Health inspection·September 30, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 09/29/2021 at 12:45 p.m. with Staff B, LPN Unit Manager. Staff B, LPN stated residents were not assessed for use of bed rails upon admission to the facility and were only assessed if the resident asked for bed rails to assist with bed mobility. Staff B, LPN reviewed Resident #100's Medical Record and stated Resident #100 did not have an assessment for use of bed rails and she was not aware that Resident #100 requested bed rails. Staff B, LPN said if a resident requested bed rails the floor nurse would communicate to the Unit Manager, who would then pass the communication on to the Director of Nursing (DON). An assessment for bed rail use would be conducted on the same day and, if appropriate, maintenance would install the bed rails for the resident. An interview was conducted on 09/29/2021 at 01:23 p.m. with the facility's DON. The DON stated bed rail assessments were not conducted upon admission. The DON stated if a resident requested bed rails, the floor nurse would communicate to the Unit Manager, who would pass the communication on to her. An assessment for bed rail use would be conducted by the DON or the Unit Manager to see if bed rail use was appropriate for the resident. A review of the facility policy titled Restorative Nursing - Side Rails revised December 2016, revealed under the section titled Policy the use of side rails by a resident may be considered a restraint or an enabler, depending on the resident's functional status and whether or not the side rail restricts freedom of movement. Prior to use of side rails, the resident's strengths and needs should be evaluated by the Interdisciplinary Team to determine the reason for the side rail and any alternative devices that may be used to achieve the same goal. A review of the policy also revealed, under the section titled Procedure, that the Side Rail Evaluation should be conducted upon admission, readmission, quarterly, and with a significant change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 2 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide timely response to concerns voiced by the resident council group. Residents Affected - Few Findings included: A review of the resident council minutes revealed on 8/18/21 the group reported during the council meeting they received cold breakfast meals. A review of the Resident Council Concern Response Form, dated 8/18/21 indicated Breakfast meal cold. Continued review of the form revealed under the Corrective Action section: Will check trays to make sure is the correct temp. And will check with nurses to make sure trays are getting passed on time. A review of the Grievance Log for August 2021 revealed a grievance was logged by Resident #47 on 08/25/2021. The Nature /Type of Complaint was food. Review of the Grievance Report revealed resident stated while doing room rounds that his breakfast was late and cold. The Corrective Measures taken were informed all staff on hall to make sure resident is bedside before food off cart. During an interview with the Dietary Manager on 09/29/2021 beginning at 3:50 p.m. she reported she had been asked to speak with Resident #47 about his grievance filed on 08/25/2021. She reported he did not tell her that his food was cold, rather he had preferences he wished to file with her. She reported she had not been aware that residents were complaining of cold food. A continued review of the resident council minutes revealed on 9/24/21 the group reported during the resident council meeting that Carts of food sitting & Dietary/nursing-Cold Breakfast & not hot meals. Review of the Concern Response Form dated 9/24/21 revealed that Residents feel most meals are not hot, breakfast is especially cold. Carts are being dropped off on units & sit for a long period of time before being passed out per residents. Continued review of the form revealed that under the section titled Corrective Action, the plan was for Unit managers to round early to ensure trays are being passed in a timely manner audit to be put in place by 9/28/21. This document was signed and dated by the Director of Nursing (DON) on 9/27/21. Additional review at this time revealed that there was a second Concern Response Form with the same date of 9/24/21 and the same concern. The noted difference on this form was the Correction Action section which indicated New Manager to make sure food is palatable, no paper products, as some temps for food is above 100 degrees for all items signed and dated by a manager on 9/24/21. An interview with a group of alert and oriented residents on 9/29/21 at 10:46 a.m. revealed the group reported that the food is cold. They reported all three meals are cold, but that the worst is breakfast because the eggs are always cold. The group reported the staff do not warm up the meals, even if asked. In an interview on 9/29/21 at 12:29 p.m. the Director of Social Services (DSS) revealed she is also the Grievance Coordinator. She reported she was unaware of residents' concerns voiced at the resident council meetings related to cold food. She confirmed she was also unaware of any type of resolution to the group's concerns. The DSS said food concerns are given directly to the food department. She reported if the concern was given to her, she would complete the grievance process and provide the resolution to the concern. She reported she was not sure why the concerns were not given to her, but that she would educate the Activities Director to the correct process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 3 