Inspection·February 25, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's MDS Nursing Home Quarterly, dated 02/18/2025, revealed a BIMS score of 13, which indicated cognition was intact. Section G- Functional Status: I. Toilet use Limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance. 3. Record review of Resident #3's, undated, admission Record revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #3 had a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD is an on-going lung condition caused by damage to the lungs.) Record review of Resident #3's Care Plan, dated 01/27/2025, revealed Focus: ADL Self-care performance deficit. Goal: will maintain or improve current level of function in through the review date. Interventions: Assist with personal hygiene as required; hair, shaving, oral care as needed. Record review of Resident #3's MDS Nursing Home Quarterly, dated 02/03/2025, revealed a BIMS score of 13, which indicated cognition was intact. Section G- Functional Status I. Toilet use- Supervision - oversight, encouragement or cueing. Observation on 02/25/2025 at 9:40 AM revealed, upon attempting to access hot water in Resident #1's bathroom by turning on the faucet, it was observed the water supply was non-operational as no water flowed through the fixture. There was standing feces in the resident's toilet , the bathroom had a strong foul odor that could be smelled outside the restroom into the resident's room with the restroom door closed . Interview on 02/25/2025 at 9:42 AM with Resident #1 revealed she did not use the restroom, she used the bedside commode. She stated direct care staff emptied the commode into the resident's toilet and then they rinsed out the basin in the restroom sink. She stated she did not use the restroom because there was no hot water. She was unable to give a timeframe for how long the hot water water was not working. She stated she did not like it because everything smells like poop. Interview on 02/25/2025 at 10:19 AM with LVN A revealed there was no hot water on the 300 hall. She stated residents had not had hot water for a few days. The specific days or weeks were unknown. Interview on 02/25/2025 at 10:25 AM with the Maintenance Director revealed, he was informed on this date (02/25/2025) the hot water was not working on halls 100, 200 and 300. He stated there was a slab leak and the hot water pump for the listed halls were not functioning properly. He stated the facility experienced two slab leaks, they were repaired and another leak happen. He stated, it's an old building . Interview on 02/25/2025 at 10:21 AM with LVN B revealed, the resident's on hall 300 did not have hot water in their rooms and she couldn't remember how long the hot water was off but stated it was longer than a week . Interview on 02/25/2025 at 12:01 PM with CNA C revealed, he was caring for the residents on hall 400 and they did not have hot water. He stated the residents scheduled for showers were taken to the shower room on hall 500. Residents who were unable to ambulate to the shower, warm water was collected in a basin and transported to the resident's room for their use. He stated he could not recall how long residents were without hot water, but it was longer than one day . Interview on 02/25/2025 at 12:10 PM with Resident #1 revealed housekeeping came and cleaned her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 2 of 5 Printed: 05/15/2026 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 455903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Lodge Nursing & Rehabilitation 3800 Marina Dr Lake Worth, TX 76135 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 0584 room but did not clean the restroom. Level of Harm - Minimal harm or potential for actual harm Observation on 02/25/2025 at 12:10 PM revealed standing feces in the toilet and a foul odor coming from the restroom. Residents Affected - Some Observation and interview on 02/25/2025 at 12:12 PM with LVN B revealed she was alerted to the restroom by the State Surveyor. She stated this was not her resident but would assist with needs. She stated the toilet appeared to be clogged. She flushed the toilet and the water rose up in the toilet basin but the feces did not go down the drain. She stated she would alert the CNA assigned to the resident . She stated the risk of the toilet not working properly was infection control. Interview on 02/25/2025 at 12:16 PM with Housekeeper D revealed she cleaned Resident's #1's room today and the room was cleaned and mopped daily. She stated she did not go into the restroom because the resident did not use the restroom and she was unaware of the feces in the toilet. Interview on 02/25/2025 at 12:18 PM with CNA E revealed she verbally informed housekeeping of the toilet in Resident #1's room . She stated she did not empty the bedside commode in the toilet but noticed the feces in the toilet when she rinsed out the bedside commode in the sink. She stated she always cleaned the bedside commode in the sink even though there was no hot water. She stated she used cold water and soap to clean the commode and returned it to the resident's bedside. She stated she deposed the contents of the commode in a liner and