Health inspection·November 16, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sprayed the entire room with disinfectant starting in the bathroom and then proceeded to side A and then B of the room. She wiped down all sprayed items top to bottom of the room, including the air conditioning unit, bed rails, etcetera, all areas sprayed with disinfectant. She sprayed the bathroom and shower floor, then scrubbed with a long-handled brush including the rubber stripping that runs along the shower edge to the bathroom floor. She let Staff U, Maintenance Director know of any repairs were needed. If Staff U, Maintenance Director was unavailable she filled out a work order log located on the Maintenance Director's office door. During an interview conducted on 11/16/2023 at 8:50 a.m., the Housekeeping Director stated the room cleaning process included spraying disinfectant over all room surfaces. The sprayed surfaces were wiped down from top to bottom after the disinfectant had sat a minimum of 5 minutes. An interview was conducted on 11/16/2023 at 11:20 a.m. with Staff U, Maintenance Director and Staff T, Former Maintenance Director. Staff T revealed he was previously the full-time Maintenance Director at the facility and was now training Staff U. Staff T revealed there were no new renovations at the facility. Staff T stated they started cleaning the filters this week for the PTAC units. He confirmed there was no current form or written cleaning policy in place. Staff U, Maintenance Director said any staff could write a work order if equipment was noted to need repair or be replaced. They (management team) also did Angel Rounds each day and could let maintenance know or write a work order for needed repairs. There was a work order book at each nurses' station, and we checked them daily. Staff U said, We are not currently replacing the tan strips until we figure out what product was a better option, now just disposing of them when notified they were loose, or unsecured. Staff T stated, There is no audit for the rubber tan strips and staff can alert us or write a work order for repairs. We used to do a commode seat audit once a month as they got loose but none for a commode base. Review of a Housecleaning Schedule revealed all rooms on the 200 and 400 halls were to be cleaned daily and signed off on by the housekeeping staff. 2. During a facility tour on 11/13/23 at 10:42 a.m. and at 12:16 p.m., room [ROOM NUMBER] was noted with urine odors. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 11/13/23 at 12:16 p.m. She stated the resident had been changed and the odor could not be from the resident. During subsequent tours on 11/14/23 at 10:33 a.m. and on 11/15/23 at 10:12 a.m., room [ROOM NUMBER] was noted with the on-going urine odor. On 11/15/23 at 10:20 a.m. an interview was conducted with Staff A, RN Unit Manager. Staff A went to the room and confirmed a strong urine odor. She stated she would get Housekeeping to clean the room. She stated she thought it was from the floor. On 11/15/23 at 10:29 p.m., an interview was conducted with Staff D, Housekeeping Aide. She stated she was assigned to clean this room. She stated she had not cleaned it yet. She walked into the room with surveyor and confirmed she smelled strong urine odor. On 11/15/23 at 10:34 a.m., an interview was conducted with Staff B, CNA. She confirmed the room smelled like urine. She said, it was urine that leaks to the floor sometimes. She stated housekeeping would clean the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 2 of 25 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 11/16/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm A Follow up was conducted with the Housekeeping Manager on 11/15/23 at 12:51 p.m. She stated usually if the room had an on-going odor, it would indicate the bed needed to be stripped and the mattress needed to be disinfected. She stated this happened with residents who were in bed all the time. She stated if there were concerns, she would expect the nursing staff or housekeeping aides to let her know. She stated the room had been cleaned today and she would keep an eye on it. Residents Affected - Some Review of a facility policy titled, Cleaning and Disinfecting Residents' Rooms, Revised August 2013, showed a purpose to provide guidelines for cleaning and disinfecting resident's rooms. 1. Housekeeping surfaces . will be cleaned on regular basis, when spills occur, and when these surfaces are visibly soiled. 12. Clean spills . or bodily fluids as outlined in the established procedure. The policy did not have specific instructions for cleaning PTAC units or rubber strips in bathrooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 3 of 25 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 11/16/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for nine (Residents #41, #21, #12, #14, #13, #90, #108, #103, and #87) of nine residents sampled for PASRRs Residents Affected - Some Findings included: 1. Review of the electronic medical record (EMR) revealed Resident #41 was admitted to the facility on [DATE] with diagnoses to include Major depressive disorder, Vascular Dementia, and anxiety disorder. Review of a level I PASRR for Resident #41 dated 04/16/21 showed qualifying diagnoses were not checked or indicated. Review of the electronic medical record (EMR) revealed Resident #21 was admitted to the facility on [DATE] with diagnoses to include Major depressive disorder, Mood disorder, unspecified dementia, generalized anxiety disorder, anxiety disorder, schizoaffective disorder, and bipolar disorder. Vascular Dementia, and anxiety disorder. A level I PASRR for Resident #21 dated 7/16/20 showed qualifying diagnoses were not checked and a level II was not submitted. Review of the electronic medical record (EMR) revealed Resident #12 was admitted to the facility on [DATE]. The resident was admitted with a primary diagnosis of Alzheimer's disease. Review of Resident #12's Level I PASRR showed this diagnosis was not checked. Further review of the face sheet showed the resident had acquired a new diagnosis of major depressive disorder on 10/31/23. Review of Resident #12's PASRR Level I screen dated 01/09/15 revealed no qualifying mental health diagnosis were indicated and that no PASRR Level II was required. Review of the electronic medical record (EMR) revealed Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of diagnosis information showed diagnoses to include schizoaffective disorder 10/30/21, major depressive disorder 2/21/21, Generalized Anxiety Disorder 02/21/21 and unspecified dementia unspecified severity with other behavioral disturbance dated 01/25/23 and unspecified depression on 01/25/23. Review of Resident #14's PASSAR Level I screen dated 02/18/21 revealed page 2 of the PASRR form was missing and no qualifying mental health diagnosis were indicated and that no PASRR Level II was required. Review of the electronic medical record (EMR) revealed Resident #13 was admitted to the facility on [DATE]. Review of diagnosis information showed the resident was admitted with a primary diagnosis of Alzheimer's dated 06/09/22. Other diagnoses included major depressive disorder 10/25/22, mood disorder due to unknown physiological condition 10/11/22, schizoaffective disorder 10/25/22, Bipolar type 6/9/22, and anxiety disorder 6/9/22. Review of Resident #13's PASSAR Level I screen dated 06/08/22 revealed no qualifying mental health diagnosis were indicated and that no PASRR Level II was required. An interview was conducted on 11/15/23 at 02:16 p.m. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the Social services Director (SSD). The DON stated the ADON was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 4 of 25 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 11/16/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some still in training, but she would be responsible for ensuring PASRR's were completed accurately in the future. She stated the SSD would be assisting. She stated she could not speak of the previous administration. The SSD stated their goal was to complete a full audit of all PASRRs to see if they were incomplete and if they were, the ADON would update them. The DON stated they had initiated education and training for the ADON to ensure competency with the task. The ADON reviewed incomplete PASRRs with surveyor and said, Yeah, I see that. The diagnoses were not checked. The process is for admissions department to review the PASRRs prior to the resident's admission. The DON said, If they have issues, they should let the ADON know so she can re-do them. The DON stated if a resident needed their level II PASRR updated, their goal was to bring them to clinical team for review. The DON said, We will be auditing and sending recommendations to Kepro. On 11/15/23 at 03:54 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated the process is for admissions to review the PASRR prior to admission and to notify clinical team if there were any discrepancies. She stated their goal was for SSD, DON, and DON to follow up and update the PASRRs as applicable. She stated they would request level II updates if required. 2. A review of Resident #90's medical record revealed Resident #90 was admitted to the facility on [DATE] with diagnoses of depression and anxiety disorder. A diagnosis of schizophrenia was added to Resident #90's medical record on 1/25/2022. A review of Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/23/2023 revealed under Section I - Active Diagnoses, Resident #90 had diagnoses of anxiety disorder, depression, and schizophrenia. A review of Resident #90's PASRR assessment, dated 7/27/2021 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Schizophrenia was checked. The checkboxes for the selections Anxiety Disorder and Depressive Disorder were not checked. A review of Resident #108's medical record revealed Resident #108 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, mood disorder, and major depressive disorder. A diagnosis of anxiety disorder was added to Resident #108's medical record on 9/19/2023. A review of Resident 108's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/23/2023 revealed under Section I - Active Diagnoses, Resident #108 had diagnoses of cerebral palsy, anxiety disorder, depression, and mood disorder. A review of Resident #108's PASRR assessment, dated 6/16/2023 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Other (specify): mood disorder and depressive disorder were checked. The checkbox for the selection anxiety disorder was not checked. The assessment also revealed, under the section titled Related Condition, the checkboxes for the selection cerebral palsy was not checked. 3. On 11/13/2023 review of Resident #103's electronic medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the admission diagnosis sheet revealed an admission diagnosis to include but not limited to: Depression. Review of the entire electronic medical record revealed no level 1 Pre admission Screen and Record Review (PASRR). On 11/14/2023 at 8:30 a.m. an interview with the 200 unit Licensed Practical Nurse (LPN) Staff G, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 5 of 25 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 11/16/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assisted looking for the PASRR in the electronic chat. He was unable to locate any PASRR information for resident #103. On 11/14/2023 at 9:15 a.m. an interview with the Social Service Director. She was not able to locate Resident #103's level 1 PASRR screen for both admission dates, 10/9/2023 and 10/25/2023. The Social Service Director confirmed a level 1 PASRR screen should have been completed prior to her admission and should have already been uploaded into the electronic record. She was not sure why there was not a level 1 PASRR screen completed prior to her admission on [DATE]. On 11/15/2023 at 9:45 a.m. an interview with the Director of Nursing revealed she was not sure why the level 1 PASRR was not in Resident #103's electronic or hard record, but she would try to find it. At 11:00 a.m. the Director of Nursing provided a completed level 1 PASRR screen which was completed by herself on 11/15/2023. The Director of Nursing confirmed she had just competed the PASRR on the current date, 11/15/2023, and there was no other PASRR to provide. She confirmed there was no level 1 PASRR screen completed prior to Resident #103's 10/9/2023 or 10/25/2023 admissions. During an interview conducted on 11/13/2023 at 2:05 p.m., the Social Service Director (SSD) said she was responsible for obtaining the PASRR (Pre-admission Screening and Resident Review) prior to a resident's admission. She and nursing were responsible for updating the PASRRs when it was needed. Review of the admission Record revealed Resident #87 was admitted to facility on 5/17/2021, with diagnoses to include schizoaffective disorder, bipolar type, depression, adjustment disorder with mixed anxiety and depressed mood. Careplan review dated 11/29/2021 showed focus of use of psychotropic medications (Risperdal) r/t [related to] Behavior management, Schizoaffective disorder. The MDS dated [DATE] showed section C Cognitive Patterns with a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Review of Resident #87's PASRR revealed it was from [out of state] and dated 2/1/2021. Resident #87's PASRR had a total of 4 pages. Answers to the questions on page 2 and page 3 were illegible. Pages 1 and 4 were grainy in spots and difficult to decipher 50% of the writing on each page. The PASRR showed on page 4, Based on the information provided during the screening process, the individual MAY require a Level II. Question 2 showed, Does the individual have a current, suspected or history of a Major Mental Illness as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM), current edition? Choose no if the person's symptoms are situational or directly related to a medical condition (e.g. depressive symptoms caused by hyperthyroidism, depression caused by stroke, or anxiety due to COPD (Chronic Obstructive Pulmonary Disease), these conditions must be documented in the medical records by a physician answered Yes. Under Question 2a If yes, check the appropriate disorder below. (referring to question 2) Anxiety was checked. Schizoaffective disorder was blank. During an interview conducted on 11/15/2023 at 8:00 a.m., the SSD stated there was no set policy for an out of state PASRR. The SSD was unable to read, and or decipher page 2 and 3 of Resident #87's PASRR dated 02/01/2021. The SSD stated this is the resident's only PASRR, I will look for a more legible copy in her hard chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 6 of 25 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 11/16/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm Review of an undated facility policy titled, Pre-admission Screening and Resident Review (PASRR), showed the purpose of PASRR is to ensure individuals who are being considered for placement in a nursing facility are evaluated for serious mental illness and/intellectual disability and are offered the most integrated setting appropriate for their long-term care needs (including determining whether a nursing facility is appropriate). Residents Affected - Some Level 1 PASRR determines whether an individual referred for admission into a nursing facility has or is suspected of having an SMI and/ID diagnosis. Level II PASRR is an individualized, in-depth evaluation of the individual, including confirming or ruling out the suspected diagnosis and determining the need for nursing facility services. If a nursing facility is the most integrated setting appropriate to meet the individual's long term care needs, level II PASRR must also evaluate what specialized services if any are needed for this individual. Under procedure. (2). A level I PASRR must be fully and accurately completed and distributed in accordance with rule 59G-1.040, F.A.C. Upon or prior to admission, if the facility finds the level I to be incomplete or inaccurate a corrected level I PASRR must be completed by hospital staff or appropriate nursing facility staff (physician, RN MSW, or LC SW). (4). When applicable a request for a PASRR level 2 evaluation must be made by the social services director/ designee using the FL PASRR provider portal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 7 of 25 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 11/16/2023 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 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 observation, interview, and record review, the facility failed to ensure one (Resident #12) of 30 residents in hall 400, received care in accordance with professional standards of practice related to a change in condition (CIC). Residents Affected - Few Findings included: Review of an undated facility policy titled, Change in A Resident's Condition of status, showed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status e.g., Changes in level of care . 