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 9/29/21 at 12:39 p.m. the Activities Director revealed when she gets concerns from the Resident Council, she would give the concerns directly to the department heads responsible. She reported the department heads will give the concerns back to her with a resolution and any corresponding documentation. In an interview on 9/29/21 at 12:45 p.m. the Director of Nursing (DON) reported she found out about the cold food on the Monday after the Resident Council meeting, and she put an audit in place on Tuesday, 09/28/2021. In an interview on 9/29/21 at 12:57 p.m. the Activities Coordinator revealed she checked the facility policy regarding the resident council, which referred her to the facility grievance policy. She reported from now on when concerns come from resident council, she will give them to the Grievance Coordinator. A review of an undated policy titled Resident Council revealed The Administrator receives a copy of the minutes as soon as possible, so that problems and suggestions can be acted upon. A follow-up is made by the Administrator or his/her designee at the following meeting. Review of the facility policy titled Grievance with an effective date of Feb. 2006 and a revision date of November 2016 revealed The facility will promptly and responsibly investigate these grievances to initiate timely resolution and determine if the facility has areas that need correction to achieve the goal of providing quality care and a safe environment. The facility will consider a grievance an opportunity to enhance care and services. 4. The Social Service Director will serve as the facility Grievance Official. The Grievance Official is responsible for overseeing the grievance process, receiving, and tracking grievances through to their resolution; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 6. The Grievance Official will make every attempt to resolve the grievance in a timely manner and will keep the resident and /or their representative aware of the progress towards resolution. The resident or representative will be notified of the result of the grievance and may receive a written decision regarding his/her grievance if requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 4 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review the facility failed to provide activities of daily living (ADL's) for 1 (#35) of 32 sampled residents related to nail care. Residents Affected - Few Findings include: A review of the care plan for Resident #35 revealed a focus of ADL self-care performance deficit related to the resident's weakness, compromised cardiac status, dementia, lack of coordination, difficulty walking, and dysphagia. The interventions included: Personal Hygiene: He requires (Extensive) by (1) staff with personal hygiene Observations on 9/27/21 at 10:20 a.m. of Resident #35 revealed the resident lying on his back in his bed with both hands lying on his chest. It was noted the resident's spouse and son were both seated at his bedside. An attempted interview with the resident revealed that he was able to answer all questions independently. The resident's fingernails were observed to be long, and the resident was able to indicate he did not like his nails long and he would like them cut. The resident's spouse reported during the observation the resident never had his nails this long. Observations on 9/30/21 at 9:45 a.m. of Resident #35 revealed him sitting up in bed watching TV with his hands lying on his chest. It was noted that Resident #35's fingernails were still long. An interview with the resident at that time revealed that no one had cut his nails and that he does not like them this long and would like them cut. An interview on 9/30/21 at 9:46 a.m. with Staff C, Licensed Practical Nurse (LPN), who was present in the resident's room during the resident interview revealed all staff who provide care to the resident should make sure his nails are cut. Staff C, LPN reported he would ensure it was taken care of. In an interview on 9/30/21 at 9:48 a.m. with Staff E, Certified Nursing Assistant (CNA) she confirmed she was assigned to Resident #35 and had worked with him earlier in the week. She reported if a resident's nails were too long, she would let the nurse know. She said she would file them down and she would also let activities know as they do nail care activities. She reported she was not aware the resident's nails were long. During an interview on 9/30/21 at 9:55 a.m. with Staff F, Activities aide, she revealed she goes around with the nail care cart and checks all nails. She reported nursing will cut them because activity personnel are not allowed to cut nails, but she will file them down and make sure that they are clean. She reported she was unaware of Resident #35's nails needed care. In an interview on 9/30/21 at 11:32 a.m. with Staff B, LPN, Unit Manager she revealed the resident was diabetic so the aides should not be trimming his nails, and the nurse would be responsible for that. Review of the facility policy titled Nails, Care of Fingernails and Toenails dated January 1999 revealed The purpose of this procedure are to clean the nailbed, to keep nails trimmed, and to prevent infections. 