Inspection·February 6, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some improvements, report declines to MD. Observe that dressing is covering and adhering. Report lose dressing to nurse. No revisions noted on care plan. Review of the SBAR Communication Form (Situation, Background, Assessment, and Recommendation) dated 01/16/2024 showed this started on 01/15/2024, 8. Skin Evaluation showed abrasion. Appearance: open area noted to right buttock, site cleansed, patted dry and dressed. Resident denies pain at site at this time. Primary Care Clinician notified on 01/16/2024 at 12:00 a.m. Family notified on 01/16/2024 at 12:00 a.m. Signed by Staff A, LPN, (Licensed Practical Nurse). Review of the Skin and Wound Evaluations showed: -01/16/2024: abrasion of the coccyx was acquired in-house. The exact date was left blank. Area was 2.9 cm (centimeters); length was 2.8 cm; width was 1.4 cm. The bed was covered with epithelial. There was no evidence of infection. It was pink or red. There was no exudate or odor. No induration or edema was present. The resident did not have any pain. The goal of care was slow to heal; wound healing is slow or stalled but stable, little / no deterioration. Treatment included normal saline, and hydrocolloid. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD (medical doctor) order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. -01/23/2024: abrasion of the coccyx was acquired in-house. The exact date was left blank. Area was 1.4 cm2; length was 2.9 cm; width was 1.2 cm. The bed was covered with epithelial. There was no evidence of infection. It was pink or red. Exudate was light and sanguineous / bloody, no odor. No induration or edema was present. The resident did not have any pain. The goal of care was slow to heal; wound healing is slow or stalled but stable, little / no deterioration. Treatment included normal saline, and hydrocolloid. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. -01/30/2024: abrasion of the coccyx was acquired in-house. The exact date was left blank. Area was 6.6 cm2; length was 3.8 cm; width was 2.6 cm. The bed was covered with granulation. There was no evidence of infection. It was pink or red. There was light serosanguineous exudate and no odor. No induration or edema was present. The resident did not have any pain. The goal of care was slow to heal; wound healing is slow or stalled but stable, little / no deterioration. Treatment included normal saline, and biologic and composite dressing. Wound progress was stable. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. -02/05/2024, an incomplete noted showed wound was pressure, Stage II, length was 6.4 cm x 4.3 cm. On 02/05/2024 at 9:40 a.m. Resident #5 was sitting up in bed. Resident #5 stated, they do not change my dressing every day. Staff C, CNA (Certified Nursing Assistant) and Staff D, CNA assisted the resident over to her right side. Observation of the buttocks dressing showed a dressing that was coming off, saturated in red drainage and had no date documented. Staff C, CNA verified the dressing lacked a date. The wound was the size of a square orange, open, shallow, red and angry in appearance, with red drainage. The wound had an odor. Staff A, Licensed Practical Nurse (LPN) stated the wound was to be changed on the 3-11 shift. Staff A stated the dressing was to be dated. She stated the resident was not on an antibiotic. She stated the resident was not on an air mattress. Observed Staff A, Licensed Practical Nurse (LPN) perform wound care. Staff A came into the room with her gloves already (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 2 of 18 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 02/06/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on. She had a border dressing, gauze dressings, a tube of medi-honey and multiple tubes of normal saline into the room and sat the supplies beside the sink. She opened the border dressing and placed it on the wrapper beside the sink. She dated it with a pen she had removed from her pocket. She then put the pen back into her pocket. She then opened the gauze sponges and placed them on top of each other on one of the gauze wrappers also next to the sink. She then moved the stack gauze on the wrapper, the border dressing on a wrapper, the normal saline and medi-honey onto the bed. She opened the normal saline and squirted it onto the wound and used the gauze to clean the wound, she replaced the used gauze onto the same wrapper as the clean gauze. Staff A patted the wound dry with gauze from the same wrapper. She opened the medi-honey and rubbed it onto the wound with her gloved finger. She then applied the dated border dressing. She placed the gauze into the trash. She left the remaining normal saline on the sink area. She removed her gloves and washed her hands. She picked up the medi-honey tube and replaced it into the treatment cart. On asking she removed the medi- honey and stated that she had to get it from central supply and dated it and replaced it in the treatment cart. An interview was conducted on 02/05/2024 at 4:42 p.m. with the Director of Nursing (DON), she stated the Unit Manager (UM) stated an abrasion was the top layer of skin, like shearing. She did state her expectation was for the dressings to be dated. The DON stated as long as on Treatment Administration Record (TAR) was documented as performed they staff did not have to date the dressing. DON stated she thought documenting on the TAR only was following the policy. Informed the DON had observed two dressing today and neither were dated. The DON stated she looked at Resident #5s wound last week and felt it was an abrasion. The DON stated the physician does not look at the wounds unless they are asked to look at them. The Clean Dressing Change Competency Checklist was reviewed with the DON point-by-point. An Interview was conducted on 02/06/2024 at 1:45 p.m. with Director of Nursing (DON) and described the wound care procedure. The DON stated Staff A should have washed her hands, had a barrier on the sink for her supplies. She stated that Staff A had multiple opportunities for break in infection procedures / process. DON stated the (UMs (Unit Managers) follow up on the wounds. She stated all the UMs are (RN), Registered Nurses. She stated the RNs did not have any additional or training regarding assessing a wound, treatments, etc. She stated they do not have an Advanced Practice Registered Nurse (APRN) or physician specifically to assess the wounds and assess if an abrasion versus a pressure ulcer. The UMs make the decision of the wound by the appearance of the wound, by looking and evaluating. She stated that the wounds are evaluated by different nurses, the UMs. The DON stated, We have something (guidelines) for pressure ulcers, but don't know about the abrasions. She stated they do not use an air mattress unless the resident has multiple stage II wounds or a stage III or stage IV wound. Reviewed the list of wounds with the DON and she verified that 15 of the documented wounds were abrasions and 11 of those were in known pressure areas. Ten wounds were labeled as pressure areas. Total of 41 wounds were documented. 