Inspection·July 27, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure an assessment was completed and transmitted for the residents discharged from the facility within 14 days of discharge for 2 of 3 residents reviewed, Residents #2 and #3. Residents Affected - Few Findings include: Review of Resident #3's records revealed that the resident was discharged on 3/31/2022 to the resident's home with family. Review of Minimum Data Set (MDS) did not show a discharge assessment on Resident #3. Review of Resident #2's records revealed that the resident was discharged on 3/31/2022 to the resident's home with family. Review of Minimum Data Set (MDS) did not show a discharge assessment on Resident #2. During an interview on 7/26/2022 at 12:02 PM, Staff G, Registered Nurse MDS Coordinator, stated that Resident #2 and Resident #3 had missing discharge assessments that they should have had at the end of PPS (perspective payment system), weather a return was anticipated or not anticipated to the facility. Review of the facility policy titled MDS 3.0 Completion dated April 1, 2022, reads, Policy: Resident are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines . 2. Types of OBRA [Omnibus Budget Reconciliation Act] Assessments . f. Discharge Assessment- completed using the discharge date as the ARD [Assessment Reference Date]. Must be completed within 14 days of the discharge date /ARD . 7. Transmission Requirements: a. All assessments shall be transmitted to the designated CMS [Centers for Medicare and Medicaid Services] system (QIES ASAP) [Quality Improvement and Evaluation System Assessment Submission and Processing] within 14 days of completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 2 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written summary of the baseline care plan to 1 of 4 residents reviewed for baseline care plans, Resident #339. Findings include: Review of Resident #339's clinical record revealed the resident was most recently admitted to the facility on [DATE] with diagnoses that included: displaced fracture of right tibial tuberosity, subsequent encounter for closed fracture with routine healing; morbid (severe) obesity due to excess calories; synovial cyst of popliteal space (Baker), right knee; unspecified asthma, uncomplicated; hyperlipidemia, unspecified; essential (primary) hypertension; and personal history of COVID-19. Review of the resident's Brief Interview of Mental Status (BIMS) completed on 7/26/22 revealed the resident was cognitively intact with a score of 15. Review of the resident's baseline care plan completed on 7/21/22 revealed the section labeled, A copy of this care plan and an Order Summary have been provided to me was blank. During an interview on 7/26/22 at 10:08 AM, Resident #339 stated that on the second day at the facility, so many people came to talk to her and asked her to sign documents that she doesn't know who they were or what she was signing. When asked if she received a copy of the care plan, the resident stated, No, I would have loved to have got a copy of it so I can see what's on it. During an interview on 7/26/22 at 3:00 PM, the Interim Director of Nursing stated that residents are supposed to get a copy of the baseline care plan after they sign it, but there is no system in place so prove the residents were provided a copy. Review of facility policy titled, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates, dated 4/1/22, revealed it stated in part, The facility will provide the resident and their representative with a summary of the baseline care plan when requested that includes, but is not limited to: the initial goals of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility; personnel acting on behalf of the family; and any updated information based on the details of the comprehensive care plan, as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 3 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide personal hygiene for resident's dependent on staff for activities of daily living for 1 (Resident #29) of 5 residents reviewed. Residents Affected - Few Findings include: Observation of Resident #29 on 07/24/22 at 11:59 AM revealed the resident had long and jagged fingernails with visible dark matter underneath the nails. Observation of Resident #29 on 7/26/22 at 8:40 AM revealed the resident had fingernails that were long and jagged. Observation of Resident #29 on 7/26/22 at 10:00 AM with Staff D, CNA (Certified Nurse Assistant) who confirmed the resident's fingernails were long and jagged. During an interview on 7/26/22 at 10:00 AM Staff D stated that Resident #29 is total care and that he received hygiene care this morning. Staff D stated [Resident #29's name] fingernails look bad, it looks like it's been a while since they have been taken care of. I'm going to do that right away. He is my resident, and I should have [provided care]. Review of Resident #29's care plan, dated 5/26/22, documented Staff to assist with activities of daily living such as bed mobility, transfers, dressing, toileting, personal hygiene and bathing according to need at the time. Review of Change of Status Minimum Data Set (MDS), completed 5/13/22, documented Resident #29 was coded as total dependence for personal hygiene. Review of the Quarterly Minimum Data Set, dated [DATE], documented Resident #29 needed extensive assistance for personal hygiene. Review of the facility policy titled Care of Fingernails/Toenail last reviewed on 1/28/22 reads Purpose. The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections General Guidelines. 