Inspection·May 7, 2025

F 0656 4/29/2025 and Target Date: 7/28/2025. Level of Harm - Minimal harm or potential for actual harm Interventions initiated on 4/29/25 included - Encourage and assist resident to use bed in the lowest position as tolerated. Encourage and remind resident to use call bell and to wait for staff assistance with transfers, ambulation, toileting, etc. as indicated. Encourage and assist the resident to wear appropriate footwear such as rubber-soled shoes, non-slip bedroom slippers, non-skid socks, etc. when ambulating, transferring, or mobilizing in w/c. Physical and Occupational therapy consult as needed. Residents Affected - Few The review showed the resident's care plan was not updated/revised following the fall with injury on 5/5/25. On 5/7/25 at 12:06 p.m. an interview was conducted with Staff F, Certified Nursing Assistant (CNA). She stated the resident was positioned outside his room so she can easily monitor him and four other residents observed nearby. She stated the resident was normally confused but he can be aware of his surroundings sometimes. She stated he fell 2 days ago, had some skin tears and stated he must have hit his head. She stated he was taken out to the hospital. Staff F stated Resident #21 was slowly getting back to self. Staff F, CNA stated the resident was assisted with all ADLs, and all transfers and was dependent on staff. On 5/7/25 at 12:10 p.m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN) assigned to the resident. She stated she was not at the facility when the resident fell. She stated they were supposed to be monitoring him closely. She stated most of the time this resident was confused and did not know where he was or what the time was. She stated he required close supervision all the time. Staff E stated when a resident falls, the nurse completes the Change in Condition evaluation and a post fall assessment. She stated the care plan should be updated if there were new interventions. During an interview on 5/7/25 at 11:29 a.m. with the DON and the Regional Nurse Consultant (RNC), the RNC stated Resident #21 was observed on the right side of the bed on the floor. He stated the resident had a forehead laceration and skin tear. He stated the fall was not witnessed. He said, He was found on the floor, there was blood from a laceration on his forehead. He was sent out. During this interview and record review, the DON confirmed the resident fell on 5/5/25 and a CIC was initiated and not completed. She reviewed the resident's record and stated, It should have been completed fully. She stated the resident had an injury, a hematoma to the face, and was found on the floor. Review of the care plan with the DON and the RNC revealed there were no post fall interventions. The DON stated she just updated the care plan. She stated it should have been updated in timely manner. Review of a facility policy titled, Standards and guidelines: Falls - Managing, preventing and documentation, dated 1/2024 showed, a standard - based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Guideline - The residents plan of care will be developed and followed accordingly to prevent or minimize the risk of falls or fall related injuries Under Resident-Centered Approaches to Managing Falls and Fall Risk, the policy showed: - The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 2 of 19 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 05/07/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm - If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). - Examples of initial approaches might include bed in lowest position, call light in reach, improving footwear, changing the lighting, etc. Residents Affected - Few - If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. - If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or until the reason for the continuation of the falling is identified as unavoidable. - Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. - The facility is a restraint free environment. Meaning, bed alarms, chair alarms, side rails solely for fall prevention, and chemical interventions for fall prevention are not utilized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 3 of 19 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 05/07/2025 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure wound care orders were put in place and completed timely for one resident (#1) and did not ensure medications were administered appropriately for two residents (#10 and #22) out of twenty-two sampled residents. Residents Affected - Few Findings included: 1. Review of admission Record showed Resident #1 was admitted on [DATE] with diagnoses including hereditary and idiopathic neuropathy, chronic pain syndrome, morbid obesity, and primary generalized (osteo)arthritis. Review of Resident #1's Weekly Skin checks showed resident had clear skin on 4/9/25. The Weekly Skin check on 4/16/25 documented Left toe-open ulcer with current treatment in place. Review of Resident #1's physician orders showed an order for Mupirocin External Ointment 2%. Apply to left 2nd toe topically every day shift for rash. Start date 2/19/25. Discontinued 4/29/25. Review of Resident #1's provider notes showed the resident went to an outside foot specialist on 4/8/25. The Assessment/Plan showed Ulcer of left foot- Dressing changes daily, Dakin's moist/dry dressing left 2nd toe and Cellulitis of left food-Dakins solution 0.25%. 