3. Unless otherwise instructed by the resident, the nurse supervisor/charge nurse/designee will notify the resident's family or representative when: There is a significant change in the resident's physical, mental or psychosocial status. 4. Regardless of the resident's current mental or physical condition, the nursing supervisor/charge nurse will inform the resident of any changes in his/her medical care or nursing treatments. 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 6. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MD 3.0 RAI instruction manual. On 11/13/23 at 12:04 p.m. Resident #12 was observed in her room sitting on her bed during lunch meal. Resident #12 was not eating her meal. The Responsible Party (RP) was assisting this resident with her meal. The RP stated she had recently started falling asleep during meals. She said, yesterday she did not eat breakfast nor lunch. She ate a little bit of her dinner. Today she is very sleepy. She stated this has been on-going. On 11/13/23 at 12:06 p.m., an interview was conducted with Staff W, COTA (Certified Occupational Therapy Assistant). She stated she had delivered the tray for the family member to assist Resident #12. She stated if a resident was not eating, the Certified Nursing Assistant (CNAs) would document the amount eaten and let the nurse know. She stated if the meal intake was below average the Speech Therapist (ST) would be notified. She stated she was not sure if this had happened. She stated the resident had declined quite fast. Review of the Electronic Medical Record (EMR) showed Resident #12 was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's. Newly documented diagnoses included pneumonia unspecified on 10/31/23, other symptoms and signs concerning food and fluid intake on 10/26/23, Acute cough on 10/31/23, hypomagnesemia on 10/27/23 and cutaneous abscess of back on 11/14/23. A Minimum Data Set (MDS) dated [DATE] Section C showed Resident #12 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. Section G Functional Status showed Resident #12 required extensive assistance with ADLs (Activities of Daily Living). For (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 8 of 25 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eating, the MDS showed the resident required supervision with set up only. Section G0400 showed the resident had impairment on both sides of the upper extremities and impairment on one side of lower extremity. A care plan for Resident #12 reviewed on 09/20/22 showed an ADL self-care performance deficit related to Alzheimer's, weakness, difficulty walking, contractures left and right hands, and need for assistance. An intervention for eating showed Resident #12 was independent with meal, requiring setup help only. On 11/14/23 at 9:19 a.m., an interview was conducted with Staff X, Certified Nursing Assistant (CNA). She stated Resident #12 had eaten a little bit that morning. She stated she had noticed Resident #12 was declining. She said the resident had not been as responsive as she normally was. Staff X stated the resident was sleeping a lot more. She did not know if the resident was in any pain. Staff X stated Resident #12 was normally independent with her meals. On 11/15/23 at 9:38 a.m., an interview was conducted with Resident #12's Responsible Party (RP). She stated her main concern was that the facility did not communicate with her when there was a change in [Resident #12's] condition. She stated she lived out of state and when she came to see [Resident #12] she noticed she had lost weight. She said, No one has said anything about the weight loss. They have not reached out to me about care plan meetings. The last one I attended was in June. Someone said they could not reach me. I have not changed my phone number and I have not moved. It has been impossible to reach anyone at the facility. Sometimes there is a missed call from the facility without a message. When I call back, I'm transferred from office to office or to the nurses' stations. The phone rings and no one answers. That keeps me worrying. I keep trying sometimes for hours. That is my biggest concern. The RP stated no one called her regarding [Resident #12] having pneumonia. She stated she happened to have visited the facility and asked questions and that was when she became aware of the pneumonia diagnosis. Review of record showed a care plan meeting was last held with the RP's participation in June 2023. There was no documented contact with the Responsible Party for the month of July and August 2023. Review of Resident #12's weight record showed on 6/11/23 the resident weighed 146.2 lbs. on 11/9/23 her weight was 125.8. Resident #12 lost 16.4 lbs. in 6 months and 27 lbs. in 12 months. Review of a CNA nutrition intake log dated 09/15/23 to 11/16/23 showed Resident #12 consistently consumed 0-25% of her meals. Review of a nursing progress note dated 10/31/23 showed, MD (medical Doctor) in to see resident. New orders received for CMP (Comprehensive Metabolic Panel) in the morning, IV (intravenous) dextrose 5%-0.45 two liters, and a speech evaluation. Resident continues to present with poor appetite. Assist dining offered and declined. Resident states that she does not want to eat. Fluids were offered and consumed with a 25% intake. Comfort and safety measures maintained. Call bell within reach. Review of a dietary progress note dated 11/1/23 showed Resident #12 a [AGE] year-old female with a diagnosis of Alzheimer's. CBW (current body weight) was 129.4 #. BMI (body mass index) 24.8. She has a weight loss of -7.6 x 30/-10.5 x 90-12.3 x 180 days. [Resident #12] is refusing all food and fluids is currently on Remeron and she still is not eating. Currently on a mechanical soft diet with 0 intake. Skin is intact with 0 open wounds, no edema noted . Doctor is aware of the resident's weight loss and refusal to eat. [Resident #12] is in a state where she says she just gives up and doesn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 9 of 25 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm want anything. No new recommendations at this time due to resident's refusal. We will continue to monitor changes in weight, intake, labs, and skin integrity. Review of a dietary progress note dated 11/14/23 showed current body weight was 129.4 pounds. Resident is refusing all food and fluids is currently on Remeron and she is still not eating. Residents Affected - Few Review of a physician note dated 9/7/23 showed Resident #12 was seen by this physician, disoriented in time, forgetful, cognition, declining and denies pain. Review of nursing progress notes dates 11/07/23 to 11/15/23 showed Resident #12 continued with antibiotics for pneumonia. Review of Resident #12's EMR showed a change (CIC) in condition was not documented. Review of the care plan showed no evidence that the plan of care had been updated. On 11/15/23 at 10:06 a.m., an interview was conducted with Staff A, Registered Nurse (RN)/Unit Manager. She stated she became aware the resident had a change in condition when staff reported she had not been eating. She stated the resident had a speech evaluation conducted. She stated she assisted