Inspection·April 10, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of Resident #18's MDS assessment dated [DATE] showed no broken dentures or resident being edentulous under section L- Oral/ Dental Status. During an interview on 4/10/2025 at 12:00 PM, Staff K, MDS Coordinator, stated, It was marked incorrectly on her annual assessment. Residents Affected - Few 2) During an interview on 4/7/2025 at 10:19 AM, Resident #49 stated that his gastrostomy tube was being used for his medications. Review of Resident #49's MDS assessment dated [DATE] read, Section K- Swallowing/Nutritional Status.

K0100. Swallowing Disorder . Z. None of the above . K0520. Nutritional Approaches . B. Feeding tube (e.g., nasogastric or abdominal (PEG)) [No box checked to indicate the resident having feeding tube while a resident]. During an interview on 4/10/2025 at 11:50 AM, the MDS Coordinator stated that the documentation of Resident #49 not having a PEG, or any type of feeding tube was incorrect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 2 of 26 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 04/10/2025 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 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 and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for 1 of 5 residents reviewed for unnecessary medications, Resident #61. Residents Affected - Few Findings include: Review of Resident #61's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including bipolar disorder (onset date of 3/10/2025), major depressive disorder, and anxiety disorder. Review of Resident #61's Level I PASRR dated 3/5/2025 showed anxiety disorder and depressive disorder listed under mental illness. No bipolar disease was listed. Review of Resident #61's hospital Discharge summary dated [DATE] read, Hospital course to date . complex past medical history including . bipolar disease. Review of Resident #61's MDS assessment dated [DATE] showed anxiety disorder, depression and bipolar disorder under Section I- Active Diagnoses. During an interview on 4/10/2025 at 8:15 AM, the Administrator stated, When a resident is admitted from the hospital, it is our responsibility to review the PASRR for accuracy and get it corrected if necessary. We did not follow our process. Review of Resident #61's visit note for psychiatric services dated 3/24/2025 read, HPI [History of Present Illness] General . admitted to the facility on 3.9.25 . She has a hx [history of] DMI [diabetic muscle infarction], COPD [chronic obstructive pulmonary disease], morbid obesity, HTN [hypertension], bipolar, MDD [major depressive disorder], anxiety, RLS [restless leg syndrome]. Review of the facility policy and procedure titled Social Services- PASRR with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Purpose: The facility shall ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to meet their needs . Procedure: I. Preadmission Screening: 1. The External Liaison or Internal admission Staff/Designee will obtain a completed preadmission screen (PASRR Level I) on all individuals being admitted to the Skilled Nursing Facility (SNF) prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 3 of 26 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 04/10/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 2 of 9 residents reviewed, Residents #3 and #114. Findings include: 1) Review of Resident #3's transfer/discharge report showed the resident was admitted on [DATE] with diagnoses including generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of Resident #3's physician order dated 3/5/2025 read, Behaviors- Monitor for the following: Sad affect, continuous crying, seems withdrawn, mood changes, Document: 'N' if none of the above observed. 'Y' if any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift. Review of Resident #3's visit note for psychiatric services dated 3/6/2025 read, DX [Diagnosis] . 1: Generalized anxiety disorder: Patient is stable. Staff to monitor, document, and report worsening symptoms of anxiety symptoms: excessive worry, not able to control worry, restlessness/agitation, being easily fatigued, poor concentration, irritability, muscle tension, sleep disturbance, panic attacks . 4: Post-traumatic stress disorder: Patient is stable. Continue to monitor for changes. Review of Resident #3's care plan did not show a focus for generalized anxiety or post-traumatic stress disorder. During an interview on 4/10/2025 at 11:46 AM, Staff K, Minimum Data Set (MDS) Coordinator, stated, [Resident #3's name] has a diagnosis of post-traumatic stress disorder. The PTSD or anxiety were not included in her care plan and needs to be added. 2) Review of Resident #114's physician order dated 4/1/2025 read, Dialysis on T-Th-Sa@ [Tuesdays-Thursdays-Saturdays at] 10:15 AM at [local dialysis center's name] every day shift every Tue, Thu, Sat, for dialysis. Review of Resident #114's skin evaluation dated 4/1/2025 read, A. Observations . Site: 6) Right Shoulder (front), Description: Suture noted and 2 shunts for dialysis present. Review of Resident #114's care plan showed no focus for enhanced barrier precautions. During an interview on 4/10/2025 at 9:43 AM, Staff E, Licensed Practical Nurse (LPN) Unit Manager, stated, [Resident #114's name] is a dialysis patient and has a catheter on his right chest. He [Resident #114] would need to have enhanced barrier precaution orders and also be care planned. During an interview on 4/10/2025 at 11:29 AM, the Director of Nursing stated, [Resident #114's name] should be care planned for enhance barrier precautions due to the catheter he has in place for dialysis. During an interview on 4/10/2025 at 11:51 PM, Staff K, MDS Coordinator, stated, Currently there are no orders for enhance barrier precautions for [Resident #114's name]. We also go by hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 4 of 26 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 04/10/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete records. We would expect to see a focus for enhanced barrier precautions as part of his [Resident #114] care plan. Enhance barrier precautions will need to be added to his care plan. Review of the facility policy and procedure titled Nursing- Care Plans- Comprehensive- Person Centered with the last review date of 1/21/2025 read, Purpose: To ensure the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Policy . 9. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Event ID: Facility ID: 106126 If continuation sheet Page 5 of 26 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 04/10/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm 2) During an observation on 4/7/2025 at 9:50 AM, Resident #23 was sitting in her wheelchair with a dressing on her left knee. The dressing had dried dark substance, and the dressing had no date or initials. Residents Affected - Some During an interview on 4/7/2025 at 9:50 AM, Resident #23 stated, I bumped my knee that is why I have this dressing. During an observation on 4/8/2025 at 4:20 PM, Resident #23 was sitting near the nursing station in her electric wheelchair. The dressing on her left knee had dried dark substance, and the dressing had no date or initials. Review of Resident #23's physician order dated 12/16/2024 read, Skin tear to Left knee: Cleanse with wound cleanse of choice pat dry apply TAO [triple-antibiotic ointment] and cover with dry dressing every day shift for TX (treatment). During an interview on 4/9/2025 at 4:30 PM, the Director of Nursing stated, Staff should date and initial all dressings. 3) Review of Resident #65's physician order dated 1/18/2025 read, Carvedilol Oral Tablet 3.125 MG [Milligram] (Carvedilol), Give 1 tablet by mouth two times a day related to essential (primary) hypertension. Review of Resident #65's Medication Administration Record (MAR) for March 2025 for administration of Carvedilol showed staff documented code 11 on 3/5/2025, 3/7/2025, 3/14/2025, 3/15/2025, 3/24/2025 and 3/28/2025 at 9:00 AM, and documented code 11 on 3/5/2025, 3/7/2025, 3/10/2025, 3/11/2025, 3/14/2025, 3/15/2025, 3/16/2025, 3/24/2025, 3/30/2025 at 5:00 PM. Code 11 stands for held per parameters. Review of Resident #65's MAR for April 2025 for administration of Carvedilol showed staff documented code 11 on 4/7/2025 at 9:00 AM and on 4/8/2025 at 5:00 PM. During an interview on 4/9/2025 at 1:10 PM, the DON stated, [Resident #65's name] Carvedilol did not have parameters in place and the nurses were holding the medication. The nurses should follow the doctors' orders when giving medication or call the provider to clarify any questions. During an interview on 4/10/2025 at 4:16 PM, the Advance Practice Registered Nurse #2 stated, Staff always call me and notify me when they will be holding a medication for [Resident #65's name]. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/21/2025 read, General Guidelines: 3. Medications are administered in accordance with prescriber orders, and current standards of practice. Based on observation, interview, and record review, the facility failed to ensure residents received appropriate wound care for 2 of 4 residents reviewed for skin and wound care, Residents #23 and #49, and 1 of 8 residents reviewed for medication management, Resident #65. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 6 of 26 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 04/10/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1) During an observation on 4/7/2025 at 10:19 AM, Resident #49 was sitting in a chair, dressed in street clothes. The resident had one dressing on his abdomen with drainage, which was dated 4/4, one dressing on his wrist, of dry gauze, dated 4/4, one dressing on his upper thigh with no apparent drainage, under an elastic wrap, with no date visible, and one dressing on his lower back, which could not be fully observed. During an interview on 4/7/2025 at 10:19 AM, Resident #49 stated that his wounds were last cleaned on Friday, 4/4/2025, with their dressings changed at that time. Review of Resident #49's admission Assessment, dated 3/24/2025, documented the following information in the wound/skin section: a surgical incision on the right side of the abdomen; a G-tube (gastrostomy tube) on the left side of the abdomen; and graft sites on the left wrist, front of right thigh, and front of left thigh. There was no information documented regarding a wound or a dressing on Resident #49's lower back/sacrum/coccyx. Review of Resident #49's physician order dated 3/25/2025 read, Unwrap right thigh daily and monitor graft site for any s/s [signs and symptoms] of infection. Do not remove protective dressing that is stapled in place. Place new wound veil over graft site, secure with rolled gauze and ace wrap every day shift for wound care. Review of Resident #49's physician order dated 3/25/2025 read, Apply A&D [Vitamin A and D] ointment to healed left thigh graft site daily every day shift for wound care. Review of Resident #49's physician order dated 3/25/2025 read, Cleanse left wrist wound with wound cleanser, apply bacitracin and non-adherent dressing, secure with rolled gauze daily & PRN [and as needed] as needed for soiled or dislodged. Review of Resident #49's physician order dated 3/25/2025 read, Cleanse abd [abdominal] wound with wound cleanser, apply bacitracin ointment to wound bed, cover with wound veil and dry dressing daily every day shift for wound care. Review of Resident 49's Treatment Administration Record for April 2025 showed staff initials for applying A&D ointment, cleansing abdominal and left wrist wound, unwrapping right thigh on 4/5/2025 and 4/6/2025. During an observation on 4/8/2025 at 4:10 PM, Resident #49 had a large transparent dressing on his lower back which had a date of 3/2x/25 (the 2nd digit of the day could not be clearly observed). During an interview on 4/8/2025 at 4:15 PM, Staff H, Licensed Practical Nurse (LPN), stated she was not aware of a dressing on Resident #49's sacrum/coccyx. During an interview on 4/8/2025 at 4:22 PM, the Director of Nursing (DON) stated that her expectation was that when a resident was admitted , the nurse in the facility would complete a head-to-toe assessment of each resident and document all wounds and dressings. During an interview on 4/9/2025 at 10:05 AM, Staff A, LPN, stated, On Saturdays and Sundays, the nurse from the other hall works 7:00 AM to 3:00 PM and does wound care for the residents on my hall. The nurse let me know what wound care was completed, and I documented the wound care and dressing changes. I did not recall if I checked to see that [Resident #49's name] wound care had been completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 7 of 26 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 04/10/2025 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 0684 on Saturday 4/5/25 or Sunday 4/6/25. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/9/2025 at 10:08 AM, Staff G, Registered Nurse (RN), Unit Manager, stated, On new admissions, the expectation is that a head-to-toe skin assessment is completed, and all wounds and dressings are documented. The dressing on [Resident #49's name] lower back should either have been removed or orders should have been obtained. If there are orders for daily wound care and/or dressing changes, it should be done daily. Residents Affected - Some Review of the facility policy and procedure titled Dressing- Dry/Clean with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry/clean dressings. General guidelines: 1. Verify that there is a physician's order for this procedure . 3. Check the treatment record . Procedure . 11. Label tape or dressing with date, time and initials. Place on clean field . 