2. Resident #6 was admitted on [DATE] and readmitted on [DATE]. Review of admission record showed diagnoses included but were not limited to encephalopathy, diabetes, morbid obesity, immune disorder, local infection of the skin, muscle wasting, psoriasis, candidiasis, panniculitis and weakness. Review of the Minimum Data Set (MDS) dated [DATE] showed in section C, Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section GG, Functional Abilities and Goals showed she was dependent for toileting and bed mobility. Section M, Skin Conditions showed she was at risk for developing pressure ulcers / injuries. Review of the Physician Order Recap report, Treatment Administration Record (TAR) for January and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 3 of 18 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 02/06/2024 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 0684 February showed Level of Harm - Minimal harm or potential for actual harm -Cleanse right abdominal fold with normal saline, pat dry, and apply hydrocolloid dressing every 3 days for blisters as of 01/23/2024. The February TAR showed the wound care was not documented as performed on 02/04/2024. Residents Affected - Some -Cleanse under left breast with normal saline, pat dry, apply nystatin powder every day for rash as of 01/18/2024. -The February TAR showed the powder was not applied on 02/02/24 and 02/04/2024. -Apply Nystatin External Cream to bilateral groins topically every morning and at bedtime for fungal rash as of 12/11/2023. -The February TAR showed the cream was not applied on 02/02/2024 and 02/04/2024 in the a.m. Review of care plans showed resident at risk of developing a wound related to decreased mobility and multiple comorbidities initiated on 01/27/2023 and revised on 10/26/2023. Interventions included but not limited to encourage / remind/assist to turn/reposition as needed or requested; pressure reducing mattress; observe any new areas of skin breakdown. Care plan was updated with rash to groin and wound to right abdominal fold on 02/06/2024 (during survey). Review of SBAR dated 01/23/2024 showed skin wound or ulcer has worsened. Blisters ruptured. Primary Care Clinician notified on 01/23/2024 at 12:00 a.m. Recommendations of Primary Clinicians: antibiotic. Review of the Skin and Wound Evaluation showed: -01/23/2024: abrasion of right lower quadrant of the abdomen was acquired in-house. The exact date was left blank. Area was 2.8 cm2; length was 4.9 cm; width was 1.1 cm. The bed was covered with granulation. It was pink or red. There was moderate serosanguinous / bloody exudate and no odor. No induration or edema was present. The resident did not have any pain. The goal of care was slow to heal; wound healing is slow or stalled but stable, little / no deterioration. Treatment included normal saline, and hydrocolloid. Progress was new. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. -01/30/2024: abrasion of right lower quadrant of the abdomen was acquired in-house. The exact date was left blank. Area was 1.3 cm2; length was 3.2 cm; width was 0.7 cm. The bed was covered with granulation. It was pink or red. There was light serosanguinous / bloody exudate and no odor. No induration or edema was present. The resident did not have any pain. The goal of care was slow to heal; wound healing is slow or stalled but stable, little / no deterioration. Treatment included normal saline, collagen and a composite dressing. Progress was stable. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. -02/06/2024: abrasion of right lower quadrant of the abdomen was acquired in-house. The exact date was left blank. Area was 0.8 cm2; length was 2.3 cm; width was 0.4 cm. It was pink or red. There was moderate serous exudate and no odor. Peri-wound: Surrounding tissue: blister. No edema was present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 4 of 18 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 02/06/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident did not have any pain. The goal of care was slow to heal; wound healing is slow or stalled but stable, little / no deterioration. Treatment included normal saline, and hydrocolloid. Progress was stable. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. On observation and interview was conducted on 02/05/2024 at 10:35 a.m. Resident #6 was lying in a bariatric bed. The head of the bed was elevated. An ostomy bag was in place on her abdomen and appeared full. Staff C, CNA (Certified Nursing Assistant) and Staff D, CNA positioned resident to enable the observation under her right abdominal area. Observed an open area about the size of a nickel. There was no dressing in place. She stated the area on her abdomen was painful. Resident #6 stated she was supposed to have barrier cream on her abdomen with every brief change. She stated the facility did not have any barrier cream all weekend. She stated she needed 4-5 packets of barrier cream with every change, and she was changed 5-6 times a day due to being on a diuretic. She stated the briefs did not hold urine well and she felt like she was always wet. She stated her colostomy needed burping. Staff C, CNA and Staff D, CNA stated that either the nurses or the aides could put on the barrier cream. Staff A, LPN (Licensed Practical Nurse) looked in the treatment cart and was unable to