the resident in dining and assessed her meal intake. Staff A stated she did not document this assessment. Staff A stated the resident kept saying, I don't want it. Staff A stated she notified the doctor and got something to stimulate her appetite. After the speech evaluation her diet consistency was changed to puree. Staff A stated she spoke to a family member in person, but she could not confirm if the healthcare surrogate / RP was notified. Staff A reviewed a progress note showing family was notified but she was not sure who the family was. Staff A said, I did not initiate a CIC. I did not contact the Responsible party. I was aware of the change as of 10/31/23. At the time she showed general malaise. Staff A, RN stated she did not see a CIC entered in the EMR or evidence the responsible party was notified. She said, I don't see one. I would have expected someone to document. It will be my expectation going forward. We have a task ahead of us to ensure all nurses will be educated . I will follow up. On 11/15/23 at 11:09 a.m., an interview was conducted with the Social Services Director (SSD). She stated the RP wrote a grievance about a week earlier. The RP had concerns about general communication and not being notified when [Resident #12] was sick. The SSD said, We scheduled for the unit/manger to reach out to her once a week. we have resolved her grievance. The SSD stated they discussed scheduling video visits with activities coordinator because Resident #12 was no longer able to hold on to the phone. The SSD said, I don't think that has happened yet. I will follow up with activities. On 11/15/23 at 11:30 a.m., an interview was conducted with Staff E, Speech Therapist (ST). She stated Resident #12 had contracted Covid several months before and her appetite declined. Staff E said, Recently she was dehydrated. They tried to give her hydration through IV. She was referred to Occupational Therapy (OT) for assistance with feeding. We have changed her diet. She was on a mechanical soft diet but for a week and a half now she was on a puree diet, and she needs to be fed. She has declined more rapidly for at least a month now, but the decline has been since she had Covid. She never bounced back. Staff E stated on October 20,[2023] she had noted Resident #12's meal consumption was less than 25% consistently. She stated she had discussed it with dietary and the Unit Manager. She stated on [DATE], [2023] she changed the resident's diet to pureed diet with thin liquids and notified the Unit Manager to monitor aspiration. She stated Resident #12 was eating independently until recently. Staff E said, she lost the ability to self-feed and that was why she was referred to OT. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 10 of 25 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a speech evaluation and plan of treatment notes showed on 09/27/23 treatment approaches were modified related to treatment of swallowing dysfunction and/or oral function for eating, and an evaluation of oral and pharyngeal swallow and function. The resident was referred to ST by nursing due to coughing/choking after meals. On 9/28/23 SLP (Speech Language Pathologist) assessed resident. Patient implemented feeding using small bites and slow rate of intake , frequently expectorating chewed boluses. Patient reported significantly decreased appetite. Patient consumed less than 25% of meal with cough x 1. On 9/29/23 - 10/30/23 Patient consumed less than 25% of meal. A SLP progress note dated 10/30/23, showed Patient precautions: aspiration risk, fall risk, HOH (Hard of Hearing), patient received in room , initially reclined in bed. Immediately stated I need to spit. Patient's sputum is light yellow and brown-tinged recommended chest x-ray based on RN report of elevated WBC (White Blood Cells) recommended 100% supervision and assistance with all PO (by mouth). On 10/30/23 diet changed to mechanical soft solids, thin liquids with no overt signs and symptoms of aspiration and adequate oral clearance. On 11/16/23 at 10:58 a.m., an interview was conducted with Staff V, Occupational Therapist (OT). She confirmed Resident #12 was referred for OT service due to a decline in self-feeding. Staff V said, she was independent. ST noticed she is not able to pick up the silverware. From my evaluation she has had a significant decline. She was using her left arm but now has no active range of motion (ROM) for both arms. She is not able to feed self. Our plan is to increase ROM. In the meantime, she is to be assisted by staff for food and hydration. Staff V stated she did not know why the care plan and CNA tasks had not been updated to reflect the change. Staff V said, we are supposed to fill out an orange sheet after the assessment and give it to the MDS coordinator so they can update the care plan. I don't know if I did that yet. On 11/16/23 at 11:09 a.m. an interview was conducted with Staff Z, MDS Director. She stated she was notified of the resident's CIC yesterday and initiated a significant change assessment. She stated she had it to close on Friday so the team members can update their sections. She stated from her review of the record, the resident's status changed significantly early October when she stopped eating. She said, This is when we should have initiated the change in plan of care. We should have discussed it in the standard of care meeting. We have identified a system breakdown. I will confirm with OT and update the plan of care so the [NAME] can be updated accordingly. In an interview with the Registered Dietician on 11/16/23 11:40 a.m., she said, I have been concerned about Resident #21's refusal to eat. Two weeks ago, she did not want to eat or see anyone. She was going through a true change. The problem started in August, and it has been ongoing. I saw she had been eating less than 25 % consistently. On November 1st. I had concerns with weight loss which were discussed, and Hospice was mentioned. The [Responsible Party] was not here that day. When saw that she had lost 10 pounds in one month, I was concerned about the 15% weight loss. That percentage weight loss should have triggered a response in the [electronic medical record]. An immediate response would have been to re-check the weight, confirm it then notify the doctor and family. The RD stated a response would require updating the care plan on the risk of significant weight loss. The RD said, I did not update the care plan. That was oversight on my part. I think communication in this building has been lacking, the new administration is making changes. We will be reviewing weights every first Friday. On 11/15/23 at 4:55 p.m., an interview was conducted with the Director of Nursing. She said, to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 11 of 25 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete honest, we are lacking communication as a team. The team is new, and we have not had a good interdisciplinary focus. A change in condition should have been documented and also kept the family informed. The expectation is to make sure all staff are communicating and that they understand the plan of care for each resident and especially when significant changes occur. The DON stated if Resident #12 had a significant change, she would expect the nurses to notify the family and to document the notification. She stated the MDS coordinator should have put in a significant change evaluation. The DON said, We will do better. Event ID: Facility ID: 106120 If continuation sheet Page 12 of 25 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 11/16/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure one (Resident #2) of six resident were free from accidental hazards as evident by the identification of a heating pad in use by the resident. Findings included: On 11/14/23 at 12.31 p.m., an observation was made of Resident #2 in her room, with a heating pad observed on her back while sitting in her electronic scooter. The resident stated she has had the pad for a while now. She stated she plugged it in herself. The heat just comes