1. Nail care includes cleaning and regular trimming 4. Trimmed and smoothed nails prevent the resident from accidentally scratching and injuring his or her skin 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain or if nails are too hard or too thick to cut with ease. Reporting. 1. Notify the supervisor: a. if resident refuses care b. any difficulties in cutting the resident's nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 4 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 provide a therapeutic diet intervention as recommended by the Registered Dietician for 1 (Resident #20) of 2 residents reviewed for nutrition. Residents Affected - Some Findings include: Review of Resident #10's care plan, start date: 7/21/2022, revealed Resident #10 was at risk for malnutrition related to difficulty swallowing and requiring an altered diet. Resident #10's care plan documented nutritional interventions that included weight loss noted, supplement added. Review of Resident #10's weight history showed on 6/3/2022, Resident #10 weighed 139 pounds and on 7/2/2022, Resident #10 weighed 131 pounds which was a 5.76% weight loss. Review of Resident #10's Nutrition Risk Screen with Mini Nutritional Assessment, dated 4/21/2022, documented Resident #10 had diagnoses that included anemia and a recommendation that Resident #10 receive a health shake three times a day. Review of Resident #10's Nutrition Risk Screen with Mini Nutritional Assessment, dated 7/21/2022, documented the nutritional recommendation that Resident #10 receive a health shake three times a day on each meal tray. On 7/24/2022 at 12:37 PM, Resident #10 was observed during her midday meal. Resident #10 was dining in her room with her meal on her bedside table. A health shake supplement was not provided to Resident #10 with her midday meal. On 7/25/2022 at 8:20 AM, Resident #10 was observed during the morning meal. Resident #10 morning meal had been served in her room placed on her bedside table. A health shake supplement was not provided to Resident #10 with her morning meal. On 7/26/2022 at 8:45 AM, Resident #10 was observed during the morning meal. Resident #10 morning meal had been served in her room placed on her bedside table. A health shake supplement was not provided to Resident #10 with her morning meal. During an interview on 7/26/2022 at 8:49 AM, Staff D, Certified Nursing Assistant, stated she did not remember if Resident #10 received a health shake supplement with her meals. During an interview on 7/26/2022 at 8:50 AM, Staff E, Registered Nurse, reported that Resident #10 received supplements that included fortified nutritional shake with her medications and a health shake one time a day. During an interview on 7/26/2022 at 9:07 AM, Staff F, Licensed Practical Nurse/[NAME] Hall Unit Manager stated she had seen a health shake supplement served on Resident #10's supper tray and that the health shake supplement should come with her meal trays from the kitchen. Staff F added that Resident #10 will eat it [health shake supplement] when she has it but do not see it every meal. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 5 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 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 0692 reported that Resident #10 would ask the staff to leave the health shake supplement with her. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/26/2022 at 12:46 PM, the Registered Dietician stated that Resident #10's weight was stable until the beginning of this month [July 2022], that the Dietary Manager had completed the Nutrition Risk Screen with Mini Nutritional assessment dated [DATE] and the Dietary Manager had documented what the resident is supposed to be on. She added the health shake supplement would provide Resident #10 with 200 calories a serving or 600 additional calories a day. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 6 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - 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 respiratory care was provided consistent with professional standards of practice for 2 (Residents #63 and #337) of 4 residents reviewed for oxygen administration. Residents Affected - Few Findings include: 1. Review of Resident #63's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, unspecified, and acquired absence of other specified parts of digestive tract; ileus, unspecified; major depressive disorder, recurrent, unspecified; hypokalemia; hypothyroidism, unspecified; unspecified atrial fibrillation; urinary tract infection, site not specified; muscle weakness (generalized); essential (primary) hypertension; hypoxemia; and dependence on supplemental oxygen. Review of Resident #63's physician orders dated 6/17/22 read, Oxygen at 4L [liters] via NC [nasal cannula, a small flexible tube that sits in the nose] QHS [every night at bedtime] and prn [as needed] SOB [shortness of breath.] During an observation on 7/24/22 at 10:43 AM, oxygen was being administered to Resident #63 via a nasal cannula connected to an oxygen concentrator located on the floor next to her bed. The oxygen concentrator was set at 2 liters per minute. (Photographic evidence obtained.) During an observation on 7/24/22 at 12:30 PM, oxygen was being administered to Resident #63 at 2 liters per minute via a nasal cannula. During an