find any barrier cream. Staff A went to the central supply office. An staff member was in the room and stated she was not the central supply person; they were on vacation. Both Staff A, LPN and the other employee were unable to locate any barrier cream in central supply. The staff member told Staff A they were supposed to get a supply order tomorrow. Staff employee went to the supply shed which was another room, and no barrier cream was located. An Interview on 02/06/2024 at 1:45 p.m. with Director of Nursing (DON) stated the aides can apply barrier cream as long as it does not have zinc in it. The barrier cream can be kept in the treatment cart. The aides can ask the nurse for it. She stated the barrier cream came in yesterday (02/05/2024) and she put a box both upstairs and downstairs in the afternoon. She stated she could not speak about the weekend and did not know if she got barrier cream or not. She started the barrier cream was supposed to be stock item. Central supply was supposed to keep the supply. The DON verified the hydrocolloid dressing was not documented as applied on the right side of her abdomen on 02/04/2024. The dressing change should have been performed. 3. Resident #7 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to post laminectomy syndrome, severe protein-calorie malnutrition, Cerebral infarction with hemiplegia. Review of the MDS dated [DATE] showed Section C, Cognitive Patterns, a BIMS score of 0 or resident is rarely/never understood. Section GG, Functional Abilities and Goals showed she was dependent in Activities of Daily Living. Section M, Skin Conditions showed she had 4 Stage I pressure injuries. Review of the Physician Order Recap Report and February Treatment Administration Record (TAR) showed: -Cleanse right buttock with normal saline, apply medi-honey, cover with dry clean dressing daily and as needed for stage III as of 01/23/2024 to 02/05/2024 -Cleanse coccyx with normal saline, apply medi-honey cover with dry cleanse dressing daily and as needed as of 02/05/2024 -Cleanse surgical site with normal saline, pat dry, apply small amount of Santyl, apply calcium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 5 of 18 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 02/06/2024 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 0684 alginate and cover with bordered dressing daily and as needed as of 01/20/2024. Level of Harm - Minimal harm or potential for actual harm Review of the SBAR Communication Form dated 01/20/2024 showed resident had an impairment noted to right buttock, new treatment orders applied and to follow facility protocol. Recommendation on 01/20/2023 at 6:00 p.m. were blood tests, dietician consult, new or change in medication. Residents Affected - Some Review of the Skin and Wound Evaluation showed: -01/02/2024: surgical site, dehiscence of lumbar, middle inferior back. Present on admission. The exact date showed 12/20/2023. Area was 3.0 cm2; length was 5.6 cm; width was 0.9 cm. The bed had slough, without percentage. No exudate or odor. The resident did not have any pain. The goal of care was slow to heal; wound healing is slow or stalled but stable, little / no deterioration. Treatment included normal saline, calcium alginate, composite dressing. Progress was stable. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. -01/09/2024, surgical site, decreased in size, area 0.8 cm2; length 2.0 cm, width 0.6 cm -01/16/2024, size had increased to area 1.9 cm2; length 2.8 cm, width 0.9 cm. Wound bed had granulation and no slough was documented. Light serosanguineous exudate with no odor. -01/23/2024, size had decreased to area 1.1 cm2; length 2.2 cm; width 0.7 cm. Wound bed had slough but no percentage. Exudate was moderate serosanguineous. -01/30/2024, size had decreased to area 0.5 cm2; length 1.6 cm; width 0.4 cm. Wound bed had slough but no percentage. No exudate or odor. -02/05/2024, size had increased to area 2.8 cm2; length 4.4 cm; width 1.1 cm. Wound bed had slough but no percentage. Moderate exudate with type. No odor noted. Treatment included normal saline, enzymatic and composite dressing. Progress was stable. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. Review of the Skin and Wound Evaluation showed: -01/23/2024: abrasion of the coccyx was in-house acquired. Exact date was blank. Area 2.8 cm2; length2.7 cm, width 1.5 cm. Granulated wound bed. Serosanguinous exudate and no odor. Goal of Care: slow to heal: wound healing is slow or stalled but stable, little / no deterioration. Treatment: normal saline, biologic, composite dressing. Additional care included foam mattress. Progress was new. MD and responsible party aware of current treatment in progress. Both parties are in agreement. MD order to continue with current plan of care. Registered Dietician and therapy notified. Will continue to monitor. -01/30/2024: abrasion of the coccyx. Area 1.5 cm2; length 2.3 cm, width 0.9 cm. -02/05/2024: pressure on the coccyx, stage II. Area increased to 1.9 cm2; length 3.1 cm, width 1.2 cm, depth not applicable. Light serosanguineous drainage and no odor. Progress: deteriorating. Review of the care plans showed she had an actual wound to coccyx as of 12/29/2023 and revised on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 6 of 18 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 02/06/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm 02/05/2024, interventions included but not limited to encourage /remind/assist to turn/reposition as needed or requested; treatment as ordered; no revision dated for 02/05/2024, Care plan showed had actual kin impairment related to surgical wound spine. Interventions included but not limited to monitor/document location, size and treatment of skin. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD, Residents Affected - Some On 02/05/2024 at 10:25 a.m. Resident #7 was observed lying in bed on an air mattress. Staff C CNA and Staff D, CNA turned the resident onto her side. It was observed she had a dressing on her coccyx area that was intact but was not dated. During an interview on 02/06/2024 at 1:45 p.m. the Director of Nursing (DON) stated that the dressing should be dated. She stated that the nursing staff needed some education. not dated dressing. She stated that she felt the residents were being turned and positioned. DON reviewed the SBAR and agreed the wound care for the pressure ulcer should not have taken three days to start care. The DON stated the wound should be documented as an abrasion, stage II, stage III. Should not be stage III, abrasion to stage II. The DON stated the nurses did not have any added qualifications for wound care management or process at this point. On 02/06/2024 at 3:10 p.m. Resident #7 was observed lying in bed dressed and groomed. Her enteral feeding was infusing via her gastrostomy tube and pump. Staff A, LPN (Licensed Practical Nurse) and Staff B, RN, UM (Registered Nurse Unit Manager) were performing wound care for Resident #7 on her coccyx and back. Staff A washed her hands and applied gloves, she cleaned the overbed table off with blue top wipes. She then removed her gloves and went to the treatment cart for a barrier for the table. She replaced her gloves without hand sanitizing and spread the barrier out on the table. She removed her gloves and washed her hands. She went to the treatment cart and removed supplies. She replaced her gloves and retrieved the Santyl from the cart and squeezed some into a medication cup and placed it on the barrier on the over bed table. She did the same with medi-honey. Staff B, RN removed her scissors from her pocket and placed them on the overbed table barrier. Then Staff A located her scissors and pens in a plastic baggie from the treatment cart and placed them on the barrier and Staff B removed her scissors from the barrier. Staff A with gloves opened all the supplies on the barrier. Staff B told Staff A to wash her hands after opening the supplies. Staff A removed a pen and scissors from a baggie placed on the barrier and cleaned them with alcohol. The g-tube feeding was paused so the resident could be turned. Staff A removed her gloves, handwashed and replaced her gloves. She placed a barrier under the resident. She removed two old, dated dressings, one from the back and one from the coccyx. Staff A did not remove her gloves or hand sanitize prior to cleaning the wounds. She flushed the upper back wound (surgical) with saline and gauze. She then flushed the lower, coccyx wound with saline and gauze. She removed the barrier with the dirty dressings and barrier into the trash can. Staff B, RN continued to hold the resident on her side. Staff A removed her gloves, hand washed and replaced her gloves. Staff A took over for Staff B holding the resident while Staff B removed her gloves, hand washed and replaced her gloves. She brought her wound measurement tablet to the bedside. The upper wound was 1.2 cm2 in area and the bottom was 0.8 cmcm2 in area. Staff B placed the tablet beside the sink. She then changed sides with Staff A. Staff A removed her gloves, washed her hands and re-gloved. She started with the bottom wound, she placed medi-honey on the wound using a tongue blade, placed calcium alginate in the wound and applied a border dressing. (Staff A did not change her gloves or hand sanitize between sites.) Staff A placed Santyl on the upper wound using a tongue blade, applied calcium alginate and a border dressing. She placed the trash items into the trash can. Staff A and B turned the resident onto her back and made her comfortable. Staff A removed her gloves, washed her hands and removed blue top wipes from the cart. She replaced her gloves and wiped the over bed table off. She then also cleaned the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 7 of 18 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 02/06/2024 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 0684 measurement tablet and pen with blue top wipes. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/06/2024 at 3:45 p.m. Staff B, Registered Nurse (RN) Unit Manager (UM) stated the DON had taught them (the nurses) how to use the measurement tablet. She stated she had no other wound assessment training other than at (nursing) school. She stated an abrasion was a superficial wound, a removal of the top layer or skin. She stated it was like shearing. The shearing was possibly done when the staff moved a resident up in bed or something. She stated they had a paper which showed pictures of the stages of a pressure ulcer. She stated a stage I pressure ulcer was not open and non-blanchable. She stated a stage II was an open area. She stated the measuring tablet takes a picture and it transfers to the electronic medical record and inputs the size of the wound. She stated they must measure the depth themselves. She stated she would provide the paper they go by for wounds. (It was never provided to the surveyor by Staff B, RN). Residents Affected - Some 4. Resident #24 physician orders showed cleanse wound with normal saline, pat dry, apply medi-honey and alginate to ulcer bed. Do not pack. Apply skin prep to peri-wound are. Cover with self-adhesive foam dressing daily and as needed. Observation on 02/07/2024 at 3:50 a.m. with Staff A and Staff B with Resident #24, Staff A, LPN washed her hands, gloved and cleaned the overbed table with the blue top wipes. Staff B, RN washed her hands and placed gloves on and assisted with positioning the resident. Staff A removed her gloves and hand washed. The resident was lying in bed on an air mattress. Staff A gathered the supplies and placed them on the overbed table on the barrier. The bed was moved up, and the resident was turned with the aid of Staff B. Staff A, LPN removed her gloves, washed her hands and replaced her gloves. She opened the supplies on the barrier on the overbed table. She removed her gloves, went to the cart and squirted the medi-honey into a medicine cup (she had brought the medi-honey into the room with her and exited the room and placed it in a cup and replaced medi-honey into the treatment cart). She then placed the medication cup onto the barrier. Staff A washed her hands and replaced her gloves. She placed a barrier under the resident and removed the old, dated dressing. The wound was the size of a tangerine. Staff A (without hand sanitizing) used normal saline and gauze to cleanse the wound including the edges and inside of the wound. She patted it dry with gauze. The inside of the wound had a yellow appearance. Staff