Inspection·November 14, 2023

F 0609 device, dated 10/13/23. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Abuse Log 2023 did not show any reports had been filed related to Resident #4. On 10/13/23 at 9:30 a.m. the Nursing Home Administrator (NHA) confirmed the list of reported incidents was accurate. Residents Affected - Few A review of Resident #4's progress notes showed the following note dated 10/20/23 at 8:23 a.m. written by Staff D, LPN: [Electronic monitoring system] alarm activated @ emergency exit door outside of room [ROOM NUMBER] (to back parking lot 5:35 a.m.), resident observed near tiled patio ambulating toward back parking lot. Writer and staff CNA introduced selves, approached resident. Resident stated, I'm waiting for my [family name], she's coming to get me. Writer, and CNA encouraged resident to wait for [family member] inside in his room. Resident in agreement. Writer, and CNA escorted resident back inside building, and to bed. DON & [family member] advised. Resident placed on Q [every]15 min safety checks. 7-3 nurse advised of above. Resident remains as per baseline. [Electronic monitoring device] intact and functioning wnl [within normal limits] LT [left] wrist. A review of Resident #4's progress notes showed the following IDT (Interdisciplinary Team) note dated 10/20/23 at 9:05 a.m. written by the DON: IDT met to review incident this morning. Based on interview with staff members, [Resident #4] was found in the hallway by his room, walking towards the emergency exit. The Nurse rushed to get to him, however, the resident had pushed on the door activating alarm. Another staff member who was in the room adjacent to the door responded to the alarm approached the resident who stated, I am waiting for my [family member]. The two staff members were able to easily direct resident back to his room by approximately 5:45 a.m. Resident was placed on Q15 minute checks. A staff member was assigned to sit in the hallway with line of sight to the resident's room at 6:40 a.m. At approximately 8:35 a.m., resident's [family member] who was informed about the incident arrived and assumed responsibility for the safety of the resident. IDT met with the resident's [family members] and explained that the resident is expressing wishes to go home. Explained the resident's functional levels; which is supervision for all ADLs [activities of daily living] including ambulating indoors. Resident's [family members] agreed that he would do better at home and can provide the required supervision for him. Psychiatric consult was initiated and completed. Resident to DC [discharge] home with HH [home health]. An interview was conducted on 11/13/23 at 3:06 p.m. with the DON and the NHA. The NHA stated an elopement is when a confused resident goes out the door without anyone knowing about it. He said on 10/20/23 the DON spoke with the staff members regarding the situation with Resident #4. He said he did speak with Resident #4's family that morning. The NHA said the family told him the resident gets anxious when he doesn't see his family members and it was best if they took the resident home. The DON said an elopement is when someone leaves a safe area unsupervised to an area that could be potentially unsafe. The DON said on 10/20/23 she got statements via phone from Staff D, LPN and Staff E, CNA, since they were the only two staff members who responded to the alarm. The DON said the nurse called her and said Resident #4 exited one of the side doors. The DON said the nurse told her she was in a resident room when she heard an alarm and responded. She said the nurse told her she saw the resident at the door and the door opened and the resident went out. The DON said the CNA came out of a room and both the LPN and CNA could visualize the resident outside. The DON provided a typed statement from Staff D, LPN for review. The statement showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 2 of 8 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 11/14/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/20/23 at approximately 5:35 a.m. I was outside of room [ROOM NUMBER] preparing medications when I heard the alarm for the emergency exit by room [ROOM NUMBER]. I saw [Resident #4] at the door. I walked down the hallway toward him when the door released and opened and closed behind him before I could get to the door. [Staff E, CNA] came out of room [ROOM NUMBER], she and I were both at the door and could see [Resident #4] just outside the door approximately 5 feet away from the door still on the sidewalk. I never lost sight of him from the hallway. I just could not get to the door before it closed. I opened the door and went outside, upon approach I introduced myself and asked him to come back in the building. He told me he was waiting for his [family member]. I was able to redirect him back into the building and to his room where he would wait for her to arrive. He was placed on 15-minute safety checks. He remained in his room for the remainder of my shift. The statement was signed by the DON and the Assistant Director of Nursing (ADON.) Staff D, LPN did not sign the statement. An interview was conducted on 11/13/23 at 3:50 p.m. with Staff E, CNA. Staff E, CNA said on 10/20/23 she was changing a resident. She said she heard an alarm but didn't know which alarm it was. She said she went ahead and finished changing the resident then hurried out the door. She said the alarm was going off for probably 1-2 minutes at that point. She said when she came out of the resident room Staff D, LPN was walking to the back door. Staff E, CNA said when they opened the door, they could see Resident #4 outside. She said he turned and started walking towards them and they got him back inside easily. She said