19. Apply the ordered dressing . Label with date and initials on top of dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 8 of 26 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 04/10/2025 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 - Few 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 medication regimen recommendations agreed by the physician were followed for 1 of 5 residents reviewed for unnecessary medications, Resident #8. Findings include: Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 2/25/2025 that read, Per clinical record resident with recent falls. A daily intake of 800-1,000 IU of Vitamin D is currently recommended in the elderly to maintain bone health and reduce the risk of falls and fractures. Please evaluate. Consider adding Vitamin D3, 1000 IU once daily, if appropriate. The physician's response was documented as, Agree; will do. Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 3/26/2025 that read, Per clinical record resident with recent falls. A daily intake of 800-1,000 IU of Vitamin D is currently recommended in the elderly to maintain bone health and reduce the risk of falls and fractures. Please evaluate. Consider adding Vitamin D3, 1000 IU once daily, if appropriate. The physician's response was documented as, Agree; will do. Review of Resident #8's current physician orders showed no order for Vitamin D3. During an interview on 4/9/2025 at 2:51 PM, the Director of Nursing (DON) stated, The monthly recommendations [from the Consultant Pharmacist] are divided between the unit managers and the ADON [Assistant Director of Nursing]. The expectation is whoever gets an order from a provider should address it in the computer [electronic medical record]. During an interview on 4/10/2025 at 3:49 PM, the Nurse Practitioner 1 stated, The expectation for the medication regimen reviews is that if we fill out those papers, they [the facility staff] are supposed to update the orders. We cannot write the information in 3 or 4 different places. That is why we write the responses on the pharmacy reviews. Review of the facility policy and procedure titled Pharmacy Services - Drug Regimen Review with an effective date of 4/1/2022, and the last review date of 1/21/2025, read, Purpose: The facility shall maintain the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing. Procedure: 1. The drug regimen of each resident should be reviewed at least monthly by a licensed pharmacist and the pharmacist should report any irregularities to the attending physician, the facility's medical director and the director of nursing and these reports should be acted upon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 9 of 26 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 04/10/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure residents' medication regimen was free from unnecessary drugs, for 1 of 5 residents reviewed for unnecessary medications, Resident #8. Residents Affected - Few Findings include: Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 1/9/2025 that read, Currently receiving Guaifenesin LA [long acting] tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate. The physician's response was documented as, Agree; will do. DC [Discontinue]. Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 3/26/2025 that read, Currently receiving Guaifenesin LA tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate. The physician's response was documented as, Disagree; State Reason: PRN [as needed]. The physician signed the recommendation on 4/1/2025. Review of Resident #8's physician order dated 1/7/2025 read, Guaifenesin ER [extended release] Oral Tablet Extended Release 12 Hour 600 MG [milligram] (Guaifenesin), Give 600 mg by mouth two times a day for congestion. Order Status: Active. Review of Resident #8's Medication Administration Records (MARs) for administration of Guaifenesin showed the resident received the medication from 1/8/2025 through 1/31/2025, from 2/6/2025 through 2/28/2025, from 3/1/2025 through 3/31/2025, from 4/1/2025 through 4/9/2025 at 9:00 AM and 9:00 PM. During an interview on 4/9/2025 at 2:51 PM, the Director of Nursing (DON) stated, The monthly recommendations [from the Consultant Pharmacist] are divided between the unit managers and the ADON [Assistant Director of Nursing]. The expectation is whoever gets an order from a provider should address it in the computer [electronic medical record]. During an interview on 4/10/2025 at 3:49 PM, the Nurse Practitioner 1 stated, The expectation for the medication regimen reviews is that if we fill out those papers, they [the facility staff] are supposed to update the orders. We cannot write the information in 3 or 4 different places. That is why we write the responses on the pharmacy reviews. Review of the facility policy and procedure titled Pharmacy Services - Drug Regimen Review with an effective date of 4/1/2022, and the last review date of 1/21/2025, read, Purpose: The facility shall maintain the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing. Procedure: 1. The drug regimen of each resident should be reviewed at least monthly by a licensed pharmacist and the pharmacist should report any irregularities to the attending physician, the facility's medical director and the director of nursing and these reports should be acted upon. 2. Irregularities include, but are not limited to, any drug that meets the following criteria . b. Excessive duration, or c. Without adequate monitoring; or d. Without adequate indications for its use . 5. The attending physician shall document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 10 of 26 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 04/10/2025 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. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle in 1 of 4 hallways. Findings include: 1) During an observation on 4/7/2025 at 10:11 AM, Resident #95 was lying in bed. There was one bottle of nasal saline spray on top of the nightstand. During an interview on 4/7/2025 at 10:11 AM, Resident #95 stated, I have used the spray for years. I will use the nasal spray at night if I feel clogged. During an interview on 4/7/2025 at 12:48 PM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, [Resident #95's name] should not have medication at bedside. We do not really have any resident that self-administers medication. If they do, we would have to evaluate the resident and care plan them. We would also have to put an order in place. 