on. The resident could not verbalize how hot it was. She stated she liked it on her back. The resident stated her family member brought it to her. Upon further observation the heating pad had a digital display of 140 degrees Fahrenheit. On 11/14/23 at 12:35 p.m., an interview was conducted with Staff K, Certified Nursing Assistant (CNA). She confirmed the resident used the heating pad often, but not all the time. She asked to use it daily, but not all hours of the day. The CNA said, I assist her with her it. I position it to her lower bag [sic] and position the cord. She plugs and unplugs it herself. She stated the resident has had the pad for about a couple of months. She stated if a resident had a heating pad brought in by a family member, it would be documented in their inventory sheet. The CNA stated she did not know how hot a heating pad should be. She stated she did not know if the resident would be at risk of heat exposure. She stated the resident monitored how hot it was herself. A review of the resident's medical record showed no documentation of the resident's orders, care plan, and/ or progress notes related to the heating pad. A review of the resident's inventory sheet did not include a heating pad. On 11/14/23 at 12:55 p.m., an interview was conducted with Staff A, Registered Nurse (RN)/ Unit Manager (UM). She stated she did not have any residents using heating pads. She stated she was not aware Resident #2 used a heating pad. The Unit Manger reviewed orders and said, I don't see that she has orders. She stated if a family member brought any item which required to be plugged in, it must be checked out by maintenance. She said, We just can't plug it in like that. We have to make sure the resident is aware enough to maintain safety for themselves and others. If a resident had authorization to use a heating pad or blanket, it would be documented. There would be a progress note and physician orders. She stated no other residents that she knew of were using any heating devices. She said, We'll have to review our policy. We would have to evaluate the competency of the user and ensure settings were monitored for safe usage. This is not just for heating pads, it's on any device accessible to residents. An interview was conducted on 11/14/23 at 1:00 p.m. with Staff I, RN. Staff I stated there were no residents in her hall using a heating pad. If she saw it, she would probably take it away. Staff I stated it was a safety concern, which could cause the resident potential burning, electrical shock, or it could cause a fire. Staff I stated residents should not be using those without assessments, if at all. An interview was conducted on 11/14/23 at 1:04 p.m. with Staff X CNA, she works in the 400 halls. Staff X stated she had not seen any heating pads in her hall and stated they were not allowed because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 13 of 25 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 11/16/2023 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 0689 it was a safety risk. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 11/14/23 at 1:05 p.m. with Staff N, Restorative CNA. Staff N stated that she had not seen a heating pad in use in this facility, stating, I go through each room almost daily. It's not safe for the residents. Residents Affected - Few An interview was conducted on 11/14/23 at 1:07 p.m. with Staff O, CNA. Staff O stated she had not seen any heating pads or any residents using a heating pad and confirmed residents should not have a heating pad. Staff O stated the resident in room [ROOM NUMBER] had inquired about using a heating pad but she had told her she could not have one. Staff O stated she would turn up the heat in the resident's room if she was cold. Staff O stated if a resident had a heating pad, I would remove it and let the UM know. An interview was conducted on 11/14/23 at 1:08 p.m. with Staff F, LPN. Staff F had not seen any heating pads in his unit. They were not allowed in nursing homes because of the safety concerns. An interview was conducted on 11/14/23 at 1:09 p.m. with the Regional Nurse Consultant (RNC) who stated heating pads were not allowed in the facility, stating, It is too dangerous. An interview was conducted on 11/14/23 at 1:11 p.m. with the Nursing Home Administrator (NHA). She stated there should not be any residents using heating pads. She said, I'd imagine no, we do not allow use of items that require to be plugged in. There should be a skin assessment, orders, and a care plan. We would monitor use for safety. An interview was conducted on 11/14/23 at 1:13 p.m. with the former Director of Maintenance. He said, No, absolutely not. They cannot have anything electrical. It must be checked and cleared for safety. An interview was conducted on 11/14/23 at 1:14 p.m. with Staff A, RN/UM. Staff A stated the policy did not allow devices that needed to be plugged in. It must go through maintenance for clearance. He stated, I don't believe we have any residents using the heating pads. I just found out Resident #2 was using the pad. I will call the family to pick it up and assess the resident. We will complete a skin assessment. An interview was conducted on 11/14/23 at 1:51 p.m. with the DON and the NHA. The DON said, I just found now the resident had a heating pad. They are not allowed. I spoke with the resident. She said she did not notify nursing staff, we are doing a whole house audit. The DON stated she had concerns related to the nursing staff, not saying anything. I asked the CNAs they said they did not know she was not supposed to have it. Obviously, we need to do some education related to concerns with heat exposure. We will contact the family and let them know it is not allowed. The DON stated she will interview the resident to address the reason why she thought she needed the heating pad. The DON stated, We will speak to the physician and address any pain concerns. Therapy will do a screen. The expectation would have been to let the family know heating pads are not allowed. The NHA stated, I would have expected staff to remove it and notify the administration so her concerns can be addressed. It is a safety concern. We will do a whole house sweep to confirm no other residents are using the heating pads. We have initiated education for all nursing staff. A policy for the use of heating pads was requested but the facility did not have a policy. The NHA stated in their Resident Admissions packet there was a letter requesting the following items to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 14 of 25 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 11/16/2023 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 0689 leave at home. Upon review of the letter, number 9 states no extension cords. (All electrical items MUST be approved and inspected by maintenance first). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 15 of 25 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 11/16/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure accurate accountability and storage of controlled medications in one of three medication carts inspected and in one of two medication storage rooms inspected. Findings included: An inspection of a medication cart on the 300 unit of the facility was conducted on 11/15/2023 at 12:41 PM with Staff F, Licensed Practical Nurse (LPN). An interview with Staff F, LPN was conducted prior to counting the controlled medications drawer in the medication cart. Staff F, LPN stated he administered several controlled medications during the morning medication pass but did not sign them out as being administered. Staff F, LPN stated it was difficult to sign the controlled medications out of the controlled substances record during the medication pass due to time constraints and the way my mind works is to pass the medications first and sign them out as administered by the end of the shift. Staff F, LPN stated the controlled medications should be signed out in the controlled substance record at the time of the administration. A count of the