6. Nail care includes daily cleaning and regular trimming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 5 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to act upon a pharmacy recommendation in a timely manner for 1 (Resident #1) of 5 sampled residents for unnecessary medications. Findings included: A review of Resident #1's Medical Record revealed that he was admitted to the facility on [DATE], with a readmission to the facility on [DATE], with diagnoses of vascular dementia and Major Depressive Disorder (MDD). A review of Resident #1's Physician's Orders revealed an order, dated 09/22/2021, for Sertraline Hydrochloride (HCl) 100 milligrams (mg) given by gastric tube one time daily for depression. A continued review of the Physician's Orders did not reveal an order for behavioral or side effect monitoring related to use of antidepressant medications. A review of Resident #1's Care Plan revealed a problem, revised on 12/21/2020, that Resident #1 was at risk for complications related to depression. Interventions included to administer medications as ordered and to monitor for side effects and effectiveness. A review of the Consultant Pharmacist's Medication Regimen Review Recommendations, Pending a Final Response, with a date range of 07/01/2021 to 07/27/2021, revealed the following: - A recommendation, dated 06/29/2021, to ensure behavioral monitoring was in place for use of Sertraline 100 mg daily for MDD. Routed to: Nursing. The Recommendation Status portion of the review revealed that the status of the recommendation was Pending. An interview was conducted on 09/30/2021 09:32 a.m. with Staff G, Registered Nurse (RN). Staff G, RN stated that Resident #1 received Sertraline HCl for a diagnosis of MDD and that residents' taking antidepressant medications would normally have monitoring in place for side effects and behaviors related to antidepressant medication use. Staff G, RN addressed that Resident #1 did not have orders in place for side effect monitoring or behavioral monitoring related to antidepressant use and stated the nurse that processed Resident #1's admission should have put orders into place for the monitoring. An interview was conducted on 09/30/2021 at 02:55 p.m. with the facility's Director of Nursing (DON). The DON stated residents who received antidepressant medications should have orders in place for monitoring of side effects and behaviors. The DON also stated all recommendations from pharmacy reviews were forwarded to nursing and the nursing department would put in the orders for psychotropic medication monitoring if recommended by the Consultant Pharmacist. The DON stated the recommendations would usually be addressed within a few days of receiving them and she and the Unit Managers processed them. The DON confirmed Resident #1 did not have an order for behavioral or side effect monitoring related to antidepressant use. An interview was conducted on 09/30/2021 at 03:04 p.m. with Staff D, Consultant Pharmacist. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 6 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few D, Consultant Pharmacist stated the Medication Regimen Reviews were conducted monthly and she provided recommendations related to psychotropic medication use, the dosages of medications, start and stop dates, and monitoring of medications. She reported lack of behavioral monitoring were referred to the nursing department to be addressed. Recommendations are followed up on during the following month's review to ensure the recommendation was addressed. If the recommendation was not addressed, it would be placed on pending status. The Consultant Pharmacist stated the recommendation would be made again after a couple of months if she noticed it still was not followed up on. The Consultant Pharmacist also stated he would expect to see behavioral monitoring in place for Sertraline HCl. A review of the facility policy titled Drug Regimen Review, last revised in October 2017, revealed under the section titled Policy, that the Consultant Pharmacist will review each resident's clinical chart monthly. Apparent irregularities will be reported in writing to the DON, Medical Director, Attending Physician, and Administrator. The facility shall follow up on Consultant Pharmacist recommendations to ensure all residents maintain the highest practicable level of functioning. The policy also revealed, under the section titled Procedure that recommendations and apparent irregularities will be reported timely to ensure the safe and appropriate medication utilization to meet the individual needs of the residents. All non-urgent recommendations/irregularities must be addressed within 30 days of the Consultant Pharmacist monthly visit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 7 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to provide appropriate monitoring of psychotropic medication use for 1 (Resident #1) of 5 residents sampled for unnecessary medications. Findings included: A review of Resident #1's Medical Record revealed he was admitted to the facility on [DATE], with a readmission to the facility on [DATE], with diagnoses of vascular dementia and Major Depressive Disorder (MDD). A review of Resident #1's Physician's Orders revealed an order, dated 09/22/2021, for Sertraline Hydrochloride (HCl) 100 milligrams (mg) given by gastric tube one time daily for depression. A review of Resident #1's Physician's Orders did not reveal an order for behavioral or side effect monitoring related to the use of antidepressant medications. A review of Resident #1's Care Plan revealed a problem, revised on 12/21/2020, that Resident #1 was at risk for complications related to depression. Interventions included to administer medications as ordered and to monitor for side effects and effectiveness. A review of the Consultant Pharmacist's Medication Regimen Review Recommendations, Pending a Final Response, with a date range of 07/01/2021 to 