1 application every day by miscell. For 30 days. The doctor noted Dakin's Solution 0.25% 1 application every day by miscell for 30 days as prescribed. Review of Resident #1's physician orders showed the orders from the outside foot specialist were not put in place. Further review of Resident #1's provider notes showed the resident returned to the outside foot specialist on 4/22/25. The Assessment/Plan showed Ulcer of left foot- Dressing changes daily, Dakin's moist/dry dressing left 2nd toe. MRI of foot without contract. Review of Resident #1's physician orders showed the order for Apply Dakins moist/dry dressing to left 2nd toe daily. Every day shift for ulcer left 2nd toe. Started 4/23/25. Discontinued 4/28/25 Review of Resident #1's April 2025 Treatment Administration Record (TAR) showed this order was not completed on 4/23, 4/25, and 4/28/25. On 4/26 and 4/27/25 it was documented as 9, Other/See Nurse Notes. The progress notes for those day showed cleansed documented. Review of Resident #1's physician orders showed the wound care order was changed on 4/28/25 to Cleanse left 2nd toe with normal saline, gently pat dry, soak gauze with Dakins (1/4) strength solution, apply soaked gauze to toe wound, cover with dry gauze, wrap with rolled gauze, secure with tape. Change daily on 7-3 shift and PRN (as needed) if dressing becomes soiled or dislodged. May use normal saline for wet-to-dry dressing if Dakins is not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 4 of 19 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 05/07/2025 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 An interview was conducted on 5/6/25 at 10:40 a.m. with the Minimum Data Set (MDS) Director who was observed on the 200 unit and stated she helped with nursing tasks when needed. She reviewed Resident #1's medical record and confirmed there were no wound care orders put into place until 4/23/25 for the 2nd left toe. She said the doctor should have been notified when the skin check was completed on 4/9/25 showing the open ulcer because no treatment orders were in place. Residents Affected - Few An interview was conducted on 5/6/25 at 11:20 a.m. with the Director of Nursing (DON). She reviewed Resident #1's weekly skin checks, progress notes, and orders. She confirmed the order for Mupirocin External Ointment 2%. Apply to left 2nd toe topically every day shift for rash would not be considered wound care orders for an open ulcer on the left 2nd toe. The DON said she did not see any progress notes documenting a provider was notified. An interview was conducted on 5/7/25 at 12:48 p.m. with Staff D, Licensed Practical Nurse (LPN). She said when a resident goes to an outside provider, they sometimes come back with paperwork and the nurse will put new orders in. She said if the resident does not have paperwork, they will ask any family that may have accompanied the resident or they will call the provider to get orders and the nurse will enter them into he medical record. A follow-up interview was conducted on 5/7/25 at 1:00 p.m. with the DON. She said when a resident goes to an outside provider they typically come back with paperwork with new orders. She said if they do not, medical records will call and follow-up. The DON reviewed the provider's notes for Resident #1's visit to the foot specialist on 4/8/25. She said she had not seen the notes until 5/6/25. The DON stated someone must not have followed up. She confirmed the wound care orders were not put in place until 4/23/25 after the resident had a second visit to the foot specialist. An interview was conducted on 5/7/25 at 11:17 p.m. with the Nursing Home Administration (NHA). The NHA said she was the risk manager and looked at concerns related to Resident #1's wound care. She said on the weekend of 4/26-4/27/25 the nurse did not use Dakins solution because it was locked in the wound care office. She said she was under the impression a provider was called to change the order. The NHA reviewed Resident #1's medical record and confirmed the call and change in orders was not completed until 4/29/25. The NHA was unaware of the outside foot specialist orders from 4/9/25. Review of a facility policy titled Clean Dressing Changes, revised 1/2024, showed: Standard: the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Procedure: 1. Verify that there is a physician's order for this procedure period (Note: this may be generated from a facility protocol.) 2. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. . 9. Document completion of procedure in the resident record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 5 of 19 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 05/07/2025 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 10. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. Reporting: Residents Affected - Few Notify the supervisor if the resident refuses the dressing change. Report other information in accordance with facility policy and professional standards of practice. 2. Review of Resident #10's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include insomnia, aftercare following joint replacement surgery, and anxiety disorder. Review of the Resident #10's January 2025 Medication Administration Record (MAR) revealed the following orders: Zolpidem Tartrate Oral Tablet 10 MG (Zolpidem Tartrate), Give 1 tablet by mouth at bedtime for Insomnia. oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl), Give 1 tablet by mouth every 4 hours as needed for Pain Review of the January 2025 MAR revealed the sleep medication Zolpidem Tartrate was marked with a chart code of 9 on 01/18/25, 01/19/25, 01/20/25 and 01/21/25; marked as given on 01/22/25; marked with the cart code 5 on 01/23/25. The chart code 9 is defined as Other/See nurses notes. And 5 is defined as Hold/see nurses notes. Review of resident #10's MAR for January 2025 revelaed there were no nurses notes related to this medication, indicating the medication was not given. Further review of the January 2025 MAR revealed the pain medication oxycodone was not given on 01/18/25 or on 01/20/25 3 An observation and interview was conducted with Resident #22 on 05/07/25 at 12:35 p.m. Resident #22 was observed lying in bed dressed in day clothes. Resident stated she almost left this morning because she could not get her pain medications, and this is not the first time. She stated it has been going on since she got here on 05/02/25. She stated they do not give her pain medications when she requests them. She requests them every day. She stated I was in so much pain I was sick to my stomach; I get a different excuse each time I ask for pain medication. She stated it is something different each time such as we don't have it, or it's on order, the pharmacy has to bring it, and we're still waiting for it She stated it has been horrible since she got here and she has