controlled medication drawer in the medication cart revealed the following: - An empty box of fentanyl 12 micrograms (mcg) per hour transdermal patches. The controlled substance record documented one patch remaining in the box. Staff F, LPN stated he administered a patch to a resident that morning during the medication pass but did not document the administration on the controlled substance record. - A card containing 17, 1/2 tablets of tramadol 50 milligrams (mg). The controlled substance record documented 18 tablets remaining on the card. Staff F, LPN stated he administered a 1/2 tablet to a resident that morning during the medication pass but did not document the administration on the controlled substance record. - A card containing 2 tablets of Lorazepam 1 mg. The controlled substance record documented 4 tablets remaining on the card. Staff F, LPN stated he administered 2 tablets to a resident that morning during the medication pass but did not document the administration on the controlled substance record. - A card containing 12 tablets of Lorazepam 0.5 mg. The controlled substance record documented 13 tablets remaining on the card. Staff F, LPN stated he administered 1 tablet to a resident that morning during the medication pass but did not document the administration on the controlled substance record. - A card containing 13 capsules of Lyrica 75 mg. The controlled substance record documented 14 capsules remaining on the card. Staff F, LPN stated he administered 1 capsule a resident that morning during the medication pass but did not document the administration on the controlled substance record. An inspection of a medication room on the 300 unit of the facility was conducted on 11/15/2023 at 12:54 PM with Staff F, LPN. After Staff F, LPN unlocked the medication storage refrigerator, a metal box with a locking mechanism was observed inside of the medication refrigerator. The metal box contained controlled medications for emergency use and was unlocked. Staff F, LPN stated he did not know the box was unlocked and stated the box should have been kept locked because it contained controlled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 16 of 25 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 11/16/2023 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 0755 medications. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 11/16/2023 at 10:32 AM with the facility's Director of Nursing (DON). The DON stated whenever a controlled medication was administered to a resident, she would expect the nurse to sign out the medication right there, right then in the controlled substance record to ensure an accurate count. Nursing staff should not wait until the end of the medication pass to document the removal of the controlled medication. The DON also stated controlled medications inside of the medication storage refrigerator should be kept locked inside of the provided storage box and the refrigerator should be kept locked. Residents Affected - Few A review of the facility policy titled Medication Storage in the Facility, effective March of 2019, revealed under the section titled Policy medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. The policy also revealed, under the section titled Procedures controlled-substances that require refrigeration are stored within a locked box within the refrigerator. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 17 of 25 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 11/16/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and 23 errors were identified for two (Residents #84 and #89) of three residents observed. These errors constituted a 76.6% medication error rate. Residents Affected - Some Findings Included: On 11/15/23 at 10:08 a.m. an observation of medication administration with Staff I, Registered Nurse (RN) was conducted for Resident #89. Staff I dispensed the following medications: -Amiodarone HCL 100 mg one tablet -Carbidopa/Levodopa 10 milligram (mg)/ 100 mg two tablets -Claritin 10 mg one tablet -Clopidogrel Bisulfate 75 mg one tablet -Tamsulosin 0.4 mg one tablet -Spironolactone 50 mg one tablet -Metoprolol 25 mg one tablet -Lasix 40 mg tablet one tablet -Eliquis 2.5 mg one tablet -Aspirin 81 mg DR one tablet On 11/15/23 at 10:36 a.m. an observation of medication administration with Staff F, Licensed Practical Nurse (LPN) was conducted for Resident #84. Staff F dispensed the following medications: -Aspercream lidopatch one patch to left shoulder -Claritin 10 mg one tablet -Famotidine 20 mg with two 10 mg tablets -Flonase 1 puff per nostril -Hydrochlorothiazide 12.5 mg one tablet -Lisinopril 10 mg one tablet -Meloxicam 7.5 mg one tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 18 of 25 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 11/16/2023 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 0759 -Metformin 500 mg one tablet Level of Harm - Minimal harm or potential for actual harm -Artificial tears one drop to both eyes -Vitamin B1 100 mg one tablet Residents Affected - Some -Vitamin C 1000 mg with two 500 mg tablets -Vitamin D3 1000 two tablets An interview was conducted 11/15/23 at 11:45 with Staff I, RN regarding timeliness of medication administration. Staff I, RN stated medication administration should be given one hour prior to and/or up to one hour after the scheduled ordered time. Staff I, RN was unaware of the time when medication was given for Resident #89. When asked what the facility's policy for late administration of medication was, Staff I was unable to state what should be done. When asked if the ordering provider should be notified, Staff I, RN stated yes, the physician should be made aware but was unable to state when. Staff I, RN was not able to state what else to do with late administration. An interview was conducted 11/15/23 at 12:19 p.m. with Staff F, LPN regarding timeliness of medication administration. Staff F, LPN, stated medication administration could be challenging to complete in a timely manner when there were other activities involved in the resident's day to day morning activities such as therapy and resident council meeting. Staff F, LPN, stated medication administration had a window of one hour prior and one hour after the physician's order. Staff F stated the physician should technically be notified prior to late administration of medication. Staff F would also notify his Unit Manager (UM) and/or the Director of Nursing (DON) for assistance if the medication administration was late. An interview was conducted on 11/15/23 at 1:38 p.m. with Staff J, UM/RN (100 & 200 hallways) and Staff A, UM/RN (300 & 400 hallways). Staff A, UM/ RN stated medication administration had a window of one hour prior and one hour after ordered time for medication based on physician orders. Staff A also stated if medication was to be out of this time frame, a call should be placed to the physician prior to administration for either new orders or to document notification was made to the physician. Staff J UM/RN concurred with Staff A. Staff A stated medication pass could be monitored in real time via a dashboard in their electronic charting software. Both Staff A and Staff J stated assistance was always available if a nurse was running behind on medication. An interview was conducted on 11/15/23 at 4:39 p.m. with the DON regarding timeliness of medication administration. The DON stated medication should be administered one hour prior to and up to one after scheduled time. If the medication administration was out of the time frame, then a notification should be made to the ordering provider. A review of the facility's policy entitled, Medication Administration- General Guidelines, effective date March 2019, states the following in relation to medication administration: 4) Five Rights: right resident, right drug, right dose, right route, and the right time, are applied for each medication being administered. A triple check of these Five Rights is recommended at three steps in the process of preparation of a medication for administration (1) when the medication is selected, (2) when the dose is removed from the container and finally (3) just after the dose is prepared and the medication put away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 19 of 25 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 11/16/2023 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 0759 B. Administration Level of Harm - Minimal harm or potential for actual harm 2) Medications are administered in accordance with written orders of the prescriber. 