07/27/2021, revealed the following: - A recommendation, dated 06/29/2021, to ensure behavioral monitoring was in place for use of Sertraline 100 mg daily for MDD. Routed to: Nursing. The Recommendation Status portion of the review revealed that the status of the recommendation was Pending. An interview was conducted on 09/30/2021 at 08:53 a.m. with Staff C, Licensed Practical Nurse (LPN), who stated residents who received psychotropic medications should have orders in place for monitoring of behaviors and side effects related to the medication. Staff C, LPN provided an example of the side effect and behavioral monitoring that was documented every shift for another resident receiving Sertraline HCl in the electronic health record. An interview was conducted on 09/30/2021 at 09:32 a.m. with Staff G, Registered Nurse (RN) who stated Resident #1 received Sertraline HCl for a diagnosis of MDD and residents taking antidepressant medications would have a monitor in place for side effects and behaviors related to antidepressant medication use. Staff G, RN confirmed that Resident #1 did not have orders in place for side effect monitoring or behavioral monitoring related to antidepressant use and stated the nurse who processed Resident #1's admission should have put orders into place for the monitoring. An interview was conducted on 09/30/2021 at 02:55 p.m. with the facility's Director of Nursing (DON), who stated residents who received antidepressant medications should have orders in place for monitoring of side effects and behaviors. The DON also stated all recommendations from pharmacy reviews were forwarded to nursing and the nursing department would put in the orders for psychotropic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 8 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication monitoring if recommended by the Consultant Pharmacist. The DON stated the recommendations would usually be addressed within a few days of receiving them and she and the Unit Managers processed them. The DON confirmed that Resident #1 did not have an order for behavioral or side effect monitoring related to antidepressant use. An interview was conducted on 09/30/2021 at 03:04 PM with Staff D, Consultant Pharmacist., who stated that Medication Regimen Reviews were conducted monthly. She stated she provided recommendations related to psychotropic medication use, the dosages of medications, start and stop dates, and monitoring of medications. Behavioral monitoring was referred to the nursing department to be addressed. Recommendations are followed up on the following month to ensure that the recommendation was addressed. If the recommendation was not addressed, it would be placed on pending status. The Consultant Pharmacist stated the recommendation would be made again after a couple of months if she noticed that it still was not followed up on. The Consultant Pharmacist also stated she would expect to see behavioral monitoring in place for Sertraline HCl. A review of the facility policy titled Nursing: Behavior Monitoring and Psychoactive Medication Management revised in October 2017, revealed that the presence or absence of target behaviors for those residents receiving antipsychotic, antianxiety, sedative/hypnotics, or antidepressants will be recorded using the Behavior/Intervention Monthly Flow Record for every shift each day. Side effects if noted will be recorded on the Behavior/Intervention Monthly Flow Record every shift for each day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 9 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview with the Administrator and the Director of Nurses, the facility failed to implement their Quality Assurance Program for three (Residents #8, #10, and #11) of three sampled residents, as evidence by failure to audit staff documentation of behaviors and side effects of psychotropic medications according to the plan of correction. Findings included: 1. Resident #8 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to vascular dementia, adjustment disorder with depressed mood, adult failure to thrive, cancer of the bone and prostate, depression, acute kidney failure, and Cerebral Vascular Accident with hemiplegia. Observation on 11/30/21 at 10:07 a.m. revealed Resident #8 lying in a low bed. The resident was asleep with his mouth open. He had G-tube feeding infusing. The head of the bed was elevated. He had a blanket covering his hands. There were personal items in the room. The call light was within reach. Review of the Order Summary Report showed to observe for side effects for antidepressant medication as of 09/30/21, document Y if side effects are noted, N if no side effects are noted. If Y document side effects in the progress notes; behavior monitoring as of 09/30/21 every shift, document Y if any of the above were observed, record code, and document in progress notes; document non-pharm interventions, document if intervention was effective E = effective, N = non effective; Depakote sprinkles capsule delayed release sprinkle 125 mg give 2 capsules via peg tube twice a day for adjustment disorder with depressive mood as of 10/07/21; and Sertraline HCL 100 mg via peg tube daily for depression as of 09/22/2021. Record review of the November Medication Administration Review (MAR) showed the monitoring of antidepressant medication side effects were not documented on 11/02, 11/05, 11/06, 11/07, 11/17, 11/21, and 11/26/2021 on day shift. Behavior monitoring including behavior, number of episodes and non-pharmaceutical intervention was not documented on 11/02, 11/05, 11/06, 11/07, 11/17, 