gotten her pain medication so sporadically that her pain is not controlled. She stated pain management was in this morning, and she has now gotten her medications, so she feels okay currently but is very upset. She went on to state she chose to come here for recovery and feels like she can't because she is in so much pain. She stated she just wishes she could get her pain medications on time. A review of Resident #22's admission Record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses to include infection and inflammatory reaction due to internal right hip prosthesis, abscess of bursa, right hip, unspecified mononeuropathy of bilateral lower limbs, generalized anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 6 of 19 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 05/07/2025 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 A review of Resident #22's most recent Brief Interview of Mental Status (BIMS) showed a score of 15 indicating she is cognitively intact. Level of Harm - Minimal harm or potential for actual harm A Review of Resident #22's Order Summary Report revealed the following orders: Residents Affected - Few - OxyCODONE HCl Tablet 15 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain - Lyrica Capsule 150 MG (Pregabalin) Give 1 capsule by mouth two times a day for Neuropathy A Review of the May 2025 MAR revealed the medication Lyrica was not given twice on 05/03/25, twice on 05/04/25, and once on 05/05/25. On 05/03/25 it was marked with 12 indicating the medication was on order from the pharmacy/MD [Medical Doctor] aware. On 05/04/25 it was marked with 5 indicating hold/see nurses notes Review of resident #22's MAR for MAY 2025 revelaed there were notes were found in the medical record to indicate the medical doctor was aware. Further review of of the May 2025 MAR showed the medication oxycodone was not given on 05/02/25, and 05/04/25. On 05/07/25 at 12:43 p.m. an interview with Staff E, Licensed Practical Nurse (LPN) was conducted. She stated when a resident is admitted , once we reconcile the medications the pharmacy will bring them. It depends on when the resident arrives. She went on to state if there is a medication such as pain medication like oxycodone, we have an Emergency Drug Kit (EDK) that we can pull from if we have the order or prescription for the medication. If we cannot get a medication for a resident such as a medication prescribed for pain, we would call the doctor. On 05/07/25 at 3:40 p.m. an interview with the Director of Nursing (DON) was conducted. She stated if a resident is prescribed pain medication it would not be appropriate for the resident to not get the medication. A review of policy titled Standards and Guidelines: Medication Administration with a revision date of 01/2024 revealed the following: Policy: Standard: Medications are ordered and administered safely and as prescribed. Procedure: 3. Medications are administered in accordance with prescriber orders . 16. If a drug is withheld .the individual administering the medication shall document the rational in the resident's medical record and notify the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 7 of 19 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 05/07/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure continuous oxygen therapy was provided in consistent with professional standards of practice, related to failure to ensure the resident's record included accurate and active physician orders and on-going assessment of the resident's respiratory status and response to oxygen therapy, for two (#18 and #12) of two residents reviewed, resulting in Resident #18 experiencing respiratory distress requiring emergency hospitalization. Residents Affected - Few Findings included: 1. Review of the admission record showed Resident #18 was originally admitted to the facility 2/22/24 and readmitted on [DATE] with diagnoses of acute bronchiolitis due to respiratory syncytial virus, acute chronic respiratory failure with hypoxia, and Chronic obstructive pulmonary disease (COPD). Review of a hospital History and Physicals for Resident #18 dated 5/5/25 revealed under history of presenting complaint, This is an [AGE] year-old male resident of an extended care facility with a history of COPD, congestive heart failure, chronic kidney disease, atrial fibrillation. He was brought to the emergency room with complaints of increased shortness of breath. At the time the EMS [Emergency Medical Services] got the patient 02 [oxygen] saturation was 82% on 2 L[liters] of nasal cannula oxygen. The patient was placed on nonrebreather mask and brought to the emergency room for further evaluation. In the emergency room, the patient transitioned to BiPAP [Bilevel Positive Airway Pressure]. This morning, he is currently doing better and placed back on nasal cannula oxygen, feeling much better compared to when he came to the hospital. The consultation showed, EMS responded to a call at the patient's rehabilitation facility, where they found the patient in distress with an oxygen saturation of 82% on 2L via a non-rebreather mask.The patient reported a decreased appetite over the past few days, with occasional nausea that has since resolved. He is currently on apixaban and furosemide for anticoagulation therapy. Chest x-ray shows central pulmonary vascular congestion, as well as right-sided small pleural effusion. He was started on IV [Intravenous] antibiotics and IV diuretics in the ER [Emergency Room]and was subsequently admitted to the ICU [Intensive Care Unit] for further management. Further review under medical decision making showed, the patient will be admitted for acute hypoxic respiratory distress. VBG [venous blood gas] in the ED [Emergency Department] shows hypercapnia [too much carbon dioxide (CO2) in the bloodstream]. Patient started on BiPAP to help blow off CO2. However, patient with worsening repeat measurements and becoming more sedated. Discussed with patient's power of attorney/who is his [family member]. Confirms that patient is a DNR [Do Not Resuscitate]/DNI [Do Not Intubate]. Will admit to ICU [intensive Care Unit], maximize supportive care. Started