A removed her gloves and washed her hands and replaced her gloves. Staff B, RN changed sides with Staff A, LPN. Staff B, RN measured the wound with the measurement tablet. Staff A, LPN left the resident and retrieved a clean brief from the closet and returned to the bedside. The wound measured an area of 7.7 cm2. Staff B, RN used a cotton-tipped applicator to measure the depth. Staff B, RN stated she did not have a paper measurement to measure the cotton-tipped applicator and would check the measurement of the depth later. Staff B, RN put the tablet beside the sink on a barrier and went to hold the resident. Staff A, LPN removed her gloves, washed her hands and replaced her gloves. Using a tongue blade she placed medi-honey on the wound as well as calcium alginate and a foam dressing over the top. Staff B, RN stated that they text the physician with the description of the wound and the physician sends back orders for wound care. Staff B stated when the ARNP was there she would look at the wound and give us orders. Staff B stated the measurement tablet would not measure the depth, it had to be measured separately. Review of the facility's procedure, Clean Dressing Change Competency Checklist, not dated showed 6. Wash hands and apply gloves; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 8 of 18 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 02/06/2024 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 0684 7. Clean work surface and cover with non-permeable barrier Level of Harm - Minimal harm or potential for actual harm 8. Remove gloves and wash hands Residents Affected - Some 9. Gather supplies needed for dressing change i.e.: wound cleanser/normal saline, tape, gauze, scissors, gloves, alcohol pads (for cleaning scissors), bag for dressing disposal, cotton applicators, all applicable tx medications 10. Place supplies on prepped table and position waste basket in accessible area 11. Wash hand and apply gloves 12. Open dressing packs. Write date, time and initials on cover dressing or pre-cut tape. Wipe scissors before and after use with alcohol pad. Do not place in pocket. 13. Remove gloves wash hands 14. Apply gloves 15. Place clean barrier under are to be dressed 16. Remove dressing and discard 17. Remove gloves and wash hands 18. Apply gloves. Utilizing technique moistened gauze with cleanser or normal saline or pr MD order. Clean wound using circular motion starting from center toward the outside. (Clean to dirty). Discard and repeat if necessary. 19. Cleanse peri-wound with separate moistened gauze. Discard 20. Remove gloves and wash hands 21. [NAME] gloves and apply treatment as orders. Oinements/creams should be put into medicine cup (tube of medication should not be brought into the resident's room). 22. Re-position resident 23. Clean work area. Discard used items. Clean scissors with micro-kill bleach wipes 25. Remove gloves and wash hands. Review of the facility's policy, Hand Hygiene, effective October 2021 showed the facility considers hand hygiene the primary means to prevent the spread of infections. 5. Employees must wash their hands for (20) second using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after direct resident contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 9 of 18 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 02/06/2024 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 0684 Before and after changing a dressing Level of Harm - Minimal harm or potential for actual harm Upon and after coming in contact with a resident's intact skin After removing gloves or aprons Residents Affected - Some Review of the facility's Wound Reference Sheet, updated 10/2011 showed Staging for Pressure Ulcers: Stage II, partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Predisposing factors: Immobility Pressure over bony prominences Contributing factors may include: friction, shear, infection, malnutrition, edema, obesity, emaciation, cirtulartory and endocrine disorders Location: over bony prominences Review of the facility's policy, Wound Prevention and Treatment Overview, effective October 2021 showed wound characteristics will be documented by measuring length, width and depth in centimeters. Additional documentation shall also include: Color of drainage Wound bed color &[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 10 of 18 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 02/06/2024 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to arrange and provide transportation to medical appointments for 2 out of 4 sampled residents (#11 and #14). Residents Affected - Few Findings included: 1. Resident #11 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to difficulty walking, muscle wasting, convulsions, chronic pain syndrome. Review of the progress notes showed on 01/15/2024 the Advanced Registered Nurse Practitioner (ARNP) documented, pt reports still has not gotten her scheduled to see spinal specialist following MRI results. Will speak to DON to see if this can get expedited as pt would like to see spine specialist before she moves to an [name of assisted living facility]. During an interview on 02/06/2024 at 1:45 p.m. the Director of Nursing (DON) reviewed ARNP note. She stated, I will look into it and get back with you. During an interview on 02/06/2024 at 3:05 p.m. Resident #11 stated, I still had not gone to the spinal doctor. I hope you can help arrange it. During an interview on 02/06/2024 at 5:15 p.m. the Director of Nursing (DON) stated that there was only one spinal doctor that would take Resident #11's insurance and they were in Wauchula. She stated the Unit Manager told her that the resident was supposed to be working out the transportation herself, but it has not happened. The DON verified that there was no documentation in the chart regarding this medical appointment. The DON verified there was no documentation that there had been any follow-up. The DON stated she would follow up regarding the appointment and see if they could find her a physician closer. 