11/21, and 11/26/2021 on day shift. Review of the care plans showed Resident #8 used antidepressants related to depression. Interventions as of 12/11/2020 included but was not limited to monitor / document / report as needed adverse reactions to antidepressant therapy which included behaviors. Review of the progress notes showed no documentation regarding behavior monitoring or side effect monitoring 2. Resident #10 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to spondylosis, psychosis, pain, mood disorder, and acute kidney failure. Review of Order Summary Report showed to observe for side effects for antidepressant medication as of 10/13/2021, document Y if side effects are noted, N if no side effects are noted. If Y documented side effects in the progress notes; observe for antipsychotic medication side effects as of 10/13/2021, document Y if side effects are noted, N if no side effects are noted. If Y documented side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 10 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some effects in the progress notes; behavior monitoring as of 10/01/2021 every shift, document Y if any of the above were observed, record code and also document in progress notes; document non-pharm interventions, document if intervention was effective E = effective, N = non effective; Cymbalta capsule delayed release particles 60 mg daily for depression as of 08/08/2021; Seroquel 100 mg twice a day for psychosis as of 10/29/2021; Trazodone HCL 50 mg at bedtime for mood (affective) disorder as of 10/13/2021 Record review of the November Medication Administration Review (MAR) showed the monitoring of antidepressant medication side effects were not documented on 11/02, 11/05, 11/06, 11/07, 11/17, 11/21, and 11/262021 on day shift. Behavior monitoring including behavior, number of episodes and non-pharmaceutical intervention was not documented on 11/02, 11/05, 11/06, 11/07, 11/17, 11/21, and 11/262021 on day shift and antipsychotic medication side effects were not documented on 11/02, 11/05, 11/06, 11/07, 11/17, 11/21, and 11/262021 on day shift. Review of the care plans showed Resident #10 used antidepressants related to depression. Interventions as of 09/03/2021 included but were not limited to monitor / document / report as needed adverse reactions to antidepressant therapy which included behaviors; administer antidepressant medications as ordered by physician; and monitor / document side effects and effectiveness every shift. Care plan related to use of psychotropic medications for behaviors as of 11/22/2021 showed to administer psychotropic medications as ordered by physician and monitor for side effects and effectiveness every shift; consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly; monitor / document / report as needed adverse reactions to psychotropic therapy which included behaviors. Review of the progress notes showed on 11/01/21 at 22:57 (10:57 p.m.) during mealtime this evening the resident was noted to be aggressive with another resident by removing things that were on the table in front of that resident and putting his shoes on the table in front of that resident. Resident was redirected and became increasingly agitated and went to another table and began throwing the place mats on the floor and destroying the floral arrangement that was on the table. The resident was attempted to be redirected by removing him from the area, resident was persistent that he wanted to return to the area in the dining room where resident continued to destroy the above mentioned. Resident did finally fall asleep in his chair. Incident was documented in the November MAR. Review of the progress notes showed no documentation regarding behavior monitoring or side effect monitoring 3. Resident #11 was admitted on [DATE]. Diagnoses included but were not limited to heart failure, diabetes, anxiety, depression, and dementia. Review of Order Summary Report showed to observe for side effects for antidepressant medication as of 01/31/2020, document Y if side effects are noted, N if no side effects are noted. If Y documented side effects in the progress notes; behavior monitoring as of 05/06/2019 every shift, document Y if any of the above were observed, record code and also document in progress notes; document non-pharm interventions, document if intervention was effective E = effective, N = non effective; and Cymbalta capsule delayed release particles 30 mg daily related to major depression as of 10/30/2021. Record review of the November Medication Administration Review (MAR) showed the monitoring of antidepressant medication side effects were not documented on 11/02, 11/05, 11/06, 11/07, 11/10, 11/17, 11/19, 11/20, 11/21, and 1122/2021, on day shift. Behavior monitoring including behavior, number of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 11 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some episodes and non-pharmaceutical intervention was not documented on 11/02, 11/05, 11/06, 11/07, 11/10, 11/17, 11/19, 11/20, 11/21, and 11/22/2021 on day shift. Review of the care plans showed Resident #11 used antidepressants related to depression. Interventions as of 06/13/2019 included but were not limited to monitor / document / report as needed adverse reactions to antidepressant therapy which included behaviors, administer antidepressant medications as ordered by physician, educate her / family/ caregivers about risks, benefits and the side effects of and / or toxic symptoms. Review of the behavior problem / episodes care plan initiated on 01/25/2021 related to dementia, mild cognitive