interview on 7/24/22 at 12:30 PM, Resident #63 stated she has been receiving oxygen since she came to the facility. The resident stated that it is sometimes hard for her to breathe. During an observation on 7/25/22 at 11:11 AM, oxygen was being administered to Resident #63 at 2 liters per minute via a nasal cannula. (Photographic evidence obtained.) During an observation on 7/26/22 at 9:05 AM, oxygen was being administered to Resident #63 at 2 liters per minute via a nasal cannula. (Photographic evidence obtained.) During an interview on 7/26/22, at 9:05 AM, Resident #63 stated the oxygen concentrator is supposed to be set at 4 liters per minute. The resident denied changing the setting herself. The resident said the physical therapist (Staff I) adjusted the oxygen concentrator to 2 liters per minute so she wouldn't get used to the higher amount. The resident stated the lower amount of oxygen was not sufficient and she gets out of breath when she exerts herself, such as when she straightens her bedding or organizes her things on her bedside table. During an interview on 7/26/22 at 11:00 AM, Staff I, Physical Therapist Assistant (PTA) stated there are times when he will do an oxygen study during treatment, during which he will use a finger pulse/oximeter to measure the resident's oxygen levels. Staff I stated if the resident's oxygen level is 95% or higher during exercise, he will speak to the resident's nurse and recommend that the amount of oxygen be lowered to try to ween the resident off the oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 7 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/26/22 at 11:25 AM, Staff H, RN, stated Resident #63 has been on oxygen since she was admitted . Staff H stated the oxygen concentrators are set by the nurses according to the residents' physician orders. Staff H stated they are supposed to be checked every round (usually during medication pass.) Staff H stated that Resident #63 is highly dependent on oxygen and cannot go without it. During an observation of Resident #63 on 7/26/22 at 11:40 AM, Staff H confirmed that the resident's oxygen concentrator was set at 2 liters per minute and then adjusted it to 4 liters per minute. 2. Review of Resident #337's clinical record revealed the resident was most recently admitted to the facility on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia; severe sepsis without septic shock; morbid (severe) obesity due to excess calories; chronic obstructive pulmonary disease, unspecified; other pneumonia, unspecified organism; candidiasis, unspecified; elevation of levels of liver transaminase levels; hyperlipidemia, unspecified; anxiety disorder, unspecified; low back pain, unspecified; body mass index (BMI) 35.0-35.9, adult; personal history of peptic ulcer disease; essential (primary) hypertension; retention of urine, unspecified; acute kidney failure, unspecified; and chronic lymphocytic leukemia of b-cell type not having achieve remission. Review of Resident #337's physician orders did not reveal an order for the administration of oxygen. During an observation on 7/24/22 at 12:40 PM, oxygen was being administered to Resident #337 via a nasal cannula connected to an oxygen concentrator located on the floor next to her bed. The oxygen concentrator was set at 3 liters per minute. (Photographic evidence obtained.) During an interview on 7/24/22 at 12:40 PM, Resident #337 stated she has been receiving oxygen since she was admitted to the facility. The resident said it is difficult for her to breathe, and she also has an oxygen concentrator that she uses at home. During an observation on 7/25/22, at 11:23 AM, oxygen was being administered to Resident #337 at 3 liters via a nasal cannula. (Photographic evidence obtained.) During an observation on 7/26/22 at 9:33 AM, oxygen was being administered to Resident #337 at 3 liters via a nasal cannula. (Photographic evidence obtained.) During an interview on 7/26/22 at 11:25 AM, Staff H, RN, stated Resident #337 has been on oxygen since she was admitted . Staff H stated the oxygen concentrators are set by the nurses according to the residents' physician orders. Staff H stated they are supposed to be checked every round (usually during medication pass.) Staff H stated that Resident #337 is highly dependent on oxygen and cannot go without it. During an observation of Resident #337 on 7/26/22 at 11:48, Staff H confirmed the resident was being administered oxygen at 3 liters per minute via a nasal cannula. During an interview on 7/26/22 at 12:55 PM, the Assistant Director of Nursing (ADON), stated the nurses assigned to the residents receiving oxygen are supposed to check their concentrators every shift to be sure they are receiving the prescribed amount. The ADON stated, My expectation is that staff monitor the oxygen concentrators to make sure they are set according to the orders. If there is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 8 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete an order in place, they should contact the resident's doctor to get an order before administering the oxygen. The ADON confirmed that Resident #63's physician order was for 4 liters per minute, but it was changed today to 2-4 liters per minute. The new order goes into effect on 7/26/22 at 9:00 PM. The ADON also confirmed that that Resident #337 did not have an order for oxygen administration when she was admitted . Review of facility policy titled, Oxygen