on IV antibiotics and IV diuretics. IV diuretics dosage carefully chosen due to history of hypotension requiring midodrine for Vaso [blood vessels] support. Family is not opposed to palliative care consult. On 5/7/25 at 12:23 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She stated she sent Resident #18 to the hospital on 5/5/25 because his oxygen saturations were low. She stated a CNA (Certified Nursing Assistant) was trying to transfer him from the bed when he gave out. She said, he was not himself, I called for him, he did not answer, he had a lethargic look, eyes fixed and not moving, I tried to arouse him. He was not responding. Staff D, LPN stated she asked the CNA to stay with him, and she went to get help. She stated another staff member got the DON (Director of Nursing) and the cart. Staff D, LPN stated, I continued to call him, and he did not respond, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 8 of 19 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 05/07/2025 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 0695 he was disoriented. Staff D, LPN stated Resident #18 was supposed to be on oxygen all the time, had compromised breathing, and had a similar episode before. Level of Harm - Actual harm Residents Affected - Few Review of active physician orders for Resident #18 showed an oxygen order dated 3/28/25, O2 (oxygen) at 3L (liters) NC (nasal cannula). The order was noted verbally received. The order did not show scheduling or order administration scheduling details. Review of a Hospital Transfer Form dated 5/5/25 showed under respiratory treatments, the resident received O2 at 2L/Min (minute), Chronic. Review of an SBAR (Situation Background Assessment and Recommendation) form dated 5/5/25 showed the Change In Condition (CIC) reported on this CIC Evaluation are/were: Seems different than usual Tired, Weak, Confused, or Drowsy. Since this started it has gotten: Worse. At the time of evaluation resident/patient vital signs, weight and blood sugar were:- Blood Pressure: BP 142/60 - 5/5/2025 14:45 Position: Lying l/arm - Pulse: P 75 - 5/5/2025 14:45 Pulse Type: Regular - RR: R 19.0 - 5/5/2025 15:16 Temp: T 98.0 - 5/5/2025 15:16 Route: Forehead (non-contact) - Pulse Oximetry: O2 88 % - 5/5/2025 14:45 Method: Oxygen via Nasal Cannula. The mental status evaluation showed increased confusion and disorientation. Functional status evaluation showed general weakness. Review of the notification section showed the Primary Care Physician (PCP) was notified with orders to send to ER (Emergency Room). Review of a physician encounter progress note dated 4/7/25 showed the Reason for Appointment: Cardiac Consultation. Chief Complaint / Nature of Presenting Problem: Cardiovascular disease management during admission for rehab. History Of Present Illness: . [Resident # 18] was admitted to the facility on [DATE] for COPD exacerbation with PNA (pneumonia) 2/2 (Secondary to) RSV (Respiratory Syncytial Virus). Today, patient is lying bed. He says he is doing ok. He voiced no concerning cardiovascular complaints. His BPs (blood pressures) continue to be low at times. Since last visit, patient was discharged to ALF (Assisted Living Facility). He then developed SOB (Shortness of Breath) and was readmitted to hospital for HF (Heart Failure) and COPD exacerbation. Upon discharge he was advised to use 3L NC O2. Returned to [name of facility] as of 3/27/2025. Nursing notes, Physician/ARNP (Advanced Registered Nurse Practitioner) notes, hospital records, labs, imaging, and VS (Vital Signs) trends were reviewed. Review of a document titled Respiratory Assessment and Recommendation Form - dated 4/9/25 showed Resident #18 was assessed and his FIO2 (Fraction of inspired oxygen) was documented at 3L. Breath sounds were documented to be diminished RLL [Right Lower Lobe] and LLL [left lower lobe]. The report confirmed an oxygen concentrator was in use. Review of a physician encounter progress note dated 4/21/25 showed Resident #18 was seen for a follow -up. Under respiratory assessment, reduced NC O2 to 3L diminished bases due to poor inspiratory effort was documented. Review of a care plan for Resident #18 initiated and revised on 3/6/25 showed the resident is at risk for altered respiratory status/difficulty breathing r/t (related to) recent RSV infection and pneumonia, CHF (Congestive Heart Failure), COPD and need for supplemental oxygen. Interventions included: Encourage adequate rest periods in between tasks/activities. Encourage and assist resident to elevate head of bed to facilitate breathing as tolerated. Monitor for s/sx. (Signs and Symptoms) of respiratory distress and report to MD PRN (Medical Doctor, As needed) increased Respirations; Decreased Pulse - oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 9 of 19 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 05/07/2025 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 0695 Level of Harm - Actual harm Residents Affected - Few Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Monitor 02 saturations as ordered/PRN. Change tubing per MD order and PRN. Notify MD as indicated. Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Use pain management as appropriate. Monitor/document side effects and effectiveness. Review of a skilled services progress note dated 5/5/25 showed Resident #18 was redirected for anxiety. Refused alternate meal or snacks. Resident lethargic with low saturation this afternoon. MD notified. Resident became more aroused gradually with 02 and non-rebreather. Resident then asked to go to ER. MD notified. EMS and family also notified. Review of a skilled services progress note dated 5/4/25 showed [Resident #18] has complaints of SOB (shortness of breath) this afternoon, PRN (as needed) nebulizer treatment provided and are effective. Review of a medication administration progress note dated 4/27/25 showed to encourage and assist the resident to elevate HOB (head of bed) for ease of breathing/SOB (shortness of breath) while lying flat every shift related to acute bronchiolitis due to respiratory syncytial virus, acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of