impairment, depression, anxiety, hallucinating / delusional episodes of seeing a little boy sitting in the chair in her room showed intervention included give opportunity for resident to express her feelings. Care plan related to making unfounded accusations / revisiting issues that have already been addressed / resolved, showed to monitor behavior episodes an attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of the progress notes showed no documentation regarding behavior monitoring or side effect monitoring 4. Review of the Plan of Correction showed: 1. Resident #1 (current Resident #8) pharmacy recommendation was immediately addressed for behavior monitoring and / or side effects monitoring 2. Other residents in the facility who had pharmacy recommendations for behavior monitoring and / or side effects monitoring related to psychotropic medications were addressed. 3. Licensed nursing staff were in-serviced by DON/ designee on completing pharmacy recommendations related to behavior monitoring and / or side effects monitoring related to psychotropic medication. 4. The DON or designee will perform 2-3 weekly random audits for any pharmacy recommendations related to behavior monitoring and / or side effects monitoring related to psychotropic medication. Result will be brought to the QAPI committee for the next three months. At the end of this period the committee will decide to continue the monitoring period or discontinue based on the effectiveness of the plan. Educational Moment for F756 and F758; behavioral monitoring and psychoactive medication administration. Please ensure side effects and presence or absence of target behaviors if noted are recorded in the Behavior / Intervention documentation on the MAR. Behavior monitoring and side effect monitoring are required. Review policy and sign the educational moment stating understanding on 10/05/21. A copy of the Behavior Monitoring and Psychoactive Medication Management policy was attached. Review of the DON / Designee will review monthly pharmacy recommendations to ensure recommendations are communicated to the physician with follow-up from nursing audit tool showed Plan of Correction for F-756 and F-758. Resident #10 was reviewed on 10/26/21 and 10/28/21, Side effect / behavior monitoring pharmacy recommendation requested: No; Monthly review; recommendation was added to the e-mar: yes. Resident #11 was reviewed on 10/26/21 and 11/04/21, Side effect / behavior monitoring pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 12 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0867 recommendation requested: No; Monthly review; recommendation was added to the e-mar: yes. Level of Harm - Minimal harm or potential for actual harm Resident #8 was reviewed on 10/26/21, Side effect / behavior monitoring pharmacy recommendation requested: No; Monthly review; recommendation was added to the e-mar: yes. Residents Affected - Some 5. During an interview on 11/30/21 at 1:04 p.m., the Director of Nursing (DON) reviewed Resident #8's November MAR and stated oh, boy. She asked if there were any others, reviewed Resident #10 and #11's MAR. She stated that it was the same nurse, Staff A, Licensed Practical Nurse (LPN). She stated that Staff A, LPN administered the medications but did not document the behaviors. She stated that she did not review the MARs for behavior documentation until the end of the month. She stated that she had not looked at the MARs yet. The DON stated that she would have to start looking at the MAR documentation daily and do some more education. The DON stated, There should not be holes, they should sign off on everything before leaving the building. During an interview on 11/30/21 at 1:30 p.m., Staff A, LPN stated he knew all three residents. He stated that if a behavior was new, we would call the family and the physician to inform them of the behavior and try to get a psych consult. He stated that the behavior would be documented in the progress notes. If the behavior was a repeat behavior, it would be charted in the progress notes. He stated that they were to document behaviors of residents on psychotropic medications in the e-mar. He stated that we click on it (in the e-mar) and document the type of behavior using the numbers, number of behaviors and interventions. He stated that he did not know why the documentation was not in the e-mar for those residents. He stated that if he had not documented it would have turned red by 3 p.m. He stated that he checked at the end of shift to make sure all of his documentation was done. During an interview on 11/30/2021 at 2:36 p.m., with the Nursing Home Administrator (NHA) and DON, the DON stated that initially, when the state team exited the building, was the first time that they did an entire sweep of the residents on psychotropic medications to see if they had behavior monitoring and side effect monitoring. Every admission had their medications audited to see if they had monitoring. If it was missing, the DON stated she would add it, so we would be monitoring for behaviors and side effects. She stated that the audits were telling her that on a resident on psychotropic was reviewed on admission and with a medication change. The DON stated that she was not monitoring for behavior documentation 2-3 times a week, as was on the Plan of Correction (POC), to assess if it was being done. The DON stated, She did it incorrectly. The NHA and DON stated that the POC was done with the assistance of the regional nurse. They stated that they met as a group, ADHOC, all the department heads and Medical Director. They met