2) During an observation on 4/7/2025 at 10:56 AM, Resident #45 was lying in bed. There was one bottle of lubricant eye drops on top of the bedside table and one bottle of antifungal powder on top of the wall air conditioning unit. During an interview on 4/7/2025 at 10:56 AM, Resident #45 stated, The eye drops are mine. I use them when I need them. I will have the nurses assist with applying them, and the antifungal powder, the nurses will apply for me. 3) During an observation on 4/7/2025 at 12:45 PM, Resident #64 was lying in bed. There was one tube of Neosporin antibiotic ointment on the side of the resident's bed. During an interview on 4/7/2025 at 12:45 PM, Resident #64 stated, I forgot I had the ointment. My family brought it for me. During an interview on 4/7/2025 at 12:48 PM, Staff D, LPN, stated, [Resident #64's name] has no orders for Neosporin. I do not know what she uses it for. Normally they bring meds, and we will provide it for them and get an order. During an interview on 4/7/2025 at 2:33 PM, Staff E, LPN, Unit Manager, stated, [Resident #64's name] cannot self-administer medication. I spoke to the family and they do not know how she got the ointment. 4) During an observation on 4/8/2025 at 8:30 AM, Resident #6 was sitting up in bed. There was a medication cup containing one white circular pill. During an interview on 4/8/2025 at 8:30 AM, Resident #6 stated, I do not know what that medication is for. Can you call the nurse so she can tell us what it is? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 11 of 26 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 04/10/2025 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 During an interview on 4/8/2025 at 8:32 AM, Staff D, LPN, stated, The medication in the medication cup is Tramadol. I thought she had taken all her medications while I was here earlier. During an interview on 4/9/2025 at 4:04 PM, the Director of Nursing (DON) stated, If a resident has a high BIMS [Brief Interview for Mental Status score] and they are cognitively intact, they would be able to self-administer and we would evaluate. We did not have any resident in the building that would self-administer medication. Medication should not be left unattended in a resident's room. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/21/2025 read, General Guidelines . 25. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have decision-making capacity to do so safety. Review of the facility policy and procedure titled Medication Storage with the last review date of 1/21/2025 read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health Guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 12 of 26 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 04/10/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received dental services for 1 of 2 residents reviewed for dental services, Resident #18. Residents Affected - Few Findings include: During an observation on 4/7/2025 at 9:30 AM, Resident #18 was edentulous. During an interview on 4/7/2025 at 9:30 AM, Resident #18 stated, I'm on mechanical soft because my dentures broke a while back and they still have not gotten me any. I hate having no teeth and not being able to eat. I've seen dental and they told me it'd be an issue because of my overbite. I don't want any surgery or anything. I just want my teeth back. During an interview on 4/9/2025 at 11:10 AM, Registered Dietician (RD) stated, I don't believe there is an issue with her swallowing. The only reason she's on mechanical soft is because of her having no teeth. During an interview on 4/9/2025 at 11:45 AM, Social Services Assistant (SSA) stated, I know [Staff E, Unit Manager's name] and [previous Social Services Director's name] were working on something about her dentures, but I'm not sure exactly what it was about. During an interview on 4/9/2025 at 12:00 PM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, The problem is with her insurance. She is required to go to her primary office at [name of the primary office] and they have to do a referral to dental at [name of the dental clinic]. That's a whole process that takes time. I have received an email from the dental clinic in December 2024 notifying the facility that in-house dental provider did not take the resident's insurance. Review of Resident #18's medical record showed a note that read, 5/30/24 11:45: dental referral sent to SS [Social Services] for replacement or repair dentures. Review of Resident #18's medical record showed notes that read, 7/1/24: Patient presents for screening. Upper and Lower edentulous. Soft tissue is healthy. Patient is eating well. Patient is not in pain. Dentures not located to evaluate. No upper denture or lower denture located. Attempts should be made to locate dentures for evaluation. Next visit: follow up on locating upper denture lower denture for evaluation. 7/25/2024: Patient presents for consult. Dentures not located. Patient interested in new set of dentures treatment. Patient is not in pain. Patient is currently able to obtain adequate nutrition. 11/14/2024: Per facility, patient is not experiencing any pain or discomfort and has no issues eating. Dentures are not clinically needed at this time. Will monitor and treat symptomatically. Review of the facility policy and procedure titled Dental Services with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Procedure . 10. If dentures are damaged or lost, residents shall be referred for dental services within 3 days. If the referral is not made within 3 days, documentation shall be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 13 of 26 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 04/10/2025 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 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 food was safely stored in the areas of the nutrition room and kitchen walk-in freezer. Residents Affected - Few Findings include: During an initial tour of the kitchen on 4/7/2025 at 9:10 AM with the Dietary Manager, there was one plastic see through bag containing food items with no identifying label or date in the walk-in freezer. During an interview on 4/7/2025 at 9:20 AM, the Dietary Manger stated, I don't know what it is. It should have a label and be dated. Review of the facility policy and procedure titled Food Storage revised on 1/17/2019 read, Policy: Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure . 15. Frozen Foods . d. All foods should be covered, labeled and dated. All foods will be checked to ensure that foods will be consumed by their safe use by dates or discarded. All foods should be checked so as to show no negative outcome (e.g. freezer burn, foods dried out, foods with a change of color). During an observation on 4/7/2025 at 9:35 AM, there was one bag containing wrapped crackers and bowl of covered food in the nourishment room refrigerator on Desota Hall that was not dated. During an interview on 4/7/2025 at 9:33 AM, the Dietary Manger stated, The food should have been dated. Review of the facility policy and procedure titled Guidelines for Foods Brought from the outside by Family and Visitors revised on 1/17/2019 read, Policy: Family members may bring food into Residents. Staff must be aware of and approve of food brought to a resident by family/visitors. Procedure . 