was just not done. The ADON stated, on 2/4/22 at 1:50 p.m. the Advanced Registered Nurse Practitioner (ARNP) had been notified of Resident #4's weight discrepancies. She stated the Dietician had struck off weights on 9/30/21, 10/28/21, 12/9/21, and 1/13/22 and that the weights struck out by the Dietician were the correct weights. An interview was conducted, on 2/4/22 at 2:12 p.m., with Staff Member E, Corporate Registered Dietician (RD). The RD reviewed Resident #4's record and stated the reason that documentation could not be filtered by the Dietician's name was that she had not done any documentation for the resident. She confirmed the Nutritional Assessment was started on 2/3 and did not locate any further documentation from the Dietician. On 2/4/22 at 2:16 p.m., the Nursing Home Administrator stated the Dietician should be reviewing weights weekly and at 2:48 p.m., she reported being notified on Monday 1/31/22 of the residents weight change. The Care Plan for Resident #4 identified the resident was at an increased nutritional risk related to advanced age, altered nutrition related labs, heart disease, and hepatitis, 4/27: weight stable x 30, significant (sig) gain in 90 days, oral (po) intakes good, 7/22: no sig changes, good po intakes. The interventions related to the nutritional risk of the resident instructed staff to Monitor weight regularly per facility protocol and notify MD as indicated. Review of Resident #40's record revealed the resident was admitted to the facility on [DATE] with diagnosis that included Dysphasia, oral phase, Morbid obesity due to excess calories, Type 2 Diabetes Mellitus without complications, Anemia, Adult failure to thrive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 9 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0692 Level of Harm - Minimal harm or potential for actual harm Observations on 02/03/22 at 12:52 p.m. of Resident #40 revealed him sitting up in his bed with his midday meal on his over bed table. Interview with the resident at this time reported that his meal is good but he could eat more. The meal consisted of Kielbasa on a hot dog bun, au gratin potatoes, sauerkraut. Juice, and hot beverage. The resident reported he does not ask for more food because in his culture it cost to much money for extra food. Residents Affected - Few Review of the residents record revealed on 10/13/2021, the resident weighed 228.0 lbs. On 01/24/2022, the resident weighed 191.0 pounds which is a -16.23 % Loss. On 01/17/2022, the resident weighed 192.3 lbs. On 01/24/2022, the resident weighed 191 pounds which is a -0.68 % Loss. On 12/31/2021, the resident weighed 225.0 lbs. On 01/24/2022, the resident weighed 191 pounds which is a -15.11 % Loss. Review of the residents weights revealed the following: 12/31/21 225.0 lbs (Re-admission) 1/1/22 223.8 lbs a loss of 1.2 lbs 1/10/22 221.6 lbs an additional loss of 2.2 lbs 1/17/21 192.3 lbs an additional loss of 29.3 lbs 1/24/22 191.0 lbs an additional loss of 1.3 lbs The documentation indicated that the resident had a total loss of weight of 34.0 lbs since his re-admission on [DATE]. Interview on 02/04/22 at 09:30 a.m. with the residents spouse, she reported that her husband is always hungry even at home when he eats a big meal. She reported that as far as she knows he eats all his food and she brings him additional food from home. Interview on 02/04/22 at 01:38 p.m. with the Registered Nurse (RN), Assistant Director Of Nursing (DON), revealed if a resident is on weekly weights the weights are completed on Mondays by floor staff. If the aide reported there are changes in a residents weight the resident would be given a a re-weight by restorative staff and the re-weight would be sent to the Registered Dietician (RD). The ADON reported she would always send a email to the RD about the weight change. The ADON reported her expectation is that the RD should be checking weights. Phone Interview on 02/04/22 at 01:50 PM Staff D, covering RD revealed she, as of today, is the covering RD but has no access to previous RD notes and is not familiar with the residents in this facility. She reported typically if there is weight loss for any resident that it is addressed. in some way. Phone interview on 02/04/22 at 02:00 p.m. with Staff E, Regional Dietary Consultant, RD revealed she is assigned to this facility and conducts audits to determine how the assigned RD is completing the their tasks. She reported if the RD is not doing documentation recommendations are made to the RD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 10 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0692 Level of Harm - Minimal harm or potential for actual harm and that this information is sent to the Nursing Home Administrator (NHA). Staff E reported she completed the last audit in 12/21. She reported Resident #40's weights were reviewed on 2/1/22. She confirms follow up to a residents weight change should not wait for over a month to be reviewed. Staff E reported as soon as a weight change happens nursing is to do a re-weight to confirm the weight loss and the RD should initiate interventions right away. Residents Affected - Few Interview on 02/04/22 at 02:15 p.m. with the NHA revealed the RD should be reviewing for weights accordingly to plan if the person has orders for daily,weekly, monthly weights. She reported Resident #40 should have been reviewed a lot sooner than 2/1/22. The policy, Weight Assessment and Intervention, revised September 2008, identified The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The