6) Medications are administered without unnecessary interruptions. Residents Affected - Some 11) A schedule of routine dose administration times is established by the facility and utilized on the administration records. 12) Medications are administered within 16 minutes of the scheduled time except before with or after meal orders which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 20 of 25 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 11/16/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to properly secure medications in two of three medication carts, and for two (Residents #42 and #11) of 27 sampled residents in accordance with professional standards Findings include: On 11/14/23 at 1:50 p.m., an interview was conducted with Resident #42. Observations in her room revealed small pink plastic vials and the large bottle of nasal spray on her bedside table. The resident stated the pink vials were normal saline vials that she had obtained while at another facility. The large nasal spray she liked to keep because it was easier for the nurses to add more medication and normal saline to the bottle. Resident #42 stated the nasal spray was a compound medication that was mixed by a pharmacist but the nurses filled up the bottle for her now. She was not quite sure of the medication that was added but stated, it really helps me. When asked when the last time the bottle was filled the resident stated, a few weeks ago. An interview was conducted on 11/14/23 at 2:14 p.m. with Staff F, LPN. Staff F acknowledged the nasal spray for Resident #42 was last filled by him about a couple of weeks ago. Staff F stated he took normal saline that was used for wound care and fills up her nasal spray bottle for her. Staff F stated he did not see an order for the nasal spray but he would message her physician to obtain an order. Staff F stated he was unaware of the water bottle in Resident On 11/15/23 at 11:45 a.m., an observation was conducted for the medication cart for the 400 hallways. In the first drawer was a medication cup with nine tablets with an additional medicine cup on top of the bottom cup. Staff I, Registered Nurse (RN) stated those pills were for a resident that had refused her morning medications. Staff I, RN was holding on to them to try and give to the resident with the assistance of an interpreter. Upon further medication cart observation, personal effects such as jewelry and keys were found in another drawer. Staff I stated she did not know the policy on storage of items in the medication cart; but, the administration before did not have a problem with it so she thought it was ok. Staff I removed items to give to social service to locate the owners of items found in cart. Photographic evidence obtained. On 11/15/23 at 12:19 p.m., an observation was conducted of the medication cart for the 300 hallways. An insulin pen and glucometer test strips were not labeled. Photographic evidence obtained. Staff F, LPN stated because items were not labeled, they would be discarded. Staff F stated insulin pens should be labeled on the pen when opened. Behind the bottom drawer of the medication cart there were two medication punch out cards. When Staff F retrieved the cards, they were active medications for a current resident. Staff F stated he would look to see if the resident was still ordered to have those medications. On 11/15/23 at 1:35 p.m., an interview was conducted with Staff A, Registered Nurse/Unit Manager RN/UM regarding medication storage. Staff A stated only medication should go in the medication carts. On 11/16/23 at 1:55 p.m., an interview was conducted with the Director of Nursing regarding the results of the medication storage observations. The DON stated there was a need for further education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 21 of 25 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 11/16/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy Medication Storage in the Facility, effective March 2019, states the following regarding storage: Procedures B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and drug supplies are locked when not attended by persons with authorized access. Expiration Dating (Beyond-use-dating) D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line.) The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/ guidelines require different dating. E. The nurse will check the expiration date of each medication before administering it. F. No expired medication will be administered to a resident. G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. 2. An observation on 11/14/2023 at 10:08 a.m. revealed Resident #11 in bed asleep and a round pink tablet was on the floor area next to Resident #11's bathroom, beside the mechanical lift. There were no staff present during the observation. During an interview conducted on 11/14/2023 at 10:30 a.m. Staff S, Licensed Practical Nurse (LPN) stated, Looks like a cranberry pill. Staff S pointed at Resident #11 and stated, She gets a cranberry pill. Staff S said it probably fell off the cart when getting medications. At this time Staff S picked up the pink tablet from the floor and walked back to the nurses' station to discard it. Review of the admission Record revealed Resident #11 was admitted to the facility on [DATE] with a diagnoses to include urinary tract infection. Review of the current physician orders for November 2023 revealed an order, dated 5/17/2021, for Cranberry Oral Capsule 425 MG (milligram) (Cranberry(Vaccinium macrocarpon)) Give 1 capsule by mouth two times a day related to ENCOUNTER FOR PROPHYLATIC MEASURES, UNSPECIFIED. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 22 of 25 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility record review, the facility failed to ensure the kitchen and kitchen equipment were sanitary and with food free from cross contamination related to: 1. Two large sheet pans, which had seven to ten individualized plates of cakes on them, were shelved directly below a tray of defrosting raw red meat. The meat had dripped and pooled with blood on the plates of cakes; 2. One of One walk in freezer was observed with open food items exposed and frosted; 3. One of one reach in refrigerator/freezer unit was observed with open food items exposed and frosted; and 4. Staff from outside vendors not wearing proper hair and beard restraints when around food preparation and food cooking areas. Findings included: 1. On 11/13/2023 at 9:20 a.m. the facility's kitchen was toured with the Dietary Manager. The Dietary Manager revealed he had only been employed at the facility for approximately three months. Upon tour of the kitchen, there was a large walk-in refrigerator with the large metal door, which was closed. Once the door was opened and the unit was stepped into, it was observed the unit had multi shelving systems on either side inside of the unit. The shelving system on the left side of the unit, revealed the very bottom rack had two metal trays with approximately ten individualized plated prepared chocolate cakes. All the cakes had a plastic lid that only covered the top portion of them. The bottom half of the cakes were exposed to the refrigerator element. It was also revealed the second to the bottom shelf had boxes of what appeared to be raw meat that was defrosting. Further observations revealed the boxes of raw meat were leaking blood out through the bottom of the boxes and then down to the bottom shelf, where the cakes were located. It was found that blood had dripped onto the individualized plates of cakes and