immediately took it outside to the dumpster . She stated there was no risk to the resident for not having hot water. Interview on 02/25/2025 at 2:50 PM with LVN A revealed she was not aware of the clogged toilet in Resident #1's restroom. She stated there was no risk to the residents for not having hot water in their rooms because there was hot water in the building that they had access to. Observation and interview on 02/25/2025 at 3:47 PM with Resident #2 revealed, she did not have access to hot water in her restroom. She stated she had to go to another hallway to wash her hands and she did not like it. She would rather wash her hands in her restroom . Observation and interview on 02/25/2025 at 3:48 PM with Resident #3 revealed, she did not have access to hot water in her restroom for a couple of days. Observation of her restroom revealed antibacterial wipes by the sink. She stated she used the wipes to clean her hands because there is no hot water. She stated she felt dirty and disgusting . Interview on 02/25/2025 at 4:40 PM with DON revealed the water was shut off today for maintenance. She stated the residents could receive hot showers on hall 500 and CNA's provided hot water to residents who were unable to ambulate to the 500 hall. She stated the risk to the residents for not having hot water in their restrooms could be cross contamination. Interview on 02/25/2025 at 5:00 PM with the Administrator revealed she was aware the hot water was turned off for multiple days because of maintenance issues. She stated maintenance was currently working to repair the issue and restore the hot water to all residents. She stated staff should report maintenance issues such as the clogged toilet on the maintenance log. There was a QR code on each hallway where staff could report the issue. She stated she reviewed the log and it did not reveal an order for Resident #1's toilet. Record review of the Water Temperature check log, dated 05/08/24-02/20/25, revealed, weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 3 of 5 Printed: 05/15/2026 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 455903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Lodge Nursing & Rehabilitation 3800 Marina Dr Lake Worth, TX 76135 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature checks of the hot water should be at least 100 to 110 degrees Celsius . The Waterlog was a spreadsheet with Halls represented by columns 1-6 and a column labeled kitchen followed by a comment section. The rows represented dates the water temperature was checked. Log revealed the water temperature log was not consistently maintained on a weekly basis, as there was a deviation in the dates recorded. On 06/04/2024and the next entry was not until 09/02/2024, the next entry was not until 12/19/2024. The following notes were made in the comment section: -12/19/2024- no hot water 1,2,3 . No temperature recorded for halls 1, 2, or 3. -12/25/2024- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. -01/01/2025- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. -01/08/2025- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. -01/14/2025- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. 01/28/2025- No hot water 1, 2, 3. No temperature was recorded for halls 1, 2, or 3. 02/06/2025- Hall 1 (81.0), Hall 2 (82.0), Hall 3 (81.1) 02/13/2025- Shut 300 water heater off . No temperature recorded for halls 1, 2, or 3. 02/20/2025- No hot water 1, 2, 3. No temperature recorded for halls 1, 2, or 3 . Record review of the plumbing repair invoice, dated 12/16/2024, revealed repaired 2 leaks on 2' water main. Record review of the plumbing invoice, dated 02/05/2025, revealed access hole concrete access 5'x5' and tunnel & backfill 6 ft tunnel initially-could be more (open estimate on tunnel length) to investigate and repair hot water leak. Record review of the facility's, undated, policy titled Resident Rights revealed, Safe Environment- the resident has a right to a safe, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Record review of the facility's policy titled Hot Water Systems Environment of Care Policy & Procedure Manual 2003 revealed, 1. The hot water system will be checked daily for temperature variations. 2. The temperatures will be recorded on the water temperature log weekly and maintained by the Maintenance Supervisor. The facility will be responsible for maintaining at least twelve months of water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 4 of 5 Printed: 05/15/2026 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 455903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Lodge Nursing & Rehabilitation 3800 Marina Dr Lake Worth, TX 76135 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 0584 temperature logs for review. Level of Harm - Minimal harm or potential for actual harm 4. Water temperatures should be maintained at 100 degrees F at a minimum, and 110 degrees F at maximum. Residents Affected - Some 14. The facility will make provisions to repair the hot water problem as soon as possible. Use to the areas affected by the malfunctioning unit will be restricted until repairs are complete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 5 of 5