policy indicated the following: - 3. Any weight change of 5% of more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. - 4. The Dietitian will respond within 24 hours of receipt of written notification. - 5. The Dietitian will review the unit Weigh Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. - 2. The Dietitian will discuss undesired weight gain with the resident and/or family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 11 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed, and three errors were identified for three (#296, #295 and #69) of five residents observed. These errors constituted a 10.34% medication error rate. Residents Affected - Few Findings included: 1. On 2/2/22 at 12:18 p.m., an observation of medication administration with Staff Member Q, Licensed Practical Nurse (LPN), was conducted with Resident #296. The staff member was observed dispensing and administering the following medication: - Admelog Solostar insulin pen - 2 units. The staff member identified a blood glucose level of 170 was previously obtained for Resident #296. Staff Q applied a needle to the Solostar pen and dialed the pen to 2 units. As the staff member was walking to the residents room, holding the pen slightly perpendicular to the floor, she was observed turning the dosage selector again. The staff member stated she had to make sure the pen worked, she confirmed that she had primed the pen with the needle cap on. The manufacturer instructions, accessed at www.admelog.com/how-to-use-admelog, instructed users to Do a safety test. The instructions indicated users were to Select 2 units by turning the dose selector until the dose pointer is at the 2 mark. Press the injection button all the way in. The manufacturer identified that when insulin comes out of the needle tip, your pen in working correctly. The illustration indicated that the Solostar insulin pen was held upright with the needle pointing up as the injection button was pressed. The literature indicated the following: - If no insulin appears: --You may need to repeat this step up to 3 times before seeing insulin. - If no insulin comes out after the third time, the needle may be blocked. If this happens: -- change the needle (see Step 6 and Step 2), then repeat the safety test (Step 3). -- Do not use your pen if there is still no insulin coming out of the needle tip. Use a new pen. -- Do not use a syringe to remove insulin from your pen. - If you see air bubbles: -- You may see air bubbles in the insulin. This is normal, they will not harm you. On 2/4/22 at 8:28 a.m., the Director of Nursing stated insulin pens should be primed while the needle cap was off and held vertical. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 12 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 2. Level of Harm - Minimal harm or potential for actual harm On 2/2/22 at 12:43 p.m., Staff Member R, Licensed Practical Nurse (LPN) stated she would have to call the physician for two residents, which she pointed to a different hall on the unit. The Unit Manager assisted the staff member in calling the provider prior to the below observation and receiving okay to administer the late medications. Residents Affected - Few On 2/2/22 at 12:53 p.m., an observation of medication administration with Staff R, was conducted with Resident #295. The staff member was observed dispensing and administering the following medications that were due at 9:00 a.m.: - Omeprazole 20 milligram (mg) Delayed Release (DR) tablet - Calcium with Vitamin D 600 mg/10 microgram (mcg) tablet - Vitamin B12 500 mcg - 2 tablets - Cardizem 120 mg tablet - Eliquis 5 mg tablet - Finasteride 5 mg tablet - Furosemide 40 mg tablet - Metformin 1000 mg tablet - Potassium chloride micro 20 milliequilivalents (meq) Extended Release (ER) capsule - Vitamin B-6 25 mg tablet During the dispensing of the medications, Staff R removed 2 Lidocaine 4% topical patches from the cart then stated she would have to call pharmacy as the order was for 5%. The staff member was observed administering the above oral medications. The Order Summary Report identified the following orders: - Lidocaine cream 5% - Apply to back topically in the morning for pain, start date 1/22/22. - Aspercreme Lidocaine patch 4% - Apply to lower back topically every morning and at bedtime for chronic back pain, on in a.m., off at bedtime (hs), start date 2/4/22. The February Medication Administration Record for Resident #295 indicated that Lidocaine 5% cream was documented as 9 and the notes indicated the Lidocaine 5% cream was applied, at 12:29 p.m. on 2/2/22 to Resident #295's lower back by Staff R. 3. On 2/3/22 at 9:24 a.m., an observation of medication administration with Staff Member F, Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 13 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Nurse (RN), was conducted with Resident #69. The staff member was observed dispensing and administering the following medications: Level of Harm - Minimal harm or potential for actual harm - Ondansertron 4 milligram (mg) tablet Residents Affected - Few - Allopurinol 100 mg tablet - Amiodarone 200 mg tablet - Carvedilol 3.125 mg tablet - Docusate Sodium 100 mg softgel - Eliquis 5 mg tablet - Escitalopram 20 mg tablet - Folic Acid 1000 microgram (mcg) - Lisinopril 2.5 mg tablet - Pregabalin 50 mg capsule - Diclofenac 1% gel - Acetaminophen 325 mg 2 tablets Staff Member administered the oral medications and applied the Diclofenac gel to bilateral knees then administered the two tablets