Health inspection·December 30, 2024

F 0580 Review of Resident #1's December Medication Administration Record (MAR) revealed the following: Level of Harm - Minimal harm or potential for actual harm - Vital signs every shift revealed on 12/4/24 during the 3 p.m. - 11 p.m. shift staff recorded a blood pressure of 157/114. Residents Affected - Few - Klonopin 0.5 milligram (mg) - Give 1 tablet one time a day r/t (related to) generalized anxiety disorder. Staff documented a 5 on 12/3/24, meaning Hold/see progress notes. The progress note confirmed the medication was held but the physician was not notified. On 12/15/24 and12/16/24 documentation showed a 9, meaning other/see nurse's notes. Review of progress notes revealed there were no notes documented for both days. - Haloperidol 2 mg - Give 1 tablet by mouth two times a day related to schizoaffective disorder bipolar type. The documentation showed staff did not administer the medication. Documentation showed a 5 for the 2:00 p.m. dose on 12/2/24, 12/13/24, and 12/17/24. Further review showed this order was discontinued on 12/26/24 at 9:19 p.m. - Klonopin 1 mg - Give 1 tablet by mouth two times a day related to generalized anxiety disorder. The documentation showed staff had not administered the scheduled 2 p.m. dose on 12/1/24, 12/2/24, 12/12/24, 12/13/24, 12/17/24 and 12/25/24. Review of Behavior Monitoring Record showed the resident had not exhibited any behaviors during the month of December 2024. Review of Resident #1's progress notes revealed the following medication and notification documentation: - On12/1/24 at 1:57 p.m. Klonopin 1 mg tablet by mouth two times a day, held for lethargy. - Nursing note on 12/2/24 at 2:16 p.m. showed Resident lethargic did not administered medication. Patient is in her room eyes closed resting in bed. - 12/3/24 at 6:10 a.m. staff documented resident's Klonopin was withheld per nurse due to blood pressure. - 12/12/24 at 2:23 p.m. Nursing note revealed Resident was lethargic attempted to administered medication x2. The documentation did not reveal the medication that had been attempted to be administered. - 12/12/24 at 2:26 p.m. a nursing note revealed Not administered due to patient is lethargic. The note did not identify the type of medication not administered. - 12/17/24 at 2:10 p.m. Medication not administered, writer attempted x2, due to patient is lethargic. - 12/25/24 at 3:18 p.m. Klonopin 1 mg two times a day Resident lethargic. - 12/25/24 at 9:29 p.m. Klonopin 1 mg two times a day Held lethargic. Review of Resident #1's progress notes revealed the attending physician and Hospice were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 2 of 6 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 12/30/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified of the hypertensive incident on 12/4/24 related to a blood pressure of 157/114. The notes did not include documentation from 12/15 or 12/16 regarding the non-administration of the scheduled dosage of 0.5 mg of Klonopin. The documentation did not reveal staff had notified either the attending physician, Hospice, or family of withholding the psychotropic medications for the resident's condition of lethargy. Review of the attending physician note, dated 12/24/24, did not document the incident of hypertension on12/4/24 and revealed Staff to report any new or worsening issues, complications, or symptoms to provider via Situation, Background, Appearance (and) Recommendation (SBAR) and Blood pressure should be monitored and reported as ordered. Review of Resident #1's quarterly Minimum Data Set (MDS) dated 12/2624, showed a Brief Interview of Mental Status (BIMS) score was 11 of 15, indicating a moderate cognitive impairment. During an interview on 12/30/24 at 9:35 a.m. Staff B, Registered Nurse (RN) stated for a change in condition, she would text physician and notify the family. Staff B stated if the physician was not heard back from in 30 minutes, she would call them. An interview was conducted with Staff C, RN, on 12/30/24 at 12:10 p.m. Staff C stated orders are received from Hospice for Resident #1 and when an order was given by the Hospice provider the attending physician and family were notified. The order showed, notify everyone, it's a must. When a medication is held, Hospice, the attending physician, and the family are notified. An interview was conducted with the Hospice RN on 12/30/24 at 1:40 p.m. regarding Resident #1. The RN stated some complaints were made of the facility holding Haldol in the afternoon, so the Hospice Advanced Practical Registered Nurse (APRN) and the RN visited together last week. The Hospice RN stated the Hospice ARNP notified the staff if holding meds the ordering physician needed to be notified. An interview was conducted with the Director of Nursing (DON) on 12/30/24 at 2:32 p.m. The DON reviewed Resident #1s progress notes, and the held medications and acknowledged staff should be notifying the physician, Hospice, and family member. The DON said, of course, if it's not documented it wasn't done. During an interview on 12/30/24 at 2:43 p.m. the DON stated if a medication was held or refused, they should be notifying the physician, family, and Hospice then proceed. Review of an undated facility policy titled, Change in a Resident's Condition or Status, revealed 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, billing/ payments, resident rights, etc.). The Nurse Supervisors/ Charge Nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/ emotional/ mental condition which includes discovery of the loss of vital bodily functions (loss of responsiveness to stimuli and loss of blood pressure, pulse, and respirations) and a reaction to medication and/ or a medication error. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 3 of 6 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 12/30/2024 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%. Twenty-two medication administration opportunities were observed, and six errors were identified for two (#2 and #3) of two residents observed. These errors constituted a 27.27% medication error rate. Residents Affected - Some Findings included: 1) On 12/30/24 at 8:32 a.m., observation of medication administration with Staff A, Licensed Practical Nurse (LPN) was conducted. Staff A, LPN dispensed the following medications for Resident #2: - 2 tablets of Vitamin B12 500 microgram (mcg) tablet over-the-counter (otc) - Vitamin C 500 milligram (mg) tablet otc - Fish Oil 500 mg softgel otc - Loratadine 10 mg tablet otc - Bumetanide 0.5 mg tablet - Gabapentin 300 mg capsule - Duloxetine 20 mg capsule - 2 capsules Guaifenesin 400 mg otc - Breo Ellipta inhaler 100 mcg/25 mcg - Acidophilus probiotic (lactobacillus acidophilus 0.5 mg - 10 million) The staff member reviewed 2 bottles - one white and one green otc bottles of probiotics before dispensing the one tablet of lactobacillus. Staff A confirmed dispensing 11 tablets and one inhaler by reviewing the medication profile without counting the tablets in the medication cup. The staff member placed the inhaler on the over-bed table and the resident inhaled one time, then picked up med cup and began taking oral medications. Staff A retrieved water from the bathroom sink and advised resident to rinse and swallow. Review of Resident #2's active physician orders and the December 2024 Medication Administration Record (MAR) included the following orders: -Fish Oil Oral Capsule 1000 mg (Omega 3 Fatty Acids) - Give 2 capsule by mouth one time a day for vitamin deficiency. -Saccharomyces boulardii oral capsule 250 mg - Give 1 capsule by mouth one time a day for prophylactic measures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 4 of 6 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 12/30/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The observation on 12/30/24 at 8:32 a.m. showed Resident #2 received 500 mgs of Fish Oil, not the 2000 mgs ordered, and received 0.5 mgs of the probiotic lactobacillus acidophilus, not the ordered 250 mgs of the probiotic Saccharomyces boulardii. Review of the website, https://www.webmd.com/vitamins/ai/ingredientmono-332/saccharomyces-boulardii showed Saccharomyces boulardii is a type of probiotic, a strain of yeast used for treating, and preventing diarrhea. Review of the website, https://www.webmd.com/vitamins/ai/ingredientmono-790/lactobacillus-acidophilus described the probiotic Lactobacillus acidophilus is a type of probiotic that can help break down food, fight of bad organisms, and absorb nutrients. 2) On 12/30/24 at 9:14 a.m., an observation of medication administration with Staff B, Registered Nurse (RN) was conducted. Staff B, RN dispensed the following medications for Resident #3: - Aspirin Enteric Coated (EC) 81 mg otc tablet - Vitamin B12 500 microgram (mcg) otc tablet - Eliquis 5 mg tablet - Fluticasone prop nasal spray - Ipratropium (Atrovent) nasal spray. Opened 9/29/24 yellow sticker read to discard after 60 days - Fexofenadine 180 mg otc tab - Potassium chloride 10 milliequivalents (meq) Extended Release (ER) - Prednisone 5 mg tablet - Vitamin D 25 mcg otc tablet Staff B confirmed dispensing seven tablets. During the observation, the nasal spray, Ipratropium was noted to have a yellow sticker attached to the box with an open date of 9/29/24 and read to discard after 60 days. The staff member removed the Ipratropium from the box and entered Resident #3's room with both nasal sprays and the oral medications, placing the medication cup in front of the resident on the over bed table. The staff member was asked to exit the room and to review the Ipratropium. Staff B reviewed the yellow sticker and confirmed the nasal spray had expired on 11/29/24. The staff member placed the medication in the bottom drawer of the cart and returned to the resident's room. Staff B obtained a blood pressure of 107/71, administered the medications and stated the resident's Metoprolol would be held due to the blood pressure. The staff member went to central supply to retrieve an over counter medication for the resident and dispensed one 500 mg tablet of the otc medication of Magnesium oxide and administered the tablet to the resident. Review of Resident #3's active physician orders included the following medication orders: - Ipratropium Bromide Nasal solution 0.03% - 1 spray in both nostrils two times a day related to Allergic Rhinitis unspecified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 5 of 6 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 12/30/2024 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 Level of Harm - Minimal harm or potential for actual harm - Magnesium Gluconate 500 mg tablet - Give 1 tablet by mouth one time a day for supplement related to deficiency of other vitamins. - Metoprolol Tartrate Oral Tablet - Give 25 mg by mouth in the morning for Paroxysmal Atrial Fibrillation. Hold if Heart Rate (HR) < (less than) 60. Residents Affected - Some - Vitamin D3 tablet (Cholecalciferol) Give 2000 unit by mouth one time a day related to Deficiency of other vitamins. The observation on 12/30/24 at 9:14 a.m. showed Resident #3 received Magnesium Oxide 500 mg (and not Magnesium Gluconate 500 mg as ordered), received Vitamin D 25 mcg otc tablet (and not Vitamin D3 tablet Cholecalciferol 2000 units by mouth as ordered), would have received expired Ipratropium Bromide nasal spray, but was halted by the state surveyor, and did not received Metoprolol Tartrate 25 mg by mouth as ordered. Review of the electronic MAR notes dated 12/30/24 at 9:29 a.m. revealed Staff B documented the Metoprolol Tartrate was held for BP 107/70. The MAR nor clinical record showed a blood pressure monitoring parameter for this medication. The parameter for administration of this medication was a HR less than 60. Review of the Vital Signs Summary showed Staff B documented the resident's HR on 12/30/24 at 8:08 a.m. of 95 beats per minute (bpm), which did not meet the parameter to withhold this medication. On 12/30/24 at 2:43 p.m., the Director of Nursing (DON) was informed of the medication observation concerns. The DON stated these were legit errors. Review of the undated policy titled Nursing Administration of Drugs revealed residents shall receive their medications on a timely basis in accordance with our established policies. The procedure for the administration of medications showed Should there be any doubt concerning the administration of medication(s), the physician's order must be verified before the medication is administered. The policy did not include general nursing standards such as assuring that the correct medication is administered in the correct dose and in accordance with manufacturer ' s specifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106120 If continuation sheet Page 6 of 6