Administration, dated 4/1/22, read in part, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in The Procedure: Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Event ID: Facility ID: 106126 If continuation sheet Page 9 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview the facility failed to ensure the licensed pharmacist conducted a medication regimen review at least monthly for 2 residents (Resident #18 and #75) and failed to ensure the physician acknowledged and responded to the pharmacist's recommendations for 1 resident (Resident #67) of 5 residents reviewed for unnecessary medications. Findings include: Review of Resident #18's pharmacy consultation report records failed to reveal documentation the consultant pharmacist had reviewed Resident #18's medication regimen during October 2021. Review of Resident #75's pharmacy consultation report records failed to reveal documentation the consultant pharmacist had reviewed Resident #75's medication regimen during June 2022. Review of Resident #67's pharmacy consultation report record, dated 6/24/2022, documented the pharmacist recommended the physician consider discontinuing polyethylene glycol due to lack of use in the previous 60 days. Review of Resident #67's clinical record failed to reveal documentation the physician had responded to the pharmacist's recommendation to consider discontinuing Resident #67's polyethylene glycol medication due to lack of use in the previous 60 days. During an interview on 7/27/2022 beginning at 8:03 AM, the Interim Director of Nursing confirmed she was unable to locate the missing pharmacy consultation reports for Resident #18 and Resident #75. The Interim Director of Nursing confirmed she was unable to locate documentation the physician had responded to the pharmacist's recommendation to consider discontinuing Resident #67's polyethylene glycol medication due to lack of use in the previous 60 days. Review of the facility policy titled Medication Regimen Review, last reviewed 1/28/2022, showed the policy read The medication regimen will be reviewed at least monthly by a licensed pharmacist. The facility develops a system which supports irregularities acted upon in order to minimize adverse consequences which may be associated with medications 4. The pharmacist reports any irregularities in a separate written report to the attending physician, medical director, and the director of nursing. The recommendations are reviewed, and a response provided, in a timely manner, dependent upon the nature of the concern. 5. If recommendation is declined, the response includes a valid clinical rationale for rejection of the pharmacist's recommendation unless warranted by a change in the resident's condition or other circumstances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 10 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview the facility failed to ensure an anti-anxiety medication prescribed on an as needed basis was not prescribed for more than 14 days, failed to ensure the physician acknowledged and responded to the pharmacist's recommendations for a gradual dose reduction of an atypical antipsychotic, and failed to ensure the physician acknowledged and responded to the pharmacist's recommendation for the addition of a stop date on an as needed antianxiety medication for 1 (Resident #18) of 5 resident reviewed for unnecessary medications. Findings include: Review of Resident #18's pharmacy consultation report, dated 9/25/2021, showed the pharmacist recommended the physician consider a gradual dose reduction of the antipsychotic medication Rexulti 1 milligram daily for schizoaffective disorder to 0.5 milligrams daily. Review of Resident #18's clinical record failed to reveal documentation the physician had responded to the pharmacist's recommendation to consider a gradual dose reduction of Resident #18's prescribed antipsychotic medication Rexulti 1 milligram daily to 0.5 milligrams daily. During an interview on 7/27/2022 beginning at 8:03 AM, the Interim Director of Nursing confirmed she was unable to locate documentation the physician had responded to the pharmacist's recommendation to consider a gradual dose reduction of Resident #18's prescribed antipsychotic medication Rexulti 1 milligram daily to 0.5 milligrams daily. Review of Resident #18's physician's order records documented Resident #18 was prescribed Ativan tablet 0.5 milligrams by mouth every 6 hours as needed for pain. The order documented a start date of the medication as 5/12/2022. Review of Resident #18's pharmacy consultation report, dated 6/24/2022, showed the pharmacist recommended the physician add a stop date to Resident #18's order for Lorazepam [Ativan] 0.5 milligrams every 6 hours. The consultation report read Recommendation: Please discontinue PRN [Pro re nata] Lorazepam. If the medication cannot be discontinued at this time, current regulations require that the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration of the PRN order. During an interview on 7/27/2022 beginning at 8:03 AM, the Interim Director of Nursing confirmed she was unable to locate documentation the physician had responded to the pharmacist's recommendation to consider discontinuing or adding a stop date to Resident #18 prescribed antianxiety medication. Review of the facility policy titled Medication Regimen Review, last reviewed 1/28/2022, showed the policy read The medication regimen will be reviewed at least monthly by a licensed pharmacist. The facility develops a system which supports irregularities acted upon in order to minimize adverse consequences which may be associated with medications 4. The pharmacist reports any irregularities in a separate written report to the attending physician, medical director, and the director of nursing. The recommendations are reviewed, and a response provided, in a timely manner, dependent upon the nature of the concern. 