Inspection·January 19, 2024

F 0677 services to maintain good nutrition, grooming, and personal and oral hygiene. 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 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 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 ensure the insulin pens used in the facility were stored in accordance with currently accepted professional principles in 2 of 4 medication carts observed. Findings include: During an observation of Medication Cart #2 on [NAME] Hall on 1/17/2024 at 9:20 AM with Staff A, License Practical Nurse (LPN), there was one Insulin lisp 100/ml [milliliter] injectable pen for Resident #10 with an opened date of 12/4/2023. During an interview on 1/17/2024 at 9:22 AM, Staff A, LPN, stated, The insulin expired on January 1, 2024. We should probably write the expiration date on the medication. I will throw it away. During an observation of Medication Cart #1 on Magnolia Hall on 1/17/2024 at 9:24 AM with Staff B, LPN, there was one Basaglar Kwikpen 100 unit/ml insulin pen for Resident #106. The insulin pen was unopened and undated. The insulin pen was not cold to touch, and there was no condensation on the bag. The insulin pen bag had a label that reads, Refrigerate until opened. During an interview on 1/17/2024 at 9:45 AM, Staff B, LPN, stated, The pharmacy just delivered this medication. Pharmacy delivers the insulin to the nurse at the medication carts and the nurse is responsible to place the insulin in the refrigerator until it is used. Insulin is to be kept refrigerated until is needed for the patient's use. Review of the medication delivery slip for Resident #106 showed three Basaglar Kwikpen 100 unit/ml insulin pens were delivered on 1/16/2024 at 5:01 AM. During an interview on 1/17/2024 at 9:53 AM, the Assistant Director of Nursing stated, Insulin pens are delivered to the unit by the pharmacy and the nurses will place the unopened insulin syringe in the refrigerator until it is needed. The insulin expires per pharmacy regulations. We have a book on all medication carts that have the insulin brand and expiration date per pharmacist. The nurses are to look at the book to see when the insulin expires and dispose of insulin when expired. Insulin pens that are expired should be removed from the cart and thrown away. During an interview on 1/18/2024 at 1:52 PM, the Director of Nursing stated, My expectation is for all medications carts to be checked on Fridays and Mondays for expired medications and expired medications are to be removed from the medication cart and disposed of. Insulin pens are delivered to the nursing medications cart. When the insulin pen is needed for the assigned patient, it is removed from the refrigerator at that time and the open date is written on the pharmacy bag and pen. Review of the document provided by the facility, titled Injectable Diabetes Medication Expiration Dates After Opening, issued by Guardian Consulting Services, Inc. showed all insulin pens should be stored in refrigerator prior to first use, and after first use, they may be stored at room temperature. Humalog (Insulin lispro) can be stored at room temperature for 28 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedures titled Medication Storage dated 12/4/2023 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 guideline. Procedure . F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy . H. Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2-8 degrees Celsius (36 to 46 degrees F). Event ID: Facility ID: 106126 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure expired or outdated food was properly discarded in the areas of the kitchen coolers or refrigerators and that all kitchen equipment were cleaned and maintained in proper working order. Findings include: During an observation while a walk-through tour of the kitchen on 1/16/2024 at 9:15 AM with the Certified Dietary Manager (CDM), there were two full containers and one partially opened container of cottage cheese with the manufacture's expiration date of 1/8/2024 on all three containers in the walk-in cooler. Paper products including food containers, Styrofoam cups, and plastic utensils were being used on the tray line for all residents receiving a meal tray. The microwave oven had numerous dried food particles inside on the sides, top and base. The stove drawer had a large amount of buildup of black and brown food particles and debris. A tabletop mixer had food particles and debris. There was a buildup of dirt and grease on the top and running down the sides of the deep fryer. During an interview on 1/16/2024 at 9:35 AM related to paper products being used for meal service for residents, the CDM stated that the dishwashing machine, the combo oven (equipment that has a combination of steam and convection type cooking method), and the tabletop mixer were not operational and with the dishwashing machine down, paper products have been used during food service for all three meals since 1/1/2024. The CDM confirmed that two unopened and one partially opened containers of cottage cheese had an expiration date of 1/8/2024 and should have been discarded. The CDM confirmed the microwave oven had a large buildup of food particles and debris that would not have been from the most recent breakfast meal. The CDM stated that the cleaning assignments were not followed for cooking equipment. Review of the facility policy and procedures titled Dietary Department Sanitation last reviewed on 11/25/2023 reads, Policy: It is the dietary department's goal to maintain a clean, sanitary and safe environment. Responsibilities for all sanitation of the dietary environment shall be shared as designated by the dietary supervisor. Policy Interpretation and Implementation . 2. Associates must complete their respective cleaning assignments through the course of the day or as directed on the cleaning schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 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 106126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: During an observation on 1/17/2024 at 8:32 AM, Staff A, License Practical nurse (LPN), exited Resident #32's room after administering the resident's medication. Staff A returned to medication cart and began preparing medications for Resident #10 without performing hand hygiene. Staff A obtained Resident # 10's medications and mixed the medications in fluids and then proceeded to Resident #10's room. Staff A obtained manual vital signs (blood pressure 122/64, heart rate 67 and oxygen saturation 96%) without donning gloves or performing hand hygiene. Staff A administered oral (by mouth) medications to Resident #10. Staff A exited Resident #10's room and returned to the medication cart, unlocked the medication cart and obtained Resident #10's Insulin pen. Staff A returned to Resident #10's room, donned gloves without performing hand hygiene and administered insulin subcutaneously in the resident's right arm. Staff A exited Resident #10's room, returned to the medication cart, and began preparing medications for Resident #16 without performing hand hygiene. Staff A proceeded to provide oral medications to Resident #16 and administered Advair inhaler 1 puff. Staff A did not wear gloves or perform hand hygiene prior to administration of the medication. During an interview on 1/17/2024 at 9:30 AM, Staff A, LPN, stated, Hand hygiene should be done as needed or after every 3 or 4 patient's medications are delivered. During an interview on 1/17/2024 at 9:53 AM, the Assistant Director of Nursing stated, Hand hygiene is to be completed before and after each patient's medication administration. During an interview on 1/18/2024 at 1:52 PM, the Director of Nursing stated, Hand hygiene is expected to be done before and after medication administration. Review of facility policy and procedures titled Hand hygiene dated 12/4/2023 reads, Policy: It is the policy of the facility that handwashing/hand hygiene be regarded as the single most important means of preventing the spread of infections. All employees will wash their hands and any other skin with antimicrobial soap and, or flush mucous membranes immediately or as soon as feasibly following contact of such body areas with blood or other potential infectious materials .When . 2. If hands are not visibly dirty or soiled, use an alcohol-based rub for the following situations: a. Before direct contact with residents, b. Before donning gloves, c. Before preparing or handling medications . f. After contact with inanimate objects (equipment, bedpans, urinals, over bed tables, bed rails in the immediate vicinity of the resident), g. After the removal of gloves including between glove changes during procedures. 3. The use of gloves does not replace or eliminate the need for hand washing/ hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 6 of 6