6. Perishable foods must be stored in a re-sealable containers with tight fitting lids in the refrigerator. Containers will be labeled with the resident's name, the items name and the use by date. The use by date should be 5 days after food is brought in. 7. Nursing staff is responsible for discarding perishable foods on or before the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 14 of 26 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 04/10/2025 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide therapy evaluation and services for 1 of 3 residents reviewed for rehabilitation, Resident #27. Residents Affected - Few Findings include: During an interview on 4/8/2025 at 10:40 AM, Resident #27 stated, I used to have therapy and then I was participating in the restorative program. I was walking with a walker and they were providing different trainings. It all stopped and they never came and got me again. The facility got rid of the restorative program. I would like to have therapy again. Review of Resident #27's physician order dated 9/20/2024 read, PT [Physical Therapy] to eval [evaluate] and treat as indicated . Order Status: Active. Review of Resident #27's physician order dated 9/20/2024 read, OT [Occupational Therapy] to eval and treat as indicated . Order Status: Active. Review of Resident #27's care plan initiated on 3/12/2025 showed the resident had activity of daily living self-care performance deficit related to hemiplegia and hemiparesis following cerebral infraction affecting left dominant side, with the intervention including functional maintenance program. Review of Resident #27's Physical Therapy Evaluation and Plan of Treatment dated 12/3/2024 showed the resident was on restorative nursing program and no further physical therapy interventions indicated. During an interview on 4/9/2025 at 2:29 PM, the Functional Maintenance Coordinator stated, The functional maintenance program is to monitor patients who are off of therapy. We will monitor the progress and use the strategies that were given in therapy. We mostly communicate with the certified nursing assistants for splints. [Resident #27's name] has been off therapy. Before the new company, we had restorative, but they cut that out and she [Resident #27] was no longer a candidate. They have to participate in therapy first. After therapy releases them, they become part of the functional maintenance program. If [Resident #27's name] had a problem and is not to where she is now, she would have to go to therapy. Nothing was implemented for the residents that were on restorative. In my opinion, I don't think they were evaluated. During an interview on 4/9/2025 at 2:53 PM, the Director of Nursing (DON) stated, The restorative program was discontinued, and therapy was going to evaluate them and pick them up as the program warranted. The restorative program ended in January or February 2025. I do not know the exact date. We should have something in place before it was completely dropped. During an interview on 4/9/2025 at 3:14 PM, the Rehabilitation Director stated, The restorative program was discontinued and the functional maintenance program was established. [Resident #27's name] does not have a current functional maintenance program. The goal is to do quarterly evaluations. The last one they did for [Resident #27's name] was in December [2024]. It was probably an oversight or human error. During an interview on 4/10/2025 at 3:51 PM, the DON stated, We should do quarterly assessments on residents to determine if there is a decline. I would expect the assessment to be done within a week (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 15 of 26 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 04/10/2025 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 0825 of when it is due. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/10/2025 at 4:34 PM, the Rehabilitation Director stated, At least one therapy disciple should have seen [Resident #27's name] for her quarterly evaluation. Residents Affected - Few Review of the facility policy and procedure titled Provide/Obtain Specialized Rehab Services with the last review date of 1/21/2025 read, Purpose: The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan to assist them to attain, maintain or restore their highest practicable level of physical mental functional and psycho-social well-being, as well as ensure that residents with Mental Disorder (MD), Intellectual Disability (ID) or related conditions receive services as determined by their Preadmission Screening and Resident Review (PASARR). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 16 of 26 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 04/10/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 2 residents reviewed for behaviors (Resident #3), for 2 of 8 residents reviewed for medication management (Residents #54 and #72), and for 1 of 3 residents reviewed for skin and wound care (Resident #49). Findings include: 1) Review of Resident #3's physician order dated 3/5/2025 read, Behaviors- Monitor for the following: Sad affect, continuous crying, seems withdrawn, mood changes, Document: 'N' if none of the above observed. 'Y' if any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift. Review of Resident #3's Treatment Administration Record (TAR) for April 2025 for monitoring behaviors showed staff documented X from 4/1/2025 through 4/8/2025 at 7:00 AM and 7:00 PM. Review of Resident #3's physician order dated 3/5/2025 read, Antidepressant Medication- Monitor for sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin) excess weight gain, Document: 'N' if none of the above observed. 'Y' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift. Review of Resident #3's TAR for April 2025 for antidepressant medication monitoring showed staff documented X from 4/1/2025 through 4/8/2025 at 7:00 AM and 7:00 PM. During an interview on 4/10/2025 at 8:54 AM, the Director of Nursing (DON) stated, When writing the order, they didn't click box for yes or no. I didn't see any behaviors in the notes for [Resident #3's name]. It was not clicked off to populate yes or no. During an interview on 4/10/2025 at 9:33 AM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, The staff are supposed to answer yes or no to the monitoring of behaviors in the treatment record. If they document yes, they must also write a progress note about the behaviors. 