Inspection·July 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Resident Rights with an effective date of February 2021 revealed that The facility strives to ensure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 2 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the admission Record indicated that Resident #30 was admitted on [DATE] with diagnoses that included not limited to other specified mental disorders due to known physiological condition and unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. The admission Minimum Data Set (MDS), dated [DATE], indicated Resident #30 had received two days of antidepressant medications. The care plan for Resident #30 indicated the resident received the psychotropic medication related to antidepressant to manage, depression. An Initial Psychiatric Diagnostic interview note, dated 5/16/23, indicated the resident had a history of depression, was on a psychotropic medication, and well known to the provider from previous stays. The provider indicated the resident would receive individual therapy for depression and the problem behaviors of intermittent depressive symptoms. The Preadmission Screening and Resident Review (PASRR) showed Resident #30 did not have any Mental Illness (MI), Suspected Mental Illness (SMI), or any Intellectual Disability (ID) based on documented history and medications. 4. The admission Record for Resident #78 indicated the resident was admitted on [DATE] with diagnoses not limited to flaccid hemiplegia affecting left nondominant side, Type 2 Diabetes Mellitus with unspecified complications, and aphasia following cerebral infarction. The 5-day MDS dated [DATE], indicated the resident received seven days of antianxiety and antidepressant medications during the assessment period. A psychiatric (psych) note dated 3/23/23, for Resident #78 showed the resident had diagnoses of adjustment disorder with mixed anxiety and depressed mood, and unspecified insomnia. The note showed the resident received the medications of Trazodone, Hydroxyzine and Zoloft for adjustment disorder with depression and anxious mood. The care plan for Resident #78 indicated that the resident was a risk of hurting self and/or with suicide ideation related to resident expresses feelings of worthlessness, hopelessness, or helplessness, secondary to history of suicide attempt. The care plan identified that the resident had a mood problem related to history of suicide attempt in the 1980's (and) depression diagnosis. The resident received psychotropic medication related to antidepressant and antianxiety and demonstrated behavioral problems related to screams out for help and does not use call light. The PASRR for Resident #78 did not identify any MI, SMI or ID due to the documented history. 5. The admission Record for Resident #80 showed the resident was admitted on [DATE] and included diagnoses not limited to dementia in other diseases classified elsewhere mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. The above diagnoses were present upon the residents' admission according to the admission Record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 3 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563 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 0644 Level of Harm - Minimal harm or potential for actual harm The PASRR, dated 3/4/23 for Resident #80 did not show that the resident had any mental illness with findings based on documented history and behavioral observations. A PASRR that was not located in the hard copy of the resident's chart and provided by the facility was completed by the facility and dated 3/30/23, showed the resident had a diagnosis of anxiety disorder based on documented history, behavioral observations, and medications. Residents Affected - Few The Psychotropic and Sedative/Hypnotic Utilization report indicated Resident #80 received Aripiprazole (antipsychotic), Buspirone (anxiolytic), and the antidepressant medications Mirtazapine and Trazodone. A review of Resident #80's medications indicated that the resident received Buspirone three times a day and Alprazolam as needed for anxiety, Trazodone and Mirtazipine for depression, and Aripiprazole for schizophrenia. A psych note dated 7/14/23, showed Resident #80's anxiety and depression were better controlled. A note, dated 7/7/23, indicated the resident had a history of dementia, depression, and anxiety, continued to refuse medications, with physical aggression, and combativeness. The 5-day MDS dated [DATE], included the diagnoses for Resident #80 of anxiety and depression and showed the resident received three days of antianxiety and antidepressant medications. An interview was conducted on 7/18/23 at 9:54 a.m. with the Social Service Director (SSD). The SSD said the Director of Nursing (DON) and the SSD reviewed PASRR's on admission and if anything was different they would make corrections. They look at medications and decide if a Level II should be done. An interview with the SSD on 7/18/23 at 10:05 a.m. revealed if Resident #80's PASRR did not include diagnoses it should have been revised and corrected. A review of Resident #78's PASRR was conducted and the SSD stated the suicide attempt may or may not be relevant but if it was documented somewhere it should be noted on the PASRR. A review of Resident #30's PASRR was conducted and the SSD stated if the resident was taking medications for depression a diagnosis should be revised on the PASRR. Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR) effective 02/21 revealed . 2. Social Services or RN will review to determine if a Serious Mental Illness (SMI) and Intellectual Disability (ID) or both exists while reviewing the PASARR form. The existence of either, or both, condition(s) triggers the requirement for Level II review and will be provided to the appropriate state agency by the Social Services Director upon admission. The Social Services Director/Nursing Administration will review for completion and accuracy during the clinical meeting process. Recommendations will be implemented into the resident's plan of care then the document will be filed in the resident record . Based on record review, staff interview, and review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR), the facility failed to complete the Preadmission Screening and Resident Review Level II upon a new qualifying mental health diagnosis for five (Resident #10, #40, #80, #78, and #30) of thirty-two residents sampled for PASARR Level II. Findings included: 1. Resident #10 was admitted on [DATE] with diagnoses of unspecified psychosis not due to substance or known physiological condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 4 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #10's PASARR Level I assessment dated [DATE] revealed no qualifying mental health diagnosis and that no PASARR Level II was required. Review of Resident #10's medical record revealed a new diagnosis of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety on 03/21/19, schizoaffective disorder on 10/31/18, major depressive disorder on 10/30/18, and generalized anxiety disorder on 10/30/18 and the resident was not assessed for PASARR Level II. Section I Active Diagnoses of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia. 2. Resident #40 was admitted on [DATE] with a diagnosis of cerebral infarction. Review of Resident #40's PASARR Level I assessment dated [DATE] revealed no qualifying mental health diagnosis and that no PASARR Level II was required. Review of Resident #40's medical record revealed a new diagnosis of unspecified psychosis not due to a substance of known physiological condition on 12/11/18 and generalized anxiety disorder on 12/11/18. The resident was not assessed for PASARR Level II. Section I Active Diagnoses of the admission MDS dated [DATE] revealed Resident #40 had diagnoses of anxiety disorder and psychotic disorder. On 07/18/23 at 9:48 a.m., the Director of Nursing (DON) stated the Social Services Director (SSD) would redo the PASARR if it came from another facility and was inaccurate. On 07/18/23 at 9:54 a.m., the SSD stated she and the DON reviewed the PASARRs upon admission. If they noticed anything that was different, they would make corrections. They review medications and diagnoses to check to see if the PASARRs were accurate. A Level II PASARR would be needed based on what was indicated in the sections on the Level I PASARR. The SSD confirmed both PASARRs were inaccurate for Resident #10 and #40. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 5 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and policy review the facility failed to ensure food items in the walk-in refrigerator were labeled, dated, and discarded when expired. The failed practice had the potential to effect 108 of 110 residents who received food from the facility's kitchen. Findings included: An observation on 07/16/23 at 9:10 a.m., revealed the walk-in refrigerator that contained items that were not labeled or dated. Photographic evidence was obtained. The items included: -Two (2) quart container of barbeque chicken -Two (2) quart container of mushroom soup -Two (2) quart container of corn -Two (2) quart container of mashed potatoes -Four (4) quart container of sausage rice -A Styrofoam container of three (3) sandwiches Continued observation, on 07/16/23 at 9:15 a.m., revealed the walk-in refrigerator contained items that were expired. Photographic evidence was obtained. The items included: -Two (2) quart container of pears with expiration date 07/09/23 -Two (2) quart container of cream of broccoli soup with expiration date 07/11/23 -Two (2) quart container of tuna salad with expiration date 07/11/23 -Four (4) quart container of rice with expiration date of 07/14/23 -Four (4) quart container of chocolate pudding with expiration date of 07/15/23 During an interview on 07/16/23 at 9:20 a.m., the Dietary Manager (DM) identified the food items that were not labeled or dated and stated the food items were from yesterday. The DM stated she stored the items in the walk in refrigerator without labeling or dating the items because I was running behind yesterday. The DM also identified the food items that were expired and stated the items needed to be discarded. A review of facility policy titled, Storage effective date 01/2023 stated, Refrigerator storage: 8. Label all leftovers with recipe name, date (month, day, and year) of storage and use by date. 9. Discard refrigerator leftovers after 72 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 6 of 6