Inspection·April 16, 2021

F 0610 to her but said it was a head honcho. Level of Harm - Minimal harm or potential for actual harm A review of the admission Record revealed that Resident #241 had been admitted to the facility on [DATE] and diagnoses included intracapsular fracture of right femur, aftercare following joint replacement surgery, generalized muscle weakness, and need for assistance with personal care. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which meant the resident was not cognitively impaired, and no signs or symptoms of delirium, disorganized thinking, or altered level of consciousness were recorded. Residents Affected - Few Progress notes were reviewed for April 2021 and documentation did not reveal concerns with resident's acceptance of care or of behavioral disturbance except for one PCT (Personal Care Technician)/CNA (Certified Nursing Assistant) note dated 04/11/21 which revealed, Patient was offered peri care and change of adult pads several times but keep on refusing. Nurse is aware. Review of the facility document titled, [name of facility] Reportable's Log revealed an entry for Resident #241 dated 04/12/21, type of event allegation abuse, immediate report filed 04/12/21. The log fields for Day 5 and Resolution were blank. Staff C, Registered Nurse (RN), Nurse Manager was interviewed on 04/15/21 at 3:53 p.m. She confirmed that she knew Resident #241 and was the nurse manager for the second floor which included the resident's unit. Staff C confirmed that on Monday 04/12/21 the resident had asked to speak with a manager at about 10:45 a.m. that morning. Staff C reported that she went to talk with the resident within 5-10 minutes of receiving the request and the resident had reported in that conversation that she was upset about the care she had been receiving from Staff H, PCT. Staff C stated the resident reported the following concerns about Staff H: she was uncaring and mean-spirited and was yelling at the resident because she didn't call for the bed pan; Staff H took her sock off and told her she didn't need it since she could not walk and refused to put it back on her foot when the resident asked her to; the resident had requested pillows under her legs but Staff H gave her a towel instead; Staff H didn't pay attention to what she was doing and was careless; one time during taking vitals Staff H's hand had brushed against the resident's left breast; when Staff H turned the resident, it caused her pain. Staff C stated that Resident #241 had reported that she was afraid of Staff H hurting her. Staff C stated that after taking the resident's report she apologized to the resident and reported the allegation to the abuse coordinator (Nursing Home Administrator). She stated that Staff H was off that day already and was immediately suspended pending investigation and was removed from assignment to Resident #241's unit. Staff C said, Afterwards (same day) I spoke with her (Resident #241) and she said that she felt better having talked to me about concerns, I left my card with her, said she felt safe, she felt better knowing (Staff H) wouldn't be assigned to her anymore. Staff C said, But while that resident is here, I don't even want her (Staff H) on that unit. During the interview on 04/15/21 at 3:53 p.m., Staff C confirmed that the investigation into Resident #241's allegation of abuse was still ongoing and that she still was planning to do the following: follow up again with Resident #241 to find out if she's refusing care and what her expectations are; talk to a nurse who was mentioned for the first time that day during Staff H's statement. Regarding whether other facility residents receiving care from Staff H had been interviewed, Staff C responded that she had interviewed the resident's roommate but no other residents and said, Didn't get a chance to do that yet. She reported that she had interviewed the other CNAs and PCTs that were working on the day the resident reported the allegation (04/12/21) and nobody knew of any concerns related to Resident #241. Staff C reported that she had begun attempts to reach Staff H for her statement starting on 04/12/21, had left a message, did not get a response until Tuesday (4/13/21), an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 2 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appointment was made for Staff H to come to the facility on 4/14/21 to give a statement but she did not show up. Staff C stated that she had called Staff H that day (04/15/21) and told her she had to come in before her shift and give her statement. Staff C confirmed that Staff H had come to the facility that day (04/15/21), given her statement, and then went to the floor to work her scheduled 3 p.m. - 11 p.m. shift on the second floor. Staff C again confirmed that Staff H was in the facility at that moment working on the floor. Regarding why Staff H was allowed to resume work when she had been suspended pending completion of an investigation that was not yet completed Staff C said, I was instructed that as long as I got a statement from her prior to starting her shift I could bring her back to work as long as not assigned to that patient. Staff H, PCT was interviewed on 04/15/21 at 04:31 p.m. She confirmed she knew Resident #241 and had been assigned as her aide including on the 11 p.m. - 7 a.m. shift 4/11/21-4/12/21. Staff H confirmed she had been suspended and reported that today (04/15/21) was her first day back working, that she was not assigned to Resident #241 and said, Better that way .she has something against me, I don't know. Then Staff H said, They said that because you guys are investigating this I have to go home .she (Staff C) told me that just right now before I got in this room to talk to you. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were interviewed on 04/15/21 at 5:52 p.m. The NHA confirmed that she was the facility abuse coordinator and the DON confirmed that she was the facility risk manager. The NHA was asked about facility protocol when an abuse allegation is made by a resident and responded, Typically if we're made aware of an allegation, whoever is made aware takes a statement from resident .at some point gets written down on a form .inform me or [DON] .we determine if it meets criteria for an allegation as far as suspending and then we suspend the employee until our investigation is complete, call State Agency Name initiate our investigation, complete required day one reporting and then any kind of follow up .psych (psychology) services, x-ray, send out, does patient feel safe here, notification of family, physician. The NHA said that an investigation would be considered completed when we've determined if substantiated or unsubstantiated, determined if need corrective action, investigation resolved with all our answers .until we cover all of our bases. Regarding the investigation for the allegation of abuse reported by Resident #241 related to Staff H, the NHA confirmed that the investigation had not been completed. She reported that she was made aware of the incident and allegation on 04/12/21 by Staff C and said, I felt it was borderline but made criteria to call it in to State Agency Name .State Agency Name did not take the case, said it didn't meet criteria. The NHA confirmed that she had filed an immediate report on 04/12/21. Regarding resident interviews as part of the investigation the NHA confirmed that only the resident's roommate was interviewed, said [I] asked [Staff C] to interview just the roommate and confirmed that no other residents had been interviewed. Regarding Staff H, the NHA confirmed she had been suspended immediately pending investigation completion and said, We received [Staff H's] statement today .began reaching out to her day one, but she didn't respond. The NHA confirmed that Staff H had come in that day (4/15/21), given a statement to Staff C, and then had gone to the floor to work her scheduled shift. She said, My understanding is that she was here today to give a statement, I did not know she was going to be working, that is not our protocol .I didn't know she was here working until I was told you were interviewing her, and I said what is she doing here? I just got her statement. I found out she had gone to the floor, don't know how that piece transpired so I said [to her] you can stay until interviewed but then you need to go home. The NHA reported that when she found out Staff H was in the building working, she told Staff C that she should not be in the building as it was against protocol and that Staff C had apologized and said that she had misunderstood. The NHA said, I coached [Staff C] that it is always our practice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 3 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to suspend staff pending investigation completion and should not consider receiving a statement completion of investigation. The DON confirmed that Staff H had punched into the facility time clock on 04/15/21 at 2:40 p.m. and punched out at 5:00 p.m. The NHA said, Probably twenty minutes for her statement and the rest of the time on the floor. Review of the facility document titled, Rehab Staff Sheet 2021, for 4/15/21 revealed Staff H's name written for PCT assignment to 2nd floor unit 2 North. Her name had been crossed out and sent home was written. At 6:25 p.m. on 04/15/21 the DON and NHA were interviewed. Regarding how Staff H ended up remaining on the schedule even though she had been suspended and the DON said, The night shift supervisors go through monthly schedules and validate .everyone on schedule is on the paper .they did not mark her off the schedule. The DON clarified that When team members punch in they go to their unit and look at the staffing sheet on the unit for their assignment. The DON confirmed, Everyone knows that X means they've been taken off .what didn't happen is they didn't notice there was an X and didn't take her off the assignment sheet. The NHA said, I told [Staff C] on Monday that [Staff H] was suspended .we'll be suspending [Staff C] today for not following our protocol. The NHA provided abuse and investigation protocol in-service documentation from February 2021 which revealed that Staff C had attended and said, I want you to know that we just recently did this review .it says right here that part of our protocol is suspension pending investigation completion .she (Staff C) was trained on this protocol. On 04/16/21 at 8:44 a.m. the NHA followed up to provide additional documentation which included a mobile x-ray report completed of Resident #241's right lower extremity on 04/15/21 and documentation that the residents assigned to Staff H while she was working on 04/15/21 had been interviewed. Regarding why no other residents besides Resident #241's roommate had been interviewed before the evening of 04/15/21, the NHA said, direction was given to [Staff C] to follow up on that as part of her investigation. She was instructed to interview the additional residents that were alert and oriented who were under [Staff H's] assignment the night of the incident .