the first time on 10/01/2021. They stated again that the regional nurse assisted with the POC. The NHA stated that they started thinking about what they were going to do and the regional nurse came the next week and we started our POC and began the audits at the same time. We wrote the POC with the regional nurse. The lack of documentation of the behaviors for the three residents was done by the same nurse (Staff A, LPN). The NHA and DON stated that 100% of the nursing staff had been educated. The NHA reviewed the Educational Moment sign-in sheet and stated that Staff A was not on the sign-in sheet as having received the education. The NHA stated that he had been off and was later re-hired. The DON stated since he was gone such a short time, we did not do another orientation. The NHA stated, He should have not needed an orientation just brought up to speed. They stated that they were not aware of a report they could pull from the system to see if documentation had been completed or not. The DON stated she was not aware of a report. The DON stated that the consultant pharmacist did not always tell her the of the findings of their audits. They stated that the next QA meeting was on 10/25/2021, which was their regular QA monthly meeting. The NHA stated that the POC was initiated and ongoing. The NHA stated that they presented what had been done at that QA meeting. The NHA and DON reviewed the POC book and what (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 13 of 14 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 106120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was found and which residents that had been audited. The DON stated that she checked the residents' charts for behavior monitoring and side effect monitoring and reported that at the QA meeting. The DON stated, I did not focus on the documentation in the e-mar. The DON stated again that only one nurse had not charted behaviors. The DON stated, Only audited that the orders were in place, did not review documentation. I misunderstood. They stated they were unable to find any notes from the first ADHOC meeting on 10/01/21, the day after the survey ended. During an interview on 12/02/2021 at 1:55 p.m. with consultant pharmacist, she stated that the nurses should be monitoring behaviors and side effects for residents on psychotropic medications. If the physician order says every shift, it should be documented every shift. They may need to do some re-education on proper documentation. 6. Record review of the facility's policy, Administrator / Risk Management - Quality management, revised in October 2019 showed Vision Statement: this facility will create a caring and nurturing environment, focused on professionalism and excellence in service delivery. The facility strives to be the provider of choice as well as the employer of choice in our community. Purpose: through Quality Assurance and Performance Improvement (QAPI), the facility will take a proactive approach to continually improving care and services for our residents. Guiding Principles: the facility will use QAPI to make decisions and improve the day-to-day operations. QAPI focuses on systems and processes, rather than individuals. Policy: the Administrator is responsible for the Quality Assessment and Assurance Committee for the facility. The facility will have an internal Quality Assurance and Performance Improvement Program designed to provide a comprehensive approach to ensuring high quality care and services. The QA&A Committee, referred to as the QAPI Committee, will meet at least monthly and will utilize the 5 Elements of QAPI which are: 1. Design and Scope: ongoing program and is comprehensive, dealing with the full range of services offered by the facility. The QAPI program will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. 2. Governance and Leadership: the governing body will develop a culture of seeking input from facility staff, residents, and families while assuring adequate resources to conduct QAPI efforts. 3. Feedback, Data Systems, and Monitoring: the facility will put systems in place to monitor care and services through the use of multiple sources. 4. Performance Improvement Projects (PIPs)-involves gathering information systematically and intervening for improvement with a written work plan by the project team and a timeline. 5. Systematic Analysis and Systematic Action-the facility will model and promote systems thing, practice root cause analysis and take action at the systems level. Composition and Duties of the QAPI Committee: 2. the committee will identify opportunities for improvement as well as recommend, implement, monitor and evaluate changes. 4. The Committee will charter Performance Improvement Projects (PIPs) to provide concentrated efforts to address a particular problem area identified in one part of the facility or facility wide. The facility conducts PIPs to examine and improve care or services by gathering information systematically to clarify issues and intervening for improvement. 5. The facility will be proficient in the use of Root Cause Analysis to determine how identified problems may be caused or exacerbated and will look across all involved systems to prevent future events and promote sustained improvement programs. 6. Once the root cause has been established, changes or corrective actions tightly linked to the root cause will be implemented. These changes or corrective measures should offer long term solutions to the problem, and must be achievable, objective, and measurable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 14 of 14