2. Resident #14 was admitted on [DATE], readmitted on [DATE] and discharged on 02/01/2024. Review of the admission record showed diagnoses included but not limited to fibromyalgia, history of malignant neoplasm of ovary. During an interview on 02/06/2024 at 12:24 p.m., The medical records clerk stated she did not have a green sheet regarding transportation for Resident #14 for 12/16/2024. During an Interview on 02/06/2024 at 1:45 p.m. with DON, she stated, I will have to look into it. During an interview on 02/06/2024 at 5:15 p.m. the DON stated that Resident #14 was in isolation from 12/15/2023 to 12/23/2024 and her follow up appointment with the oncologist was scheduled for 12/16/2023. The resident then went to the hospital on [DATE] and returned on 12/28/2023. When she returned to the facility from the hospital a new order for the oncologist's appointment was not created. The DON agreed they should have followed up on the oncology appointment on her return from the hospital. Review of the facility's policy, Transportation Services, effective February 2021 showed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 11 of 18 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 02/06/2024 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility will assist the and /or provide resident / patient transportation services when needed to ensure that each resident / patient receives a complete continuum of services. Procedure: 1. Enter outside appointments on a calendar. 2. obtain transportation preferences .3. Schedule transportation as soon as date and time of appointment is known. 4. Communicate date and time for which the transportation has been scheduled to the staff. 5. Assure resident / patient, family, or legal representative is notified of the appointment. 6. Assure resident / patient is up, dressed, and ready for the scheduled appointment. Event ID: Facility ID: 105029 If continuation sheet Page 12 of 18 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 02/06/2024 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 - Many 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 maintain a clean and sanitary kitchen as evidenced by dust attached to the wall above the coffee pot and plate covers, the outside of the oven appeared to have dried grease collected on it, and inside the one of one ice machine contained black biogrowth. Findings included: An observation conducted on 2/5/24 at 9:00 a.m. of the ice machine located in the kitchen revealed a black wet-looking substance inside the bin, above fresh ice, and around the chute. The observation showed staff continuing to plate breakfast meals. The observation of the outside of the oven showed the front of the doors appeared to have dried grease spills and the shelf above the stove was dusty. At the time of the observation, Staff F, Food Service Manager (FSM) stated the oven has been broken since Thursday, was fixed over the weekend, and the oven was normally cleaned over the weekend. An observation of the wall above the staff sink, coffee machine and above a stack of plate covers showed dark-colored dust and a splattering of a brown substance. Staff E, Cook, observed the wall and stated the wall should have been cleaned weekly. Staff F viewed the inside of the ice machine and confirmed it should not look like it did. Review of the policy - Cleaning and Sanitation, effective September 2021, revealed The facility promotes a clean and sanitary environment for its employees, residents, and visitors. The entire Food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment, walls, floors, ceiling, equipment, and utensils are clean, sanitized, and in good working order. The policy showed the Food Service Manager will review the completed Food and Nutrition Services Cleaning Schedule to ensure kitchen equipment in the operation is included. The Nutrition Services Cleaning Schedule will be posted in the kitchen accessible to employees, and Inspect kitchen sanitation daily, weekly, and monthly using the Kitchen Sanitation Checklist. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 13 of 18 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 02/06/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the medical record of two (#1 and #10) of 4 residents was complete and contained accurately documented incidents requiring a transfer to an higher level of care. Findings included: 1. Review of Resident #1's admission Record showed the resident was originally admitted on [DATE] and later re-admitted on [DATE]. The admission Record revealed the resident's diagnoses included fibromyalgia, unspecified quadriplegia, and mild dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of a Situation, Background, Appearance, and Review and Notify (SBAR) communication form dated 9/13/23 showed Resident #1 had a change in skin color or condition. The evaluation revealed there was no changes observed in the resident's mental status or functional status and the behavioral, respiratory, cardiovascular, abdominal/gastrointestinal, genitourinary/urine, pain, and neurological evaluations were not clinically applicable to the change in condition. The form showed in the available check off boxes the resident had a laceration however the Describe symptoms or signs was blank. The appearance section of the form, instructed staff to Summarize your observations and evaluation, the section was void of any description or other information. The Review and Notify section revealed the Primary Care Clinician was notified on 9/13/23 at 3:00 p.m. and did not reveal the recommendations received from the primary however the testing and interventions showed [name of hospital]. The nursing note section was empty without description of the resident's laceration, the status of the resident, or how the laceration had occurred. Review of Resident #1's Change in Condition evaluation dated 9/13/23 at 12:31 a.m, showed the resident had a change in skin color or condition and At the time of evaluation resident/patient vital signs, weight, and blood sugar were : 124/80 (blood pressure), 86 (pulse), 20 (respiration rate), 97.8 (temperature), and 97% (pulse oximetry), revealing the date the vital signs were obtained on 9/10/23 at 8:35 p.m., three days prior to the incident. The evaluation did not reveal the location of the laceration, the description of the laceration, or the status of the resident. Review of Resident #1's progress note, Hospital Transfer Evaluation Summary showed the resident