2) Review of Resident #72's physician order dated 2/19/2025 read, Metoprolol Tartrate Oral Tablet 25 MG [milligram] (Metoprolol Tartrate), Give 0.5 tablet via G-tube [gastrostomy tube] two times a day related to essential (primary) hypertension hold if SBP>110 or HR >60 [systolic blood pressure greater than 110 or heart rate greater than 60]. During an interview on 4/9/2025 at 1:08 PM, the DON stated, [Resident #72's name] order was transposed incorrectly. It should be less than a symbol. I normally like to write out the words to avoid confusion. During an interview on 4/10/2025 at 4:16 PM, the Advance Practice Registered Nurse #2 stated, [Resident #72's name] order was written incorrectly. It was a mistake. It was written greater than, but it should have been less than. 3) Review of Resident #54's Medication Administration Record (MAR) for March 2025 for the order for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 17 of 26 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 04/10/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Humulin 70/30 Kwik-Pen Subcutaneous Suspension Pen-Injector (70-30) 100 unit/milliliter- Inject 30 units subcutaneously two times a day related to type 2 diabetes mellitus without complications revealed the medication was held on 3/4/2025 at 4:30 PM for the blood sugar documented as 97, and on 3/29/2025 at 4:30 PM for the blood sugar documented as 108. During an interview on 4/9/2025 at 3:20 PM, Staff E, LPN, Unit Manager, stated, I wonder if her sugar was low and then she didn't eat. During an interview on 4/10/2025 at 10:45 AM, Staff I, LPN, stated, It's hard to remember all the way back to March 4, but if her blood sugar was only 97, I probably didn't' feel comfortable giving it to her, since she has a tendency to drop. If I held it, I must have talked to the doctor. I just forgot to put it in my nurses' note. During an interview on 4/10/2025 at 10:55 AM, Staff J, LPN, stated, I think her blood sugar was in the low 100s, and she told me she didn't feel good and wasn't going to eat dinner, so I called the doctor and held it. I must have just forgotten to enter the nurses' notes. During an interview on 4/10/2025 at 11:30 AM, the DON stated, I would expect them to document contacting the provider and that he said it was okay to hold the injection. 4) During an observation on 4/7/2025 at 10:19 AM, Resident #49 was sitting in a chair, dressed in street clothes. The resident had one dressing on his abdomen with drainage, which was dated 4/4, and one dressing on his wrist, of dry gauze, dated 4/4. During an interview on 4/7/2025 at 10:19 AM, Resident #49 stated that his wounds were last cleaned on Friday, 4/4/2025, with their dressings changed at that time. Review of Resident #49's physician order dated 3/25/2025 read, Cleanse left wrist wound with wound cleanser, apply bacitracin and non-adherent dressing, secure with rolled gauze daily & PRN [and as needed] as needed for soiled or dislodged. Review of Resident #49's physician order dated 3/25/2025 read, Cleanse abd [abdominal] wound with wound cleanser, apply bacitracin ointment to wound bed, cover with wound veil and dry dressing daily every day shift for wound care. Review of Resident 49's TAR for April 2025 showed staff initials for cleansing abdominal and left wrist wound on 4/5/2025 and 4/6/2025. During an interview on 4/9/2025 at 10:05 AM, Staff A, LPN, stated, On Saturdays and Sundays, the nurse from the other hall works 7:00 AM to 3:00 PM and does wound care for the residents on my hall. The nurse let me know what wound care was completed, and I documented the wound care and dressing changes. I did not recall if I checked to see that [Resident #49's name] wound care had been completed on Saturday 4/5/25 or Sunday 4/6/25. During an interview on 4/9/2025 at 10:08 AM, Staff G, Registered Nurse (RN), Unit Manager, stated, If there are orders for daily wound care and/or dressing changes, it should be done daily. If a nurse did not complete wound care or treatment but documented it, it would be false documenting. Review of the facility policy and procedure titled Dressing- Dry/Clean with an effective date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 18 of 26 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 04/10/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm 4/1/2022 and the last review date of 1/21/2025 read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry/clean dressings . Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage. 3.The name and title (or initials) of the individual changing the dressing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 19 of 26 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 04/10/2025 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to maintain an effective, data driven Quality Assurance and Performance Improvement (QAPI) program related to weight loss and obtaining weights for 1 of 3 current performance improvement plans. Residents Affected - Few Findings include: Review of Weight Loss Performance Improvement Plan initiated on 2/11/2025 read, Action Steps: Quality Review initiated for residents who have lost significant weight in a time of 5% (30 days); 7.5% (90 days), and 10% (180 days). Appropriate MD [Medical Doctor]/Representative notification RD [Registered Dietitian] Consult, Interventions in place. Residents to be reviewed weekly in risk meeting until weight loss and stable X [times] 4 weeks. Care plan in place and appropriate. Nursing staff educated on weight loss with emphasis on: Making sure the correct documentation for meal consumption. Resident preferences. Interventions in place. Make sure weighing is consistent (same lift pad and leg rest, etc.) RD consult. Care plans in place with interventions. Menus posted daily. Residents to be reviewed weekly in risk meeting until weight loss resolved and stable X 4 weeks. Monitoring: Quality review to be conducted by DON/designee with residents that had significant weight loss have adequate monitoring in place including weight loss monitoring weekly X 4 weeks, and then every 2 weeks X 2 months. During an interview on 4/10/2025 at 12:15 PM, the Director of Nursing (DON) stated, I started the weight loss PIP [Performance Improvement Plan] because restorative was ending and we were switching to Functional Maintenance Program and we didn't have a set plan for getting the weights. We want to ideally have the same people, weigh around the same dates, ensure they are making allowances for foot rest, oxygen tanks, using the same method and so on. Review of Resident #51's record revealed the resident was weighted weekly on 2/12/2025 and 2/19/2025. Resident #51 was not weighed again until 3/13/2025. Review of Resident #97's record revealed the resident was weighed weekly on 2/12/2025, 2/19/2025 and 2/25/2025 and was not weighed again until 3/13/2025. During an interview on 4/10/2025 at 12:30 PM, the DON stated, We identified [Resident #51 and Resident #97's names] as ones to monitor. When asked where the proof of weekly meetings were, the DON was unable to provide documentation. Review of the facility's Quality Assurance and Performance Improvement (QAPI) policy and procedure with the last review date of 1/21/2025 read, 3.a. Identifying issues with respect to quality assessment and assurance activities including performance improvement projects. b. Developing and implementing appropriate plans of action to correct any identified deficiencies. Reviewing and analyzing data collected as part of the QAPI program and acting on data as appropriate. d. Review of