[I] gave her that instruction on Monday (04/12/21) .I don't know if I gave her a time frame for completion. Regarding what responsibilities the NHA and DON had in their roles as abuse coordinator and risk manager for oversight of investigation process, the NHA said, Our responsibilities are to review the process .that we're constantly reminding our staff and managers and that staff and managers are competent, and to touch base during an investigation to make sure things have gone smoothly and ensure it's appropriate. The NHA confirmed that the investigation related to Resident #241 had been assigned to Staff C. Regarding the NHA's oversight of the investigation she said, I would say we discussed it almost daily .the only problem she brought up was the difficulty she was having reaching [Staff H]. The NHA said, Typically if a manger is having difficulty, we are notified by them if there is a problem. If it was a new manager, I wouldn't have given it to them (the investigation assignment) but [Staff C] has been here two years .she did not report any problems. The NHA confirmed that it was of concern that she did not know that Staff H was working in the building on 04/15/21 until she was being interviewed, and that it was of concern that some elements of the investigation such as interviewing other residents under Staff H's care had not been completed yet. She went on to say, these are investigations we've been doing a long time, typically our managers understand the sense of urgency .there's an understood work flow, I would say in the first 48 hours of that investigation is a good timeframe for having completed interviews with other residents .[Staff C] did not give any reason why she could not accomplish those .she did not report that to me. The DON confirmed that after they discovered that Staff H was working on the floor on 04/15/21, and after she was sent home, the DON had put a line through her name on the staffing sheet and written sent home. A facility policy/procedure titled, Abuse Prohibition, revised 03/2021, was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 4 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reviewed. It revealed that it was the policy of the facility that abuse was prohibited and that it was the policy of the facility to implement an abuse prohibition program that included, Investigation of incidents and allegations; Protection of patients during investigations . The facility procedural components included, The Center Administrator, or designee is responsible for operationalizing policies and procedure that prohibit abuse . and, .The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Event ID: Facility ID: 105128 If continuation sheet Page 5 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was completed accurately related to requirement for Level II PASRR evaluation for one resident (#55) out of two sampled residents. Resident #55 was newly admitted to the facility, had a diagnosis of a serious mental disorder as defined in 42 CFR §483.102(b)(1), and was not a provisional admission. Residents Affected - Few Findings included: Review of the medical record for Resident #55 revealed that she was admitted to the facility on [DATE]. The diagnoses documented in her record included the following: bipolar disorder; epilepsy; major depressive disorder and dementia. Review of the PASRR completed by a provider at the hospital where the resident was admitted from had a completion date of [DATE]. Section I: PASRR Screen Decision-Making included a selection of mental illness diagnoses, intellectual disability, related conditions, functional criteria, and services. The diagnoses listed included bipolar disorder and depressive disorder under part A. and epilepsy under part B. All sections/selections were blank; none of the resident's diagnoses were selected. On page 3, item 5, Does the individual have a primary diagnosis of: Dementia? was checked as No and item 6, Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an Serious Mental Illness or Intellectual Disability? was checked as No. On page 4 of the PASRR document the following instruction was written: A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. On page 5 of the PASRR document under the heading Individual may be admitted to an Nursing Facility (check one of the following) the following was entered with a check mark: No diagnosis or suspicion of Serious Mental Illness or intellectual Disability indicated. Level II PASRR evaluation not required. Staff I, Social Services Specialist (SSS) was interviewed on [DATE] at 