Resident #4 wanted to see his family member. An interview was conducted on 11/13/23 at 2:52 p.m. with the ADON. The ADON said she does staff training, and she teaches staff, As soon as they [residents] cross the outside door that is an elopement. She added if the resident opens an exit door and does not tell any staff then it is an elopement. The ADON said she didn't know exactly what happened with Resident #4 on 10/20/23. She said the DON did the investigating and statements. She said she thinks she was in the office when the DON talked to Staff D, LPN on the phone about Resident #4. She said she does not remember Staff D, LPN saying anything about being in the hallway and seeing the resident. The ADON said she thought the resident was already outside, but she doesn't remember the details. When asked if she signed the statement made by Staff D, LPN, she said I sign so many papers I don't know. A follow-up interview was conducted on 11/14/23 at 8:56 a.m. with Staff D, LPN. Staff D, LPN said she had just gotten off work and while she was there, she reviewed her note about Resident #4's elopement to make sure she had remembered the details correctly. She said while reviewing she also read the IDT note that was entered by the DON on 10/20/23 at 9:05 a.m. She stated the IDT note Is not what happened. Staff D, LPN said she never reported she was in the hall and saw the resident go to the door. She said she told the DON she was in the resident room when she heard the alarm going off. She said she never told anyone she was in the hall and saw the resident walking out. A follow-up interview was conducted on 11/14/23 at 12:45 p.m. with the NHA and the DON. The DON said she would normally get the person to sign their statement on an incident but I didn't follow back up with them to get them signed. The NHA said he noticed the note IDT wrote contradicted the note Staff D, LPN wrote on 10/20/23. He said he talked to the DON about following up with Staff D, LPN because what the IDT note said was not how the nurse explained the incident. The NHA said he never spoke with Staff D, LPN about what happened, the DON told him what the nurse said. He said he did not report the elopement because the DON said Staff D, LPN never lost sight of the resident. Review of a facility policy titled Elopement Risk & Missing Resident, undated, showed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 3 of 8 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 11/14/2023 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 0609 following: Level of Harm - Minimal harm or potential for actual harm Policy statement: The facility will implement measures to monitor residents at high risk for elopement while providing the most homelike environment possible. Residents Affected - Few Review of a facility policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of Unknown Origin (ANEMMI), reviewed 10/2022, showed the following: Standard: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property and mistreatment, collectively known and referred to as ANEMMI and hereafter defined, will not be tolerated by anyone, including staff, residents, volunteers, family members, legal guardians, resident representatives, friends, or any other individuals. The Health Center Administrator is responsible for assuring that Resident's Rights of personal privacy, confidentiality and dignity will be respected for all aspects of care and services and that resident safety, including freedom from risk of ANEMMI, holds the highest priority. Definitions: 2. NEGLECT: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when the facility is aware of or should have been aware of goods or service that a resident(s) requires but a facility fails to provide them, to the resident (s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Reporting and Response Policy: All allegations of possible ANEMMI will be immediately reported to the Abuse Hotline by the Administrator or Designee and will be evaluated to determine the direction of the investigation. Procedure: Any and all staff observing or hearing about such events must report the event immediately to the Administrator, Immediate Supervisor, AND one of the following: Directors of Nursing, ANEMMI Prevention Coordinator, or Risk Manager, so that appropriate reporting and investigation procedures take place immediately. It will also be reported to other officials in accordance with State and Federal Regulations. A. IMMEDIATE REPORT Ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 4 of 8 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 11/14/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. The ANEMMI Prevention Coordinator will also submit to The Agency for Health Care Administration (AHCA) Federal Immediate/5-day Report. Event ID: Facility ID: 106093 If continuation sheet Page 5 of 8 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 11/14/2023 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to implement an effective discharge planning process by not ensuring medical follow-up related to home health care was initiated for one resident (#1) of two residents sampled for discharge. Residents Affected - Few Findings included: A review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included fracture of right femur, history of falling, need for assistance with personal care, muscle weakness, and difficulty in walking. The record revealed Resident #1 was discharged from the facility on 10/07/2023. A review of the Minimum Data Set, dated [DATE], revealed a Brief Interview For Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of Resident #1's progress notes revealed the following: -9/25/2023 1:10 p.m. Discharge planning, SSD (Social Service Director) spoke with resident and [family member] to discuss discharge plan. Resident will return home alone. Resident will remain a FULL CODE. -10/3/2023 3:46 p.m. Communication with family, [Family member] and resident have appealed discharge, appeal packet sent to insurance vendor, Case ID [number]. -10/4/2023 10:24 a.m. Discharge Planning/Summary, Resident appealed discharge, if appeal not in her favor; Discharge plan is resident scheduled to be discharged home on Friday 10/06. Home Health Services will be set up through Home Health Vendor for PT(physical therapy)/OT (occupational therapy). DME (durable medical equipment) is a Wheelchair ordered via DME vendor. Resident informed to follow up with PCP (primary care provider). Resident's [Family member] will pick up. -10/5/2023 2:53 p.m. Care plan note, Care plan meeting held with IDT (interdisciplinary team) and [Family member]. Resident declined to attend. SSD: Resident remain a FULL CODE and discharge home with family. Family refused to sign care plan paperwork. She stated she has no concerns. -10/6/2023 3:44 p.m. Discharge planning/summary, SSD spoke with resident's [Family member] at her request, [family member] states she has decided to not wait the 14 days for the appeal process and will take resident home on [DATE]. SSD informed her that Home Health vendor will be providing home health, and I will have to notify them that resident will be discharging on 10/07/2023. Explained to [family member] that home health will not begin on tomorrow and will have to notify DME coming, and wheelchair will be delivered to residents home upon authorization from insurance vendor, [family member] expressed understanding. -10/6/2023 3:51 p.m. Skin/Wound, SSD contacted Home Health Vendor regarding, resident discharge, message left for Home Health to contact resident's [Family member]. -10/6/2023 3:56 p.m. Communication with family, SSD called DME vendor and spoke with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 6 of 8 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 11/14/2023 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Representative, states wheelchair will be scheduled for delivery on Monday 10/9/23 and will contact [family member] to inform her on delivery. An interview was conducted on 11/13/2023 at 4:19 p.m. with Staff A, Social Worker and Staff B, Social Worker. Staff B reported the resident was discharged home with a home health vendor. She reported she was unsure if the resident received home health services after discharge. She reported she typically does not call families after discharge to ensure that discharge was appropriate. Staff B reported the receptionist typically sends out a survey, but she does not see them. Staff B reported she contacted the Home Health Agency and set up care for discharge. Staff B confirmed she wrote the progress note dated 10/6/2023 at 3:51 p.m. and she contacted the Home Health vendor and left a message. She was unable to verbalize if the Home Health vendor received the message. Staff B reported she typically would not follow up if she does not hear back from the Home Health agency and if there is a problem the vendor will contact her. She reported the resident would also contact the vendor because they get the contact information at the time of discharge. A phone interview was conducted on 11/13/2023 at 4:29 p.m. with Staff C, Home Health Community Liaison. Staff A, and Staff B were present in conference room. Staff C stated they receive referrals by email or fax and once they get the referral, they run the resident's insurance. She stated on 10/4/2023 she received a fax to her office for anticipated services for Resident #1. Staff C reported the resident's insurance was run on 10/4/2023 and identified the resident's insurance was out of network and they could not accept the resident. She stated she communicated with [Staff B] on 10/4/2023 via email that the insurance was out of network, and they would be unable to accept the resident. An interview was conducted on 11/13/2023 at 4:34 p.m. with Staff B. She stated she did not remember or have documentation of an email from the Home Health vendor declining resident. An interview was conducted on 11/14/2023 at 1:45 p.m. with the Nursing Home Administrator (NHA). The NHA stated they did not have a discharge summary for Resident #1. He stated the discharge summary is the paperwork the resident signs at discharge. A review of the facility policy titled Transfer or Discharge, Preparing a Resident for, undated, revealed the following: Policy Statement: Residents will be prepared in advance for discharge. Policy Interpretation and Implementation: 1-Nursing services is responsible for: -a. Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment; -b. Preparing the discharge summary and post-discharge plan; -d. Providing the resident or representative (sponsor) with required documents (i.e., Discharge Summary and Plan); . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 7 of 8 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 11/14/2023 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 0745 A review of the Social Worker job description revealed the following: Level of Harm - Minimal harm or potential for actual harm Overview: Residents Affected - Few The social worker will work with residents in the nursing home by identifying their psychosocial, mental, and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs. Responsibilities: . -Coordinate the resident discharge planning process and make referrals for appropriate home care services prior to the resident's return to the community. --Social Services Director must maintain monthly resident discharge log of residents for the purpose of follow-up calls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 8 of 8