a summary of skilled services note dated 4/17/25 showed, New orders received for desaturation [a decrease in the amount of oxygen in the blood]. Review of progress notes dated 4/17/25 showed Resident #18 had a CIC. At the time, his oxygen was 89%. The nurse practitioner was notified of desaturation despite O2 and nebulizer treatments. New orders for STAT (without delay) CXR (Chest X-Ray) and Lasix 40mg (milligrams) p.o. (by mouth) once. Review of a physician encounter note dated 4/15/25 showed, today patient is lying in bed. BP (blood pressure) remains labile with hypotension intermittently. Denies any recent falls. States breathing is worse, O2 4L increased recently. Under respiratory assessment it was noted, congestion and attempting to cough but cannot, increased NC 4L, diminished bases due to poor inspiratory effort. Review of physician orders for Resident #18 did not show the orders to increase oxygen to NC 4L as ordered on 4/15/25. On 5/7/25 at 12:23 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff, LPN denied knowing of the order to increase oxygen to 4L on 4/15/25 stating, he has always been on oxygen. I don't remember new orders. She stated it was a nursing expectation to monitor his oxygen with a pulse oximeter and document. She stated she could not speak of the MAR/TAR (Medication Administration Record /Treatment Administration Record) documentation that was missing. She stated to ask the DON. Review of a nursing note dated 4/9/25 showed Resident #18 exhibited sob and wheezing this morning. Upon assessment, resident's lung sounds are diminished both lower lobes. Writer gave resident his scheduled inhaler. Notified [staff member] with Respiratory therapy. Resident already has DuoNeb (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 10 of 19 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 05/07/2025 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 0695 combination of two medicines) scheduled q6 (every 6 hours), we will continue that order and add PRN DuoNeb q4 (every 4 hours) for sob/wheezing. MD was notified. Level of Harm - Actual harm Residents Affected - Few Review of a skilled services progress note for Resident #18 dated 4/7/25 showed Resident is A/O (alert and oriented) x3 is able to make needs known, Resident has HX (history) of Respiratory issues. Oxygen on at O2 3L via N/C, NEB TX (nebulizer treatment) in place Q6. Review of a nursing readmission evaluation dated 3/27/25 showed O2 94% on 3/27/2025 21:16 Method: Oxygen via Nasal Cannula. Resident respirations appear even and unlabored. The resident does not exhibit or report current respiratory issues. No respiratory issues noted/observed. On the question if the resident utilizes the following respiratory devices or equipment, it is noted None. Under notifications the assessment showed physician order treatment plan of care, medications discharge planning reviewed with resident and/responsible party. Medication reconciliation completed with medical provider. All orders confirmed and verified. Review of a progress note dated 3/23/25 showed patient complained of SOB, checked pulse Ox stating at 86%. Patient stated he wanted to go to the hospital. Notified MD of change, Per orders the patient will be sent out. Review of a Social Services progress note dated 3/14/25 showed, resident stated he has oxygen at ALF. He would like a portable one and resident has a wheelchair at facility. Review of an IDT(Interdisciplinary Team) progress note dated 3/6/25 showed resident is on supplemental oxygen and states he becomes short of breath of lying flat. Care plan was updated. Review of a general admission progress note for Resident #18 dated 3/5/25 showed upon arrival the resident's O2 was 90% - - 3/5/2025 18:04 Method: Oxygen via Nasal Cannula. Resident respirations appear even and unlabeled. The resident current exhibits or has reported the following respiratory symptoms: cough short of breath while lying flat short of breath at all times. The resident utilizes the following respiratory devices or equipment: oxygen. The residents along sounds are adventitious: right upper lobe has audible wheezes, right lower lobe has audible wheezes, and the left lower lobe has audible wheezes. Review of all progress note types for Resident #18 effective 3/7/25 to 5/8/25 did not show documentation related to on-going assessment of the resident's respiratory status and response to oxygen therapy. On 5/6/25 at 3:33 p.m. an interview was conducted with the DON. The DON stated Resident #18 went out to the hospital yesterday (5/5/25) because of low oxygen. She said, He has had a history of it, he was out of it. We called the doctor. He was able to stabilized with the O2 we administered. The DON stated Resident #18 came around before the EMS arrived. The DON stated he wanted to go the ER, so they sent him out due to shortness of breath. The DON stated she could not comment on the lack of oxygen monitoring documentation in the MAR/TAR. She said, I will look at it and get back with you. On 5/7/25 at 12:41 p.m. an interview was conducted with the DON, Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). The RNC stated Resident #18 was sent out due to hypoxia (low levels of oxygen in the body tissues). Reviewing the residents electronic medical record (EMR), the RNC stated the resident had an oxygen order dated 3/7/25 -3/14/25 which was discontinued when he was sent out to the hospital. The RNC stated Resident #18 returned on 3/28/25. The DON, RNC, and NHA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 11 of 19 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 05/07/2025 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 0695 Level of Harm - Actual harm Residents Affected - Few reviewed the residents record and confirmed the oxygen order was not transcribed completely. The RNC said, The nurse should have clarified the level of oxygen and how often it should be administered. They confirmed the order was put in wrong. The RNC stated the nurses were not able to document in the MAR/TAR because it was transcribed wrong. They all reviewed the MAR/TAR and confirmed the resident was not being monitored for oxygen use from 3/28/25 to 5/5/25 when the resident was sent out for emergency care. The DON said, I see, it was entered incorrectly. The RNC and DON could not speak of the order to increase oxygen on 4/15/25 and why the administration orders were not documented. 