had a skin condition related to the left heel and sacrum at the time of transfer. The comment section of the summary was without documentation. Review of the Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, showed Resident #1 was most recently admitted on [DATE], reason for transfer was skin tear/laceration and the vital signs of the resident were obtained on 9/10/23. The form revealed the resident was dependent in Activities of Daily Living (ADL) except for eating and was alert, disoriented but could follow simple instructions. The transfer showed the resident was sent to South Florida Baptist hospital on 7/27/23 at 3:00 a.m. from the facility. The form did reveal the resident had pressure ulcers to the left heel and sacrum and a laceration to the left lower leg. Review of a progress note, dated 9/13/23 at 5:00 a.m., revealed Resident #1 had returned to the facility from [name of hospital] following an evaluation and treatment of a laceration to the left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 14 of 18 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 02/06/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm lower leg. The note showed the resident was ordered an oral antibiotic, Clindamycin four times a day for 7 days. The resident was noted with 9 sutures to the wound and edges are well approximated. Review of further progress notes, dated 9/13/23 at 8:23 a.m., showed the Director of Nursing had documented The Resident is Confused. Residents Affected - Few Review of the Facility Incidents by Incident Type for dates 9/5/23 to 2/5/24, did not reveal Resident #1 had a skin alteration , unwitnessed fall, witnessed fall, or other incident on 9/13/23. An interview was conducted on 2/6/24 at 3:16 p.m. with the Director of Risk Management (DRM) and the Nursing Home Administrator (NHA). The DRM stated Resident #1 had hit her leg on the wheelchair and had behaviors of getting out of bed and frailing around. The director stated the reason the skin alteration was not on the facility log was due to there not being an incident report. The DRM read the only witness statement obtained, from the nurse, revealed the Certified Nursing Assistant (CNA) on duty made me aware that resident appeared to have struck her leg on the wheelchair next to the bed. The DRM stated it would have been nice to (have) additional information regarding the laceration in the chart, what happened, that a pressure dressing had to be applied. She stated she could find out who the CNA was, and a root cause (analysis) determined the resident had hit her leg on the wheelchair and it did not rise to the level of injury of unknown origin. An interview on 2/6/24 at 4:11 p.m., the Regional Nurse Consultant (RNC) stated the facility did not have a documentation policy. She stated the facility charts change in conditions, skilled, and by exception, which included events and follow-ups. The RNC agreed the record should have more information regarding the laceration. 2 Review of Resident #10's admission Record showed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to multiple sclerosis, chronic pain syndrome, and cause unspecified cardiac arrest. Review of Resident #10's census report showed the resident was transferred out to the hospital on [DATE] and transferred in from the hospital on [DATE]. Review of Resident #10's physician orders revealed the following orders were written on 12/20/23: - Cyclobenzaprine (Musculoskeletal therapy agents - chemical), 5 milligram (mg) by mouth three times a day for muscle spasms for 14 days. This order was created by and revised on 12/20/23 at 10:39 a.m. by the Advanced Registered Nurse Practitioner (ARNP). The order was confirmed by Staff B, Registered Nurse (RN) on 12/20/23 at 12:38 p.m. - Discontinue (D/C) Baclofen. START Tizanidine 4 mg by mouth every (q) 8 hours for muscle spasms. The handwritten order was signed by the Rehabilitation Physician Assistant on 12/20/23 and showed Staff B received the order on 12/20/23, time undocumented. Review of the website, Medlineplus.gov, revealed the medication, Tizanidine is in a class of medications called skeletal muscle relaxants. Review of the website, Drugs.com, showed the drug interaction between Flexeril (Cyclobenzaprine) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 15 of 18 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 02/06/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Tizanidine showed a moderate interaction and Using Tizanidine together with Cyclobenzaprine may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. In addition, these medications may also have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. These side effects are most likely to be seen at the beginning of treatment, following a dose increase, or when treatment is restarted after an interruption. The website revealed The recommended maximum number of medicines in the 'muscle relaxants' category to be taken concurrently is usually one. Your list includes two medicines belonging to the 'muscle relaxants' category: - Flexeril (Cyclobenzaprine) - Tizanidine Note: In certain circumstances, the benefits of taking this combination of drugs may outweigh any risks. Always consult your healthcare provider before making changes to your medications or dosage. The December Medication Administration Record (MAR) showed Resident #1's Cyclobenzaprine was administered twice on 12/20, three times on 12/21/23, then discontinued. Review of Resident #10's progress notes revealed the following: - Signed by ARNP [advanced registered nurse practitioner] on 12/22/23 at 8:07 p.m., showed the resident complained of dysuria and a urinanalysis would be ordered. - a progress note, effective 12/24/23 at 2:22 p.m., showed the resident was noted with altered mental status, hallucinations, (and) unclear statements. The note showed the ARNP ordered a midline placement with Irtapenem daily for 10 days and STAT labs. A family member requested a leave of absence for the resident and the resident and family member was unwilling to stay at facility for treatment. - An ARNP progress note, signed 12/25/23 at 9:14 a.m., showed Resident #1 was status post left lobectomy secondary to cancer and has been bedridden for the last 2 years secondary to Multiple