1:14 p.m. She confirmed that she was the only person in the role of SSS in the facility. Regarding the PASRR for newly admitted residents she said, We get them from the hospital .social worker at the hospital completes them when they're being discharged from the hospital .the admission people request the PASRR. She said, I don't have my master's degree so I can't do them. Regarding her involvement with the PASRR, Staff I initially said, I do look at the PASRR to see if they triggered anything .depression .anxiety .then I go talk to the resident to confirm and offer services such as psych services. When asked for more details she said, I don't check the PASRR for accuracy .don't check to see if it's accurate or reflects their diagnoses .I really just really find out what their discharge plans are .I just see the PASRR in the chart .you should really be seeing the admissions people. Regarding whether anyone in the facility had responsibility for ensuring the PASRR was accurate, Staff I said, I don't know if anyone here is looking at this (PASRR) for accuracy. Staff J, Manager of Admitting and Registration was interviewed on [DATE] at 2:09 p.m. Regarding the PASRR for newly admitted residents she said, We ask for them from the hospital .my role is to get it and get it to the floor with the rest of the admitting packet. She said, I'm not licensed to do a PASRR .I don't check for accuracy or return them for accuracy, my only job is to request it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 6 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Nursing Home Administrator (NHA) was interviewed on [DATE] at 3:06 p.m. She confirmed that it was Staff I's responsibility to review the PASRR for accuracy for newly admitted residents the morning following the day of admission unless they were admitted on Friday or a weekend when review would occur the following Monday. She said that the expectation for Staff I's PASRR review included, If they trigger for a Level II, she should be requesting a Level II and initiate the Level II process .if there are any issues with the PASRR she (Staff I) should bring that to the next morning meeting and then if they need to be reassessed and re-completed. We have people here who can do that. Regarding correcting a PASRR or requesting a Level II evaluation the NHA said, We have many ways that we can resolve them .if they need a Level II, we typically trigger that through the [Company Name] system. She reported that she had spoken with Staff I about Resident #55's inaccurate PASRR today after the investigation was brought to her attention and said, When I spoke with [Staff J, Manager of Admitting and Registration] about it she said her [Company Name] password was expired. The NHA confirmed that an expired password should not prohibit checking a PASRR for accuracy and said, She (Staff J Manager of Admitting and Registration) said she missed it .it was an oversight. Review of facility policy/procedure titled, Pre-admission Screening for Mental Disorders (MD)/Intellectual Disability (ID) Patients, revised 03/2021 revealed that the policy purpose was To ensure that all individuals are screened for a MD (mental disorder) or ID (intellectual disorder) prior to admission. To ensure that individuals identified with MD or ID are evaluated and receive care and services in the most integrate setting appropriate to their needs. The policy statement was, [name of facility] will assure that all patients with Mental Disorders (MD) and/or Intellectual Disability (ID) receive appropriate pre-admission screenings according to federal and /or state regulations. The policy included the following practice standards: 1. Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: a. it is learned after admission that the Pre-admission Screening and Resident Review (PASRR) was not completed or is incorrect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 7 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/13/21 at 4:28 p.m. an interview was conducted with Staff B, CNA. Staff B, CNA said they used to have eight CNAs on the second floor, now it's seven. It's tough. You can't give quality care anymore. Sometimes they have ten patients and five need to be fed. That's mostly downstairs. Administration doesn't help. We are not allowed to say we are short staffed. Last weekend they had eleven to twelve residents in their assignment. Residents Affected - Few Based on observations, interviews, and record review, the facility failed to ensure that the necessary services required for eating to maintain good nutrition were provided in a timely manner for one resident (#230) for three of three meals observed for two of two days out of four sampled residents. Findings included: Observation of a lunch tray pass was conducted on the second floor on 04/13/21 from 12:00 p.m. to 12:45 p.m. At 12:19 p.m. Resident #230 was observed in her room in bed. Her roommate had been served their lunch tray and was eating independently. Resident #230 did not have her lunch tray. She appeared frail and spoke in a soft hoarse-sounding voice. She was alert and oriented and engaged freely. The resident reported that she had come to the facility after a long hospitalization, during which she had lost significant weight and strength. She reported she was unable to use her arms or move her legs on her own and was dependent on facility staff for everything including eating; she could not feed herself or hold cup to drink from. At 12:45 p.m. on 04/13/21 a staff member brought Resident #230's lunch tray and stayed to feed her. The resident reported that they did it that way (delivered all the trays and then came back to help her) because they had to stay to feed her. Review of the admission Record for Resident #230 revealed that she was admitted to the facility on [DATE] with diagnoses to include critical illness polyneuropathy and generalized muscle weakness. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which meant that the resident was not cognitively impaired. The MDS revealed that the resident required extensive physical assistance for eating. The active care plan for Resident #230 revealed that she required maximal assistance for self - feeding, intimated on 4/14/21, and was identified as a nutritional risk related to weight loss, poor intake, malnutrition, abnormal lab values, and poor skin integrity, initiated on 4/16/21. Observation of the lunch tray pass was conducted on 04/15/21 beginning at 12:07 p.m. At 12:09 p.m. staff began to pass the trays on Resident #230's hall; one the certified nursing assistants (CNA) and the Director of Nursing (DON) were observed delivering trays to each room starting at one end of the hall. The DON was observed delivering Resident #230's lunch tray at 12:16 p.m. and then exiting the room and resuming tray pass to other residents. At 12:39 p.m. the resident was observed in her room in bed with the unopened lunch tray on the tray table next to the bed. Her roommate had also received their lunch tray and was independently eating. Resident #230 stated she was waiting for Staff G, CNA to come and assist her to eat. At 12:55 p.m. Staff K, Licensed Practical Nurse (LPN) was observed at the resident's bedside preparing to set up the tray and begin feeding the resident. Staff K reported that she had come in to feed the resident because Staff G had to answer a light across the hall and help another resident in the bathroom. Staff G was interviewed on 04/15/21 at 1:19 p.m. and confirmed that she had been unable to provide timely assistance to Resident #230 because she had to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 8 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0677 assist another resident. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff G on 04/15/21 at 3:33 p.m. Regarding the observations made during the lunch tray pass she said, .having leaders here passing trays isn't normal .they were doing that because y'all are here. Regarding observation of Staff K feeding Resident #230 her lunch instead of her she said, I told my manager about it (needing more help) and they didn't help .asked me to do something else and then the nurse had to go do it. Staff G became tearful as she explained that the process for meals was that each CNA was responsible for feeding anyone on their assignment that needed assistance. She reported that it wasn't possible to be in two places at once and that she also had to manage other care needs for other residents at the same time. She reported that she did advocate to her managers about needing help and said, It's just not right .you go down and talk to them and they don't do anything. Residents Affected - Few Observation of the dinner tray pass was conducted on 04/15/21 beginning at 5:27 p.m. There were two CNAs passing trays, two staff members were sitting in the nurse's station, and Staff K was actively passing medications on Resident #230's hall. At 5:38 p.m. Resident #230 was observed in bed. There was an unopened dinner tray on the tray table next to the bed. The resident said, [Staff L, Personal Care Technician (PCT)] is coming. At 5:40 p.m. Staff L entered the room to begin feeding the resident. He reported he had worked in the facility for many years and said, Getting help is terrible .been going on forever. He confirmed his regular shift was 3 p.m. to 11 p.m. and stated that he regularly advocated to his charge nurse when he needed help because The unit manager goes home at 4:30 (p.m.) so she's not here. Regarding needing more help for timely assistance during meals he said, We've been talking about it forever. He reported that the current process was that a CNA or PCT was responsible for passing trays and assisting all residents on their assignment who needed it. He reported that the problem was that, If a light goes off and I'm feeding a resident; I have to also answer that light. So I have to leave the resident I'm feeding to go answer it, and that's not fair to the resident .their food gets cold and they are waiting. He said, Most important thing to me is patient care .we do the best we can. The DON was interviewed on 04/16/21 at 12:27 p.m. Regarding the process for meal tray pass and assisting residents with eating she said, All staff should be assisting to pass trays .anyone available .when they see that cart they should assist CNAs who are already assigned. She clarified that the definition of available, meant anyone who