pooled. Also, some of the cakes appeared to be saturated with the blood. Photographic evidence was taken. The Dietary Manager saw the placement of the trays of cakes and asked the Dietary Aide, Staff P why the trays of cakes were on the bottom shelf and with raw meat on the shelf above them. Staff P apologized and revealed, I know better, and we should not have food items placed under defrosting raw meats. Staff P picked up one of the trays of contaminated cakes and then lifted it and placed it on the top shelf on the right side of the refrigerator unit. It was observed there were three other shelves below the newly placed tray, and all with boxes of food items. Staff P placed the contaminated tray of cakes and placed it upon other non contaminated boxes of food. Then the Dietary Manager lifted and took away the remaining tray of cakes that was stored on the bottom shelf, where raw meat blood was dripping. Upon removal of both trays of individualized plates of cake, there was a white plastic barrier board that was pooled with blood. It was unknown how long the blood was pooled on the surface of this white plastic board. The Dietary Manager revealed this was not the practice to store food and there should never be any food items stored under any raw meat, or defrosting raw meat. He revealed that he was making room to have over fifty frozen turkeys delivered. The Dietary Manager, nor Staff P could recall exactly how long the two trays of individualized plates of cakes were on the shelf below the raw meat. 2. Observations of the walk-in freezer, which was located next to the walk-in refrigerator revealed a multi shelved system on all sides of the inner unit. The shelving system directly below the unit fan motor housing, revealed three large brown boxes. All three boxes had the lids completely open and with blue bagged liner with food items to include a mixed vegetable medley. It was found that all three boxes were completely open and with the blue bag liner completely open, exposing all the food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 23 of 25 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm item contents. Further observations revealed the contents were heavily iced and frosted over. The Dietary Manager confirmed all the boxes were completely open and with the food items exposed. He revealed that he sometimes keeps boxes of food items open with the bag open but did not have a reason for it. He did confirm that the food items in this box were iced over and frosted. He confirmed the food items could possibly be frozen burned. Residents Affected - Some 3. During the same tour observation, the kitchen's one of one reach in refrigerator/freezer unit was observed. The right side door was observed as the freezer, and the left side door was observed as the refrigerator. Upon opening the right side door, (the refrigerator), there was a multi shelf system with packaged food items on each shelf. The bottom shelf was observed with a large brown cardboard box with the top section cut away. Further observations revealed clear plastic bagging that was holding what appeared to be frozen chicken tenders. The Dietary Manager confirmed the items in the box were pre cooked frozen chicken tenders. It was also observed that the top section of the bag was pulled open and exposing the chicken tenders to the refrigerator element. The Dietary Manager confirmed the bag was left open and with the food items exposed. He noted again that he has always kept boxed food items open to the air as it was quicker to get to them, rather than reopening the package. The top layer of chicken tenders were observed with heavy frosting/freezer burn. The Dietary Manager confirmed the exposed food items with frost built up and then confirmed that perhaps leaving the bag open was not the best practice. During the same tour timeframe on 11/13/2023, one of one reach in combination refrigerator/freezer was observed near the food preparation area. The left door to the unit was to a refrigerator and the right door to the unit was to the freezer. Upon opening the right door to the freezer portion of the unit, there was a multi shelf system with one large brown box and with the top completely open. The contents of the box appeared to be frozen chicken tenders that were in a plastic bag. The plastic bag was completely open with the chicken exposed to the elements. It appeared the top layer of chicken tenders were found with heavy icing/frosting. The Dietary Manager confirmed the box was completely open and with the food items exposed. He revealed that he sometimes keeps boxes of food items open with the bag open but did not have a reason for it. He did confirm that the food items in this box were iced over and frosted. He confirmed the food items could possibly be freezer burned. 4. During the same tour timeframe on 11/13/2023 and at 9:40 a.m., an outside vendor delivery person was observed to walk to the walk in refrigerator and ask the Dietary Manager a question. Observation of this vendor was observed with a very long and bushy beard measuring approximately eight to nine inches in length and approximately six to seven inches wide. The vendor was not wearing a beard restraint. He was noted with no hair on his head, and only with the beard. He was noted to walk through the entire kitchen to include walking at and by food preparation stations, food cooking stations and to the walk in refrigerator. The Dietary Manager continued to talk with the vendor and did not ask him to don a beard restraint. On 11/16/2023 during an interview with the Dietary Manager, revealed he remembered the vendor delivery person coming in the kitchen on 11/13/2023 and was not wearing a beard restraint. He revealed he did not ask him to put on a restraint because at the time he was with the survey team. He confirmed that he should have asked him to put on a beard restraint and that the delivery person had been at the facility before to deliver food. The Dietary Manager confirmed that any person (staff or visitor), who enters the kitchen were to wear hair and beard restraints and they were posted at the entry doorway of the kitchen. The Dietary Manager revealed he had inserviced his staff and continued to do so with new hires and as need. The Dietary Manager was asked if the facility had a Hair/Beard restraint use policy and procedure for review and he was not able to provide one. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 24 of 25 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/16/2023 at 10:00 a.m., the Nursing Home Administrator provided the General Kitchen Sanitation policy and procedure, with a 2016 date, which revealed: Policy - The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Dietary employees will maintain clean, sanitary kitchen facilities in accordance with the Florida Food Code in order to minimize the risk of infection and food borne illness. The procedure revealed the following but not limited to: 1. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. On 11/16/2023 at 10:00 a.m., the Nursing Home Administrator provided the Food Storage policy and procedure with a 2016 date, and revealed; Policy - To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the Florida Food Code and HACCP guidelines. The procedure section revealed the following but not limited to areas: 1. Refrigerators; a. Keep fresh meat, poultry, seafood, dairy products and most fresh fruit and vegetables in the refrigerator at an internal temperature of 41 degrees F. or less. b. Store all foods on racks and shelves off the floor. c. Store raw meats and eggs on the bottom shelf to prevent contamination of other food. To avoid cross-contamination, store raw or uncooked food and produce away from and below prepared ready or ready-to-eat food. 2. Freezers; a. Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products, such as ice cream, in the freezer at a temperature that maintains the froze state of the foods. b. Store all foods on racks or shelves off the floor. c. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 25 of 25