2. Resident #12 was originally admitted to the facility on [DATE], readmitted on [DATE] and discharged on 1/19/25. The resident was admitted with diagnoses to include chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of progress notes dated 1/19/25 showed Resident #12's family member came to the facility and was upset the resident was not on oxygen . Resident with a history of COPD. All orders checked, and resident has no orders for oxygen at this time. Hospital discharge paperwork reviewed, and oxygen was discontinued upon discharge from the hospital patient readmitted on [DATE]. The family member called 911 and the resident was transferred to the hospital stating, [Resident #12] needed to be on oxygen. Review of the TAR for Resident #12 dated 1/1/25 - 1/31/25 showed Oxygen: NC/mask continuous. Encourage and assist resident to use O2 at 2 liters. The TAR showed oxygen was administered on 1/1/25 and 1/2/25. It was discontinued on 1/3/25 when Resident #12 went to the hospital. The TAR did not show the oxygen order was reinstated upon returning from the hospital on 1/19/25. Review of the TAR for Resident #12 dated 12/1/24 - 12/31/24 revealed documentation of continuous oxygen administered at 2 liters, documented on day, evening, and night shift. Review of Resident #12's care plan initiated on 11/11/24 showed the resident had difficulty breathing related to diagnosis of chronic respiratory failure, COPD, and dependent on supplemental oxygen. Interventions included to administer oxygen as ordered. Monitor O2 saturations as ordered/change tubing per facility protocol/MD order. Notify MD as indicated. Review of physician orders summary report for Resident #12 showed the history of oxygen orders as follows: On 12/7/24: Oxygen 2L/min via nasal cannula at continuing as needed for (left blank) On 12/7/24: Oxygen 2L/min via nasal cannula at continuing. The review showed the most recent oxygen orders dated 12/7/24, were not discontinued. Review of an admission/readmission nursing evaluation dated 1/9/25, showed Resident #12 was readmitted from the hospital. Under notifications the evaluation showed: Physician order treatment of care medications discharge planning reviewed with Resident and/resident responsible party, medications reconciliation completed with medical provider. All orders confirmed and verified. This evaluation did not indicate discontinuing of oxygen orders for a resident with a known COPD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 12 of 19 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 05/07/2025 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 0695 diagnosis and historical use of oxygen. Level of Harm - Actual harm On 5/7/25 at 2:13 p.m. an interview was conducted with the DON and the RNC. The DON stated she had reviewed Resident #12's orders and said, He had no orders at the time. The DON reviewed the EMR and could not show physician orders to discontinue oxygen use for Resident #12 who was dependent on oxygen. The RNC reviewed the hospital discharge record for Resident #12 and stated he was admitted for cardiac issues. He confirmed the oxygen orders were not discontinued by the hospital. The RNC stated he would have expected the nurse to call the doctor and re-instate the oxygen orders. Residents Affected - Few Requested and did not receive the facility's policy on oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 13 of 19 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 05/07/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, staff interview and policy and procedure review, the facility did not ensure resident medical records and confidential medical information were safeguarded in a confidential manner that would prevent unauthorized access on two (100 and 200) of two halls toured. Findings included: A tour of the 200 hall was conducted on 5/5/25 at 9: 32 a.m. A two-tiered rack was observed in the hallway. The rack contained white binders with room numbers on them, and a DNR ( Do Not Resuscitate) book containing resident specific information. The binders were observed to be easily accessible to anyone walking down the hallway to include residents, family members, vendors and visitors. Subsequent tours of the 200 hall were conducted on 5/5/25 at 4: 45 p.m. and 5/6/25 at 10: 44 a.m. The two-tiered rack containing white binders with room numbers and resident specific information and the DNR book were observed to remain in the hallway during these times,easily accessible to anyone walking down the hallway. Upon opening one of the white binders it was observed to contain a Resident Face Sheet and an AHCA (Agency for Healthcare Administration) form 3008, containing resident specific information including but not limited to resident name, date of birth ,. diagnoses and insurance information. During a facility tour on 5/5/25 at 4: 46 p.m., residents paperwork was observed on top the nursing station counter which contained resident specific medical information, this medical information was observed to be easily accessible to anyone who walked up to the nursing station counter. There were no staff observed at the nursing stations during these observations. A tour of 100 hall was conducted at approximately 9:32 a.m. to 10: 00 a.m. revealing a two-tiered rack observed in the hallway. The rack contained white binders with room numbers on them, and a DNR ( Do Not Resuscitate) book containing resident specific information. The binders were observed to be easily accessible to anyone walking down the hallway including residents, family members, vendors and visitors. Subsequent tours of the 100 hall were conducted on 5/5/25 between 4: 45 p.m. and 5 p.m. and 5/6/25 at 10 :31 a.m. The two-tiered rack containing white binders with room numbers and resident specific information and the DNR book were observed to remain in the hallway during these times easily accessible