Inspection·August 12, 2025

K0920 Electrical Equipment - Power K0920 SS = D and Extens Bldg. 05 CFR(s): NFPA 99 Electrical Equipment - Power and Extension Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assemblies that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 80601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension are not used as a substitute for fixed wiring of a structure. Extension used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6, 10.2.4, 10.5.2.3 (NFPA 99), NFPA 70 This LICENSURE REQUIREMENT is NOT MET as evidenced by: Office of Primary Care and Health Systems Management LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM Event ID: GUI621 Facility ID: 35960976 If continuation sheet Page 1 of 2 Florida Department of Health PRINTED: 09/26/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 130471022 (X2) MULTIPLE CONSTRUCTION A. BUILDING 05 - MAIN LIC B. WING (X3) DATE SURVEY COMPLETED 08/12/2025 NAME OF PROVIDER OR SUPPLIER LIFE CARE CENTER AT INVERRARY STREET ADDRESS, CITY, STATE, ZIP CODE 4300 ROCK ISLAND ROAD , LAUDERHILL, Florida, 33319 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

K0920 SS = D Bldg. 05 Continued from page 1 Based on observation and staff interview, the facility failed to maintain their electrical system in accordance with NFPA 1. The findings included: On between 12:30 PM and 2:30 PM during facility tour with the Director of Maintenance Director, the electrical water cooler inside the break room located on the first floor was not plugged into a ground fault circuit interrupter (GFCI). An interview was conducted with the Administrator and Director of Maintenance, concurrent with the observations and they acknowledged the findings. The findings were reviewed with the Administrator and Director of Maintenance at the exit on 2:45 PM. NFPA 1 (2021 Edition) 11.1.2.1 NFPA 101 (2021 Edition) 19.5.1.1, 9.1.2 NFPA 70 (2020 Edition) 422.5 (A)(2) Class III

K0920 STATE FORM Event ID: GUI621 Facility ID: 35960976 If continuation sheet Page 2 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/24/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106047 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED B. WING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER LIFE CARE CENTER AT INVERRARY STREET ADDRESS, CITY, STATE, ZIP CODE 4300 ROCK ISLAND ROAD , LAUDERHILL, Florida, 33319 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

K0000 INITIAL COMMENTS

K0000 An unannounced Fire & Life Safety recertification survey was conducted on at Life Care Center at Inverrary, a nursing home in Lauderhill, Florida. Life Care Center at Inverrary is not in compliance with 42 CFR 483.90 (a) & (b) and National Fire Protection Association (NFPA) 101 (2012 Edition) and Tentative Interim Amendments ('s) and Tentative Interim Amendments ('s) and requirements for nursing homes. Initial Plan Review: 2003 Existing NFPA 220 Construction Type: V (111) Number of licensed beds: 120 Census: 109 The following is a description of deficiencies found at the time of the visit:

K0920 SS = D Bldg. 01 Electrical Equipment - Power and Extens

K0920 Electrical Equipment - Power and Extension Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assemblies that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension are not used as a substitute for fixed wiring of a Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions). Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 ( ) Previous Versions Obsolete Event ID: GUI621 Facility ID: 35960976 If continuation sheet Page 1 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/24/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106047 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED B. WING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER LIFE CARE CENTER AT INVERRARY STREET ADDRESS, CITY, STATE, ZIP CODE 4300 ROCK ISLAND ROAD , LAUDERHILL, Florida, 33319 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

K0920 SS = D Bldg. 01 Continued from page 1 structure. Extension used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70). This STANDARD is NOT MET as evidenced by: Based on observation and staff interview, the facility failed to maintain their electrical system in accordance with NFPA 101. The findings included: On between 12:30 PM and 2:30 PM during facility tour with the Director of Maintenance Director, the electrical water cooler inside the break room located on the first floor was not plugged into a ground fault circuit interrupter (GFCI). An interview was conducted with the Administrator and Director of Maintenance, concurrent with the observations and they acknowledged the findings. The findings were reviewed with the Administrator and Director of Maintenance at the exit on 2:45 PM. NFPA 101 (2012 Edition) 19.5.1.1, 9.1.2 NFPA 70 (2011 Edition) 422.52 FORM CMS-2567 ( ) Previous Versions Obsolete Event ID: GUI621 Facility ID: 35960976 If continuation sheet Page 2 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/24/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106047 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER LIFE CARE CENTER AT INVERRARY STREET ADDRESS, CITY, STATE, ZIP CODE 4300 ROCK ISLAND ROAD , LAUDERHILL, Florida, 33319 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

E0000 Initial Comments

E0000 During the Fire & Life Safety recertification survey conducted on Inverrary, a nursing home, at Life Care Center at Inverrary, Emergency Preparedness was reviewed. Life Care Center at Inverrary is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long Term Care Facilities. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 ( ) Previous Versions Obsolete Event ID: GUI621 Facility ID: 35960976 If continuation sheet Page 1 of 1