of Acetaminophen, per resident request. A review of Resident #69's Order Summary Report indicated that Diclofenac Sodium 1% gel was to be applied to left knee topically two times a day for apply 1 gram for pain. The policy, Specific Medication Administration Procedures, dated April 2018, indicated that, Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medications to each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 14 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to maintain the kitchen in a safe and sanitary manner related to ensuring equipment is maintained in a clean manner and free from debris, related to 3 of 4 (Kitchen, Fern Unit, TCU Unit) ice machines, dish machine, and kitchen walls. Findings included: During an initial tour of the kitchen on 02/01/22 at 10:40 a.m. revealed the following: -The kitchen housed a large free standing Ice machine. Inspection of the the interior of the ice machine revealed there was a black substance noted on the plastic dispensing rim. -Debris was noted on top of the dish machine and its surrounding area. -Black substance was noted on backsplash behind the dish machine table. Observation of the kitchen 02/03/22 at 08:06 a.m. of the morning meal tray line revealed the following: -The kitchen housed a large free standing Ice machine. Inspection of the the interior of the ice machine revealed there was a black substance noted on the plastic dispensing rim. (Photographic Evidence Obtained) -Debris was noted on top of the dish machine and its surrounding area. (Photographic Evidence Obtained) -Black substance was noted on backsplash behind the dish machine table.(Photographic Evidence Obtained) Tour of the kitchen 02/03/22 at 11:15 AM with the Certified Dietary Manager confirmed there was debris on top of the dish machine and its surroundings, there was a black substance on the backsplash behind the dish machine, and a black substance was noted on the interior of the ice machine on the plastic dispenser. Tour of the nourishment rooms on 02/03/22 at 11:30 AM revealed the ice/water dispensers located on Lake Fern Unit and TCU Unit were noted to have a white substance coating ice/water dispensing spouts and the catch trays. (Photographic Evidence Obtained) Interview with the CDM revealed she will address the issues right away and include maintenance in the areas that they address. Review of the facility policy titled Sanitization with an effective date of 1/15/2021 revealed the following: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 15 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 16 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 related to: 1) not ensuring 2 staff members (K and P) disposed of Personal Protective Equipment (PPE) in the recommended manner when exiting one of nine rooms on the COVID positive unit and one (#179) of rooms where two resident (#282 and #289) were under Enhanced Barrier Precautions for COVID-19 and 2) not ensuring one staff members (N) complied with the wearing of required PPE when entering one (#177) out of thirteen rooms posted for Enhanced Barrier precautions. Residents Affected - Some Findings included: An observation, on 2/1/22 at 11:05 a.m., was made of Staff Member K, Licensed Practical Nurse (LPN), in the hallway of the COVID positive unit, which housed nine positive residents, rolling up a yellow disposable gown and threw it away in the trash can located in the hallway. Staff Member L, Certified Nursing Assistant (CNA) stated, at the time of the observation, that staff do not wear gowns in the hallway of the unit but do wear a N95 mask and face shield. The hallway had multiple trash receptacles outside of the resident rooms. During observations, on 2/3/22 that began at 9:13 a.m., multiple swing-top and foot-controlled trash receptacles were observed on two units (rooms 122-134 and rooms 174-184) in the hallways. The observations revealed that the receptacles contained unfolded disposable yellow and blue isolation gowns. On 2/3/22 between 9:15 and 9:43 a.m., rooms 123, 124, 125, 127, 128, 129, 130, 131, 132, 174, 177, 178, and 179 was posted for staff to observe Enhanced Barrier precautions while caring for residents in High-Contact Resident Care Activities. Photos obtained. On 2/3/22 at 9:56 a.m., Staff Member P, CNA, stated that she does remove isolation gowns in the hallway. The staff member donned a yellow disposable gown and entered room [ROOM NUMBER] that was posted for staff to adhere to Enhanced Barrier precautions. Staff P was observed, at 10:10 a.m. on 2/3/22, came out of room [ROOM NUMBER], wearing the yellow disposable gown and after removing the gown disposed of it in the trash receptacle outside the doorway in the hallway. On 2/1/22 Staff Member N, Physical Therapy Assistant (PTA) was observed propelling Resident #286 into the residents' room which was posted for Enhanced Precautions, then at 11:25 a.m. on 2/1/22, the staff member was observed standing in front of an over-the-bed table with #286 on the other side of the table. The PTA was observed assisting the resident with opening a soda bottle. Staff Member M, Registered Nurse (RN) observed the PTA inside the room without wearing Personal Protective Equipment (PPE) and stated that the PTA was supposed to have a gown on. Staff M asked Staff N to come to the doorway and explained to her that she needed to be wearing a gown, face shield, and N95 while in the room. Staff N exited the room and confirmed that she should have been wearing a gown while assisting the resident. On 2/4/22 at 11:59 a.m., the Infection Control Preventionist (ICP) stated that disposing of Personal Protective Equipment (PPE) outside of rooms posted with Enhanced Barrier and Special Droplet/Contact precautions was inappropriate. The ICP observed and confirmed that trash receptacles in the hallways outside rooms posted with Enhanced precautions, she stated she would be putting them into the rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 17 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The Centers of Disease Control and Prevention (CDC) described the doffing of PPE, as: Level of Harm - Minimal harm or potential for actual harm 1. Remove gloves. 