to anyone walking down the hallway. Upon opening one of the white binders it was observed to contain a resident face sheet and an AHCA form 3008 containing resident specific information including but not limited to resident names, date of birth , diagnoses and insurance information. On 5/6/25 at 10:31 a.m. and at 3:43 p.m., a book containing resident's specific laboratory (lab) information was observed on the nursing station counter, easily accessible to anyone who walked up to the nursing station counter. There were no staff observed at the nursing stations during these observations. An interview was conducted with the DON (Director of Nursing) on 5/6/25 at 4: 00 p.m. The DON stated the resident records have always been out in the hall on the cart, and not secured behind the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 14 of 19 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 05/07/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurse's stations. She stated papers should not be left on the medication carts or counters without being turned over. The DON observed the photographic evidence of the paperwork left on top of the 200-hall nursing station and stated it was a weight sheet and belonged to a CNA (Certified Nursing Assistant). She stated it should not have been left out to be seen by anyone walking by. An interview was conducted with the Nursing Home Administrator (NHA) on 5/6/25 at 4:00 p.m. The NHA stated the resident records have been in the hallway since she got here. She agreed they are easily accessible by all residents and visitors or anyone in the halls and there was no barrier to prevent anyone from accessing the resident's records. The NHA stated staff should not leave papers with resident information out on the counters or medication carts. Review of a facility policy titled, Resident Rights, issued 9/2021 Revised 01/2024 showed- Resident Rights Standards and Guidelines: Standard - A facility must treat each resident with respect and dignity and care for each resident in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents individuality. The facility must protect and promote the rights of the residents. Guideline: Employees stall treat all residents with kindness, respect, and dignity. Procedure: 3. The unauthorized release, access, or disclosure of resident information is prohibited, All release, access or disclosure or resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer. A facility policy titled, Administration Standards and Guidelines: Medical Records, Issued 3/2018, Revised 01/2024 showed - Standard: Medical Records will be maintained within the facility per federal requirements. ( Photographic Evidence Obtained ) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 15 of 19 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 05/07/2025 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** 3- Residents Affected - Some An observation was conducted on 5/5/25 at 4:46 p.m. of Staff C, Activities Assistant, who entered room [ROOM NUMBER] with no PPE on. The room had a Contact Isolation sign posted on the door and a PPE cart outside the door. The staff member was observed standing at the resident's bedside with a cart of supplies. She was then observed shaving the resident's face with no gown or gloves on. At 4:47 p.m. a second staff member, Staff G, Certified Nursing Assistant (CNA), walked into room [ROOM NUMBER] with no PPE on, went to the resident's bedside to talk to Staff C, then exited the room without performing hand hygiene. An interview was conducted on 5/5/25 at 4:48 p.m. with Staff G, CNA. She confirmed room [ROOM NUMBER] had a contact isolation sign and she did not wear PPE. She said she had been trained on the signs and PPE, but she did not see the sign. An interview was conducted on 5/5/25 at 4:57 p.m. with Staff C, Activities Assistant. Staff C exited room [ROOM NUMBER] with her supply cart and confirmed there was a contact isolation sign on the door. She said she saw the sign, but these are the ones if you are doing care with urine or stool you put on PPE. Staff C said she didn't know she had to wear PPE to go in the room and didn't know she shouldn't have taken her cart in the room. She said room [ROOM NUMBER] was her last room for one-to-one activities and she was going to wipe the cart down anyway. Staff C said she had training on PPE and isolation precautions. On 5/5/25 at 4:49 p.m. an observation was conducted on the 200 unit of a clean linen cart in the hall. There were additional items such as toothpaste, plastic bags, lotion, body wash, and gloves being stored on the shelf with clean linen inside the cart. An interview was conducted on 5/6/25 at 3:23 p.m. with the Director of Nursing (DON). She said all staff are trained in infection control and PPE use. She said her expectation if a Contact Isolation sign is on a door is for anyone that entered the room to have on a gown, glove, and mask. The DON said she would not be surprised to hear staff were in a contact room with no PPE on. She said they constantly educate but a lot of staff don't care or become so lackadaisical. She confirmed an activities cart should not have been in a contact isolation room either. The DON also confirmed no items should be stored in the clean linen cart except clean linen. A follow-up interview was conducted on 5/7/25 at 3:26 p.m. with the DON. The DON was asked why the facility had three different versions of Droplet Precaution signs with different instructions on different rooms. She said she was unaware there were different droplet precaution signs. She reviewed pictures of different droplet precaution signs and agreed it could cause confusion. The DON said she would look at the signs, but her expectation would be for anyone entering the room to have on a gown, gloves, eyewear, and masks. Review of a facility policy titled Transmission Based Precautions, revised 2/24, showed: Guideline: All staff received training on transmission-based precautions upon hire and at least annually. Procedure: 2. Contact Precautions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 16 of 19 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 