all plans of corrections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 20 of 26 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 04/10/2025 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 followed infection control standards for storing respiratory therapy equipment for 3 of 4 residents reviewed for respiratory services (Residents #45, #51, and #87), for 3 of 6 residents reviewed for enhanced barrier precautions (Residents #6, #93, #114), for 1 of 4 residents reviewed for skin conditions (Resident #2), for 4 of 5 residents reviewed for medication administration (Residents #61, #116, #321 and #324) to help prevent the possible spread of infection and communicable diseases. Residents Affected - Some Findings include: 1) During an observation on 4/7/2025 at 10:56 AM, Resident #45 was lying in bed. There was a passive nebulizer mask and mouthpiece on top of the resident's desk across from his bed, which was not bagged (Photographic evidence obtained). Review of Resident #45's physician order dated 4/1/2025 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML (milligrams per 3 milliliters). Directions: 3 ml inhale orally via nebulizer every 6 hours as needed for SOB [shortness of breath] or wheezing via nebulizer. During an interview on 4/9/2025 at 4:06 PM, the Director of Nursing (DON) stated, The mouthpiece mask of a nebulizer and tubing should be bagged when not in use. 2) During an observation on 4/8/2025 at 4:47 PM, Staff C, Certified Nursing Assistant (CNA), was in Resident #93's bathroom assisting the resident with toileting. Staff C had gloves, but no gown. During an interview on 4/8/2025 at 4:51 PM, Staff C, CNA, stated, I was helping [Resident #93's name] transfer to the toilet and helped her lift her brief. Review of Resident #93's physician order dated 4/4/2025 read, Enhanced Barrier Precautions-Wounds every shift. 3) During an observation on 4/9/2025 at 11:47 AM, Staff C, CNA, was assisting Resident #6 to get dressed while in her bed. Staff C had gloves on, but did not have a gown. Review of Resident #6's physician order dated 12/7/2024 read, Enhanced Barrier Precaution in place (i.e. precautions for door handle. Stop sign, PPE [personal protective equipment] every shift. Open wound every shift for wound. During an interview on 4/9/2025 at 1:57 PM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, Staff are expected to wear gloves and gown when a resident is under enhanced barrier precautions and they are going to provide direct care to them. [Resident #6 and Resident #93's names] are both under enhanced barrier precautions. During an interview on 4/9/2025 at 2:00 PM, Staff C, CNA, stated, I was not aware that [Resident #93 and Resident #6's names] had wounds and were on enhanced barrier precautions. Residents that have enhance barrier precautions, you should wear a gown and gloves when providing care. I was assisting [Resident #6's name] to get dressed. I did not gown because I did not know they [Resident #6 and Resident #93] were on enhanced barrier precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 21 of 26 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 04/10/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/9/2025 at 4:08 PM, the DON stated, Staff should wear a gown and gloves when going into an enhance barrier room to provide direct care to the resident. 4) During an observation 4/10/2025 at 11:04 AM, Staff L, Registered Nurse (RN), entered Resident #2's room to provide wound care. Staff L donned gloves and a gown. Staff L adjusted Resident #2's foley tubing. Staff L removed gloves, and without performing hand hygiene, donned a new pair of gloves and removed the dressing on Resident #2's left foot. Staff L removed her gloves, and without performing hand hygiene, donned a new pair of gloves. Staff L cleaned the right side of the left foot that had a wound. Without changing gloves or performing hand hygiene, Staff L cleaned another wound on the left side of the foot. Staff L removed her gloves, and without performing hand hygiene, donned new pair of gloves and applied treatment and new dressing to Resident #2's left foot. Staff L removed her gloves and gown and performed hand hygiene. During an interview on 4/10/2025 at 11:14 AM, Staff L, RN, stated, I should have done hand hygiene in between changing gloves. During an interview on 4/10/2025 at 11:31 AM, the DON stated, Staff should perform hand hygiene when removing gloves. It is two different wounds. I would expect staff to change gloves and perform hand hygiene in between wounds. Changing gloves does not substitute hand hygiene. 5) Review of Resident #114's skin evaluation dated 4/1/2025 read, A. Observations . Site: 6. Right shoulder (front) suture noted and 2 shunts for dialysis present. During an interview on 4/10/2025 at 11:29 AM, the DON confirmed that Resident #114 was not on enhanced barrier precautions and stated, [Resident #114's name] should have orders in place for enhanced barrier precautions. Review of the facility policy and procedure titled Enhanced Barrier Precautions with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organism . Procedure . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) regardless of MDRO [multidrug resistant organisms] colonization status . 4. For residents for whom EBP [Enhanced Barrier Precautions] are indicated, EBP is employed when performing the following High-Contact care activities- a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use; central line, urinary catheter, feeding tube, tracheostomy/ventilator, h. wound care: any skin opening requiring a dressing.6) During an observation on 4/7/2025 at 9:57 AM, there was a nasal cannula tubing connected to an oxygen concentrator, which was placed unbagged in the drawer of the bedside table in Resident #87's room (Photographic evidence obtained). During an observation on 4/7/2025 at 10:16 AM, there was a nasal cannula tubing connected to an oxygen concentrator laying directly on the floor unbagged in Resident #51's room (Photographic evidence obtained). During an interview on 4/8/2025 at 1:30 PM, Staff E, LPN, Unit Manager, stated, Oxygen tubing should be bagged when it is not in use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 22 of 26 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 04/10/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/8/2025 at 12:30 PM, the DON, stated, All oxygen tubing should be bagged when not in use. Review of the facility policy and procedure titled Oxygen Administration with an effective date of 4/1/2022 and last review date of 1/21/2025, read, General Guidelines . 