5. If recommendation is declined, the response includes a valid clinical rationale for rejection of the pharmacist's recommendation unless warranted by a change in the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 11 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 condition or other circumstances. 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: 106126 If continuation sheet Page 12 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 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 - Few 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 record review the facility failed to remove expired medication and supplies from 2 of 2 medication storage areas and dispose of expired medication in accordance with facility protocol. Findings include: During a tour of the 300-unit medication room on [DATE] at 10:35 AM with the Director of Nursing and the Infection Control Nurse/Assistant Director of Nursing (ADON) outdated over the counter (OTC) medication was observed: 2 boxes of Famotidine 10 milligram with an expiration date of 05/2022 (photographic evidence obtained). During a tour of the 200-unit medication room on [DATE] at 11:05 AM with the ADON, expired COVID 19 testing swabs was observed: 6 envelopes with an expiration date of 06/2021 (photographic evidence obtained). During an interview on [DATE] at 10:37 AM with the ADON, she stated the central supply clerk was the person who stocks the OTC medications and is expected to check the dates. During an interview on [DATE] at 11:07 AM with the ADON stated swabs are not supposed to be in the 200-unit medication room and did not know how they would have gotten out of the testing box. Review of the facility policy titled 5.0 Medication Storage dated [DATE] reads Policy. Medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with the Department of Health guidelines. Procedure F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 13 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food was prepared and stored in a safe and sanitary manner. Findings include: An initial observation of the main kitchen was completed with Staff A, Dietary Aide, beginning at 7/24/2022 at 9:45 AM. There was an undated plastic bag of chicken and a tray of individual servings of coleslaw stored in the walk-in refrigerator and an opened bag of cookies stored on a shelf in the kitchen. There was undated cheese, lettuce and delicatessen meats stored in a salad bar. There was food debris on the interior shelf of the salad bar. There was brown and tan substances and food debris build up on the fryer and a grey substance build up on the stove top. During an interview on 7/24/2022 beginning at 9:45 AM, Staff A verified the plastic bag of chicken and individual servings of coleslaw should be dated. She verified the bag of cookies should be closed and the fryer, stove top and salad bar needed cleaning. During an interview on 7/25/2022 at 1:40 PM, the Assistant Dietary Manager confirmed that the coleslaw had been served with the fried fish entree during the dinner meal on Friday, July 22, 2022. An observation of the [NAME] Hall nourishment room was completed with Staff A on 7/24/2022 beginning at 10:18 AM. There was a white liquid substance pooled on the bottom shelf of the nourishment room refrigerator. During an interview on 7/24/2022 beginning at 10:18 AM, Staff A agreed the [NAME] Hall nourishment room should be cleaned. An observation of the [NAME] Hall nourishment room was completed with Staff A on 7/24/2022 beginning at 10:25 AM. There was an undated/unlabeled 16-ounce cup of liquid and an opened carafe of juice stored in the refrigerator. During an interview on 7/24/2022 begging at 10:25 AM, Staff A agreed the 16-ounce cup of liquid should be dated and labeled and the carafe of juice should be sealed. Review of the facility policy titled Food Storage, last reviewed 1/28/2022, read 1. Food storage areas shall be clean at all times. Review of the facility policy titled Cleaning Schedule, last reviewed 1/28/2022, read 1. It is the responsibility of the Dietary Department Head to provide and post the weekly and monthly cleaning schedules in the dietary area. 2. Each dietary personnel are responsible to know their assigned duty and carry it out during their work shift. Review of the facility policy titled General Food Preparation and Handling, last reviewed 1/28/2022, read 2. Food Storage a. Foods are received, checked, and properly stored as soon as they are delivered 4. Food Service d. Leftovers must be dated, labeled covered, cooled, and stored (within ½ hour after cooking or service) in a refrigerator 5. Equipment. a. All food service equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 14 of 15 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake City Healthcare and Rehabilitation Center 298 SW Prosperity Place Lake City, FL 32024 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 should be cleaned, sanitized, dried and reassembled. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 15 of 15