Sclerosis and has not been able to get into a local neurologist. The note revealed the urinanalysis suggested an urinary tract infection and the resident was started on an oral antibiotic. - An eINTERACT Situation, Background, Appearance, and Review and Notify (SBAR), dated 12/25/23 at 9:55 p.m., showed the resident had developed altered mental status. The observation section revealed the resident was started on oral antibiotics which was discontinued on 12/24 and ordered intramuscularly injectable antibiotic, and showed the resident stated people were in the room that were not, events taking place that did not, and did not recognize husband. The note showed the resident had disorganized thinking, having difficulty concentrating, little to no urine output, and elevated heart rate. The Physical Medicine Rehabilitation Follow-up Evaluation, dated 12/27/23 at 12:06 a.m., (completed after resident discharged ) showed a date of service, 12/8/23, and the resident's multiple medical issues necessitated frequent clinical evaluations, placing them at moderate risk for readmission without proper care. Neglecting regular monitoring and management may result in symptom exacerbation and complications, possibly requiring hospitalizations. The evaluation was signed by the Rehabilitation Physician Assistant (PA) and documented 19 days after the date of service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 16 of 18 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 02/06/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a progress note, dated 12/27/23 at 11:42 p.m., revealed Resident #10 was readmitted to the facility. Review of a social service note, dated 12/28/23 at 3:18 p.m., revealed the resident was re-admitted last evening from hospital stay for AMS secondary to UTI. The note showed the resident and family member wished to be discontinued today. A physician order was obtained to discharge. Review of Physical Medicine and Rehabilitation Initial Evaluation, effective 12/28/23 at 10:08 p.m., revealed the date of service was 12/12/23 (16 days before documentation) and the resident was seen lying in bed, denied pain, and had increased muscle tone in bilateral legs. The evaluation was signed by the Rehabilitation PA. Review of Physical Medicine Rehabilitation Follow-up Evaluation, dated 1/8/24 at 10:45 p.m. (11 days after resident discharged ) showed the date of service was 12/15/23 (24 days before the documentation) and signed by the Rehabilitation PA. Review of Physical Medicine Rehabilitation Follow-up Evaluation, dated 1/10/24 at 3:07 p.m., (13 days after Resident #10 discharged from the facility) and the date of service was 12/19/23 (22 days prior to the documentation), showed the resident was bedridden and Baclofen was recently increased to 20 mg every (q) hours but it does not seem to be controlling (pronoun) pain. I discussed changing to a different muscle relaxer with patient and (pronoun) agrees to this. Review of a late entry note, signed by the ARNP and effective on 12/27/23 at 11:59 p.m., showed Resident #10 was sent to the Emergency Department on 12/25/23 after having increased confusion over the weekend. Patient (Pt) at the time was being treated with a antibiotics for UTI since 12/22/23. After investigating possible cause for change in mentation, it was discovered that pt had been prescribed two different types of muscle relaxers that were started on the same day by two different providers. Spoke to husband, who it pt's Power of Attorney (POA) and notified him of the error. The spouse reported resident was returning to the facility today. The Director of Nursing (DON) was made aware of (the) medication error. Review of the Physical Medicine and Rehabilitation Initial Evaluation, effective 1/16/24 at 2:13 p.m. (19 days after resident discharged ) with a date of service of 12/22/23 (25 days prior to the documentation) showed Resident #10 denied pain and stated muscle spasms had improved. The note revealed for pain management the resident was receiving Baclofen 20 mg every 6 hours. (An order from this provider, dated 12/20/23 (2 days prior to this date of service) showed the provider had discontinued Baclofen and had ordered Tizanidine. The note did not include the resident's order Cyclobenzaprine or Tizanidine. A review of the facility Incident by Incident Type log, for dates 9/5/23 to 2/5/24, did not reveal Resident #10 had a medication variance. During an interview on 2/6/24 at 12:30 p.m., the Director of Nursing (DON) stated the contracted vendor (Staff G) was associated with the Physiatry physician. She stated I would hope that the person writing the order would look at the orders, the nurse might have questioned it. The DON confirmed both muscle relaxers were signed off by the Staff B, Registered Nurse. The DON reported during morning meetings all new orders were discussed and she remembered something about this. She stated the PA did have access to reviewing the progress notes and physician orders of residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105029 If continuation sheet Page 17 of 18 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 02/06/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An interview was conducted on 2/6/24 at 12:56 p.m. with the Director of Rehabilitation (DoR) and the DON. The DoR confirmed the PA was working from the Attending Physiatry and managed the pain for residents receiving therapy. The DoR reported sending the PA a list of residents, when a new admission or having therapy, the PA would be added to the profile, would talk to therapy and order medications related to the pain and mobility. He stated the goal was more focused and to get the resident moving. The DoR confirmed the PA had access to the electronic record and could review resident medications. The DON stated the morning clinical meetings are missed maybe once a week or once every two weeks depending if the Unit Managers were put on a medication cart. She stated the attendees of the clinical meetings were herself, Assistant DON, Unit Managers, Social Work, and the Minimum Data Set Coordinator. A review of the documentation and date of service of the PA was conducted with the DoR and DON. Event ID: Facility ID: 105029 If continuation sheet Page 18 of 18