2. Remove gown. Residents Affected - Some 3. Health Care Personnel may now exit patient room. 4. Perform hand hygiene. 5. Remove face shield or goggles. 6. Remove and discard respirator (or facemask if used instead of respirator). 7. Perform hand hygiene after removing the respirator/facemask. This information was located at: (https://www.cdc.gov/coronavirus/2019-cov/downloads/A_FS_HCP_COVID19_PPE.pdf). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 18 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify residents, resident representatives, and staff members of the positive COVID-19 test results in a timely manner. Residents Affected - Some Findings included: During an interview, on 2/3/22 at 12:57 p.m., Resident #4 reported that she had not been notified when a resident or staff member had tested positive for COVID-19. The Annual Minimum Data Set, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition. The admission Record for Resident #4 indicated the resident was own responsible party and did have a health care surrogate. An observation on 2/1/22 at 11:05 a.m., identified nine residents who had tested positive for COVID-19. The listing of positive COVID-19 staff members and residents identified the following: - 3 staff members tested positive on 1/15/22. - 1 staff member tested positive on 1/28/22. The facility provided January notifications which indicated that after staff members had tested positive on 1/15/22, Families notified via sign postage and phone calls on 1/17/22. The staff were notified on 1/17/22 via posted signage. The listing of notifications identified that after one staff member had tested positive on 1/28/22, families were notified via [electronic messaging system] on 2/1/22 and staff were notified via posted signage. The facility identified that the Nursing Home Administrator, (NHA) was responsible for notifying all residents, representatives, and families of confirmed or suspected COVID-19 cases in the Center. On 2/4/22 at 11:27 a.m., the electronic notifications of COVID-19 were received from the NHA with a note attached that read Families - *sent via [electronic messaging system]. New NHA received access after 1/31, prior posted in facility. The copy of notification for staff, dated 2/4/22, indicated *posted @ time clock. The NHA stated that there had been a posting in the lobby prior to her getting access to the electronic notification and notification was posted at the time clock for staff members. The NHA stated the facility also called families by using a list and checking off names. The NHA did not provide lists of checked off names of those notified. On 2/4/22 at 12:49 p.m., an observation was made with the Infection Control Preventionist of the staff posting of COVID positive results at the time clock. The notification was posted on a bulletin board across from the time clock amongst testing information, COVID vaccine information, and candidate referral information. The policy, procedure, and information regarding COVID-19, effective 1/1/20, identified that All facilities will follow the directives of local, state, and federal guidelines for COVID-19 reporting and testing (facilities in their respective states). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 19 of 20 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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 observations, record review and interview the facility failed to maintain its kitchen equipment in a safe operating condition, related to a 6 burner stove. Residents Affected - Some Findings included: Observations during the initial tour of the facilities kitchen on 02/01/22 at 10:40 AM revealed that the kitchen housed a 6 burner stove which was located in the center of the kitchen. Inspection of the stove with Staff A, cook, and Staff B, Certified Dietary Manager (CDM) present revealed that the right front burner did not light when the knob was placed to the on position. The cook was noted to light a piece of paper towel from a lit burner and light the front right burner with the lit paper towel. Observations of the 6 burner stove during the comprehensive tour of the kitchen on 02/03/22 at 08:06 AM revealed that pilot light on the top left burner and the bottom right burner were out. Attempts of Staff A:, cook lighting the burners by turning on the knobs were unsuccessful. Interview with the CDM on 02/03/22 at 11:15 AM revealed that she will address the issues right away and include maintenance in the areas that they address. Review of the daily inspection checklist from 1/23/22 to 2/5/22 revealed no entries that would indicate that the burners on the stove had been checked and/or serviced to ensure appropriate functioning. Review of the facility policy titled Sanitization with an effective date of 1/15/2021 revealed the following: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 20 of 20