05/07/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens. 3. Droplet Precautions a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing, or talking) c. Healthcare personnel wear a surgical mask for close contact with infectious resident. Photographic evidence obtained. Based on observations interviews and policy review, the facility failed to ensure proper infection control practices were in place for two (100 and 200) out of two halls related to use and availability of personal protective equipment (PPE) and performing hand hygiene. Findings included: On 05/05/25 at 9:33 a.m. an empty PPE supply cart was observed located outside of room [ROOM NUMBER]. room [ROOM NUMBER] was observed with a contact isolation sign present. The observation revealed the facility staff did not have readily available PPE to provide care for a resident on contact isolation. An observation of lunch service on 5/5/2025 at 12:36 p.m., room [ROOM NUMBER] revealed a contact precautionsign hanging above door. Staff A, Certified Nursing Assitant (CNA), was observed entering the room without performing hand hygiene prior to entering the room. Staff A, CNA was observed putting on the gown at bedside. Staff A, CNA proceeded to touch the resident with bare hands, positioned the resident for meal and proceeded to feed the resident. Staff A,CNA did not don gloves, or wash hands or apply sanitizer during the care process. An interview was condcuted with Staff A, CNA on 5/6/2025 at 1:31 p.m. She stated she knew the resident was on contact precautions and she would normally wear the Personal Protective Equipment (PPE). Staff A, CNA stated she knew how to put on PPE. Staff A, CNA stated any staff can restock the supplies if the supply carts were empty. During a tour of Facility on 5/6/2025 at 10:35 a.m. the following was observed. An observation of room [ROOM NUMBER] revealed a Contact Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns or gloves. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 17 of 19 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 05/07/2025 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 doorway. The supply cart outside of the room did not have gowns or gloves. Level of Harm - Minimal harm or potential for actual harm An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. Residents Affected - Some An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. An observation of room [ROOM NUMBER] revealed a Contact Precautions sign posted at the doorway. The supply cart outside of the room did not have gloves. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. An observation of room [ROOM NUMBER] revealed a Droplet Precautions sign posted at the doorway. The supply cart outside of the room did not have masks or eyewear. An observation of room [ROOM NUMBER] revealed a Droplet Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns or eyewear. The observations revealed the facility staff did not have readily available PPE to provide care for a residents who were on isolation. An observation of Staff B, Housekeeper, in room [ROOM NUMBER] revealed she was in the room mopping the floor near the resident. Staff B had a surgical mask placed below her nose, no gloves, gown, or eyewear. The Droplet Precautions sign posted at the doorway indicated that staff must always wear a facemask (N-95 or higher), wear eye protection, a gown, and gloves. An interview was conducted with Staff B, Housekeeper, on 5/6/2025 at 1:55 p.m. Staff B, Housekeeper, stated she did know the resident in room [ROOM NUMBER] was on droplet precautions. Staff B, Housekeeper stated she does know how to put on PPE. Staff B, Housekeeper stated she does not know where to obtain supplies or who restocks the supply carts outside the doorway. An observation was made of Staff C, Activities Assistant entering room [ROOM NUMBER] at 1:34 p.m. There was a Droplet Precautions sign posted at the doorway, which indicated staff must always clean hands when entering and leaving the room, wear a facemask (N-95 or higher), wear eye protection, a gown, and gloves. An observation of Staff C, Activities Assistant revealed the staff member did not perform hand hygiene before entering the room. She had a surgical mask on but not an N-95 or higher. Staff C, Activities Assistant was observed writing on a clip board that was resting on the resident's dresser Staff C, Activities Assistant was observed leaving room [ROOM NUMBER] at 1:45 p.m. performed hand hygiene with Alcohol Based Hand Rub (ABHR). Staff C did not sanitize the clipboard or pen and did not wear an N-95 mask, gloves, gown, or eyewear. An interview was conducted with Staff C, Activities Assistant on 5/6/2025 at 1:47 p.m. Staff C, Activities Assistant said, a mask is required for Droplet Precautions . Staff C, Activities Assistant, stated she knows how to put on PPE and she knows where PPE is located and stored within the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 18 of 19 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 05/07/2025 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 facility. Staff C did not explain why she did not wear proper PPE. Level of Harm - Minimal harm or potential for actual harm An observation on 5/7/2025 at 1:03 p.m. revelaed room [ROOM NUMBER] had a droplet precaution signage. An unidentified therapy staff member was observed in the room not wearing eye wear.The unidentified staff member was assessing the resident for safe transfer into a wheelchair. The resident had a visitor in the room and the visitor was not wearing any PPE. Residents Affected - Some A request was made to the Director of Nursing (DON) to provide information about PPE staff education. As of 5/7/2025 at 5:30 p.m., the education was not provided. An interview was condcuted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 5/7/2025 at 1:40 p.m. said No, it would not be appropriate for staff to be in the room without PPE. The DON said, We encourage visitors to wear the right PPE, but we can't make them. We educate them on admission to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106093 If continuation sheet Page 19 of 19