5. All disposable equipment labeled with the resident's name, the date it was opened or provided, and should be changed a minimum of every 7 days. 7) During an observation on 4/9/2025 at 8:57 AM, Staff A, LPN, obtained a blood pressure reading and a pulse oximetry reading from Resident #321. Staff A did not clean the blood pressure cuff or the pulse oximeter. Staff A used the same equipment on Resident #324 to obtain a pulse oximetry reading and to attempt to obtain blood pressure reading. Staff A used a second blood pressure cuff to obtain a blood pressure reading from Resident #321 at 9:25 AM. Staff A did not clean the blood pressure cuff after using it and before returning it to a drawer. During an interview on 4/9/2025 at 10:05 AM, Staff A, LPN, stated, I should have cleaned the blood pressure cuff and pulse ox [oximeter] between patients. During an observation on 4/9/2025 at 9:49 AM, Staff A, LPN, removed two tablets for Resident #61 from the blister packs directly into his hand and then placed them in the resident's medication cup. While preparing oral medications for administration for Resident #61, three pills dropped onto the top of the medication cart. Staff A placed two pills into the medicine cup for administration to the resident and discarded one pill into the drug disposal system. During an interview on 4/9/2025 at 10:05 AM, Staff A, LPN, stated that he was unaware that he needed to avoid touching medications. During an interview on 4/9/2025 at 12:50 PM, the DON stated that the expectation was for nurses to clean equipment between residents and that they should not touch medications with their hands. During an observation on 4/10/2025 at 8:45 AM, Staff A, LPN, administered three medications to Resident #116 via percutaneous endoscopic gastrostomy (PEG) tube after donning gloves. Staff A did not don a gown. Review of Resident #116's physician order 4/4/2025 read, Enhanced Barrier Precautions for g-tube, every shift. During an interview on 4/10/2025 at 8:55 AM, Staff A, LPN, stated that EBP meant he needed a barrier on the surface used during medication preparation and administration. Staff A then stated he should have worn gown while administering medications through a PEG tube. During an interview on 4/10/2025 at 11:30 AM, the DON stated, If residents are admitted with a PEG tube, catheter, intravenous line, or wound, they were placed on EBP. A nurse is expected to wear a gown and gloves while administering medication through a PEG tube. Review of the facility policy and procedure titled Administering Medications with an effective date of 4/1/2022 and the last review date of 1/21/2025, read, Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. General Guidelines . 23. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 23 of 26 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 04/10/2025 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 isolation precautions, etc.) for the administration of medication as applicable. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled Hand Hygiene with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Purpose: To prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Procedure: 1. All staff should perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Reference the table below for conditions and indications where hand hygiene is required. Note this may not be an all-inclusive list. Indication . Between resident contacts . Before applying and after removing personal protective equipment (PPE), including gloves . Before preparing or handling medications . Before and after handling clean or soiled dressings, linens, etc. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 24 of 26 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 04/10/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm 2) Review of Resident #30's physician order dated 4/2/2025 read, Amoxicillin-Pot Clavulanate Tablet 875-12 MG [milligram], Give 1 tablet by mouth every 12 hours for bacterial infection for 7 days. Residents Affected - Few Review of Resident #30's physician order dated 4/9/2025 read, Amoxicillin-Pot Clavulanate Tablet 875-125 MG, Give 1 tablet by mouth every 12 hours for URI [Upper Respiratory Infection] until 4/10/2025 19:59 [7:59 PM]. Review of Resident #30's medical record did not show diagnostic testing for an Upper Respiratory Infection. During an interview on 4/10/2025 at 9:02 AM, the Director of Nursing (DON) stated, No test was ordered for [Resident #30's name]. The provider just ordered the antibiotics. We have spoken to him about not just ordering antibiotics without testing. During an interview on 4/10/2025 at 9:45 AM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, The facility would like to get a chest x-ray, but we have a doctor who usually comes at meal times and puts the residents on antibiotic and if the person coughs, he does not get test order and will order a z-pack. He will write orders for UTI and URIs. I would not be able to get a resident to agree to discontinue the antibiotic because the provider has already spoken to them. Review of the facility policy and procedure titled Antibiotic Stewardship Program with an effective date of 4/1/2022 and the last review date of 1/21/2025, read, Procedure . 3. Antibiotics Stewardship activities shall include but not be limited to: a. Regular review of antibiotic utilization patterns and sensitivity patterns at the committee meetings . b. Reports from the Laboratory on sensitivity and resistance patterns over time (quarter, year, past years). Based on observation, interview and record review, the facility failed to establish antibiotic stewardship program to monitor antibiotic use for 2 of 5 residents reviewed, Residents #30 and #39. Findings include: 1) Review of Resident #39's records showed a physician order dated 2/14/2025 for Hiprex 1 gram (1 tablet by mouth two times daily for prophylactic antibiotic). During an interview on 4/9/2025 at 10:30 AM, the Advanced Practice Registered Nurse 2 (APRN 2) stated, She [Resident #39's name] is so susceptible to UTI's [Urinary Tract Infections] that she seems to do better on preventative. When asked if he had ever considered an antibiotic time out, the APRN 2 stated, If it's something that's required, we can, but I haven't thought about it. During an interview on 4/9/2025 at 10:40 AM, the APRN 2 stated, I was in talking to my residents and when I saw [Resident #39's name], she just looked and sounded awful. I listened to her and her lungs were yuck sounding and she had a bad cough, so I ordered her Augmentin. When asked where the documentation for this assessment was, the APRN 2 stated, We've been transitioning and I guess they haven't transcribed my notes yet. During an interview on 4/9/2025 at 12:30 PM, the Assistant Director of Nursing (ADON) stated, We've tried to talk to the providers, but they don't always listen. The ADON was not able to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106126 If continuation sheet Page 25 of 26 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 04/10/2025 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 0881 documentation of provider discussions. 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 26 of 26