was not involved at that moment in providing direct patient care was expected to provide help. She said, Typically upstairs (Resident #230s floor) they don't usually have very many that need assistance .usually one or two at the most. Regarding expectations on who could help to feed residents who needed assistance she said, The manager can certainly help assist with eating .I'm available .typically most residents on the first floor need assist .we've assigned day shift nursing supervisor, resource nurse, myself, two managers to round throughout to check in and offer help. She reported that her expectation of CNAs or PCTs that needed help was that They would notify us. She said, For example, yesterday I was upstairs making my rounds and that's why I offered to help (lunch tray pass on Resident #230's hall) .I told [the nurse manager] that as soon as she was available she should get out on the floor and help .I let the CNA who had her (Resident #230) know I had delivered the tray. Regarding expectation for timely assistance for eating she said, Residents should get assistance when tray is delivered if they want it at that time .expectations is no longer that 5 to 10 minutes [wait] to assist .if they decline assist when offered we ask if they want to keep the tray there or if they want us to put back on cart .we don't want a resident not to be able to be eating if roommate is eating .we pull the curtain like in her (Resident #230) case to make it less of a dignity issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 9 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of facility policy/procedure titled, Food - Serving Trays, dated 04/2012, revealed that it was the facility's policy To provide adequate nutrition for the well being of the patients. Registered Nurses (RNs), LPNs, and Nurse Assistants were identified as the facility staff responsible. The procedure included, .Assist the patient willingly if he requires help. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 10 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review the facility did not ensure PRN (as needed) psychotropic medication had a stop or renewal date after fourteen days, for two residents (#1 and #5) of five residents reviewed. Findings included: 1. Resident #1 was admitted to the facility with a diagnosis of anxiety disorder, according to the admission Record. A review of the Minimum Data Set (MDS) assessment, dated 4/2/21, reflected a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #1 was cognitively intact. A review of the active physician's orders as of 4/16/21 in the medical record revealed an order dated 3/27/21 for Lorazepam tab 1 mg (milligram) every 12 hours as needed for anxiety. A review of the interim medication regimen review (MRR) dated 3/29/21 reflected there were no pharmacist recommendations. A review of the consultant pharmacist note dated 4/8/21 indicated no recommendations. On 4/16/21 at 12:36 p.m. an interview was conducted with the Director of Nursing (DON). She said medications are reviewed by the pharmacist monthly, and the physician who oversees the care. Some are seen by psychiatric medicine for continuance, discontinuance, or GDR (gradual dose reduction.) The physician makes the stop date. If it's a routine medication and they are taking it every day then we would make it a scheduled medication. On 4/16/21 at 2:59 p.m. a telephone interview was conducted with the consultant pharmacist. He said he looks on the MAR (medication administration record) to see if they have been using the prn (as needed) medication. Especially with a drug like Ativan (Lorazepam) he takes a look at the diagnoses to see if there is one with a chronic utilization at home, or a COPD (chronic obstructive pulmonary disease) type patient where anxiety is a significant issue. I look at their utilization pattern. If it's within 2 mg a day than I try to wean someone off in conjunction with the ARNP (advanced registered nurse practitioner). I try to get them off the long acting to short acting. The most I try to keep somebody on is 0.5 mg every six hours. Then I watch them for a time period, several months and look at their utilization. Then look at the pattern and see what risks they have, falls, pain medications, individual monitoring. I don't necessarily ask for a stop date. I usually do the IRRs (interim medication regimen reviews) on the first day they are admitted . I look again at the end of the month. He said he was aware of the regulation. I don't necessarily ask for a renewal order, but I try to write a reminder to do that. I try to keep the psychoactive drugs, at four to six weeks for therapeutic benefits. I try to take the variables into account when I am looking at them. I think I just did one on Resident #5 this past month. I addressed the previous month. She was on three of those and I tried to get them to reevaluate those. March was her Remeron. February was Clonazepam 1 mg twice daily prn and Lorazepam 0.5 mg every 12 hours prn anxiety. And then 1 mg IM (intramuscular) Ativan prn, and she was also on Xanax prn. I asked them to consider discontinuing Clonazepam, the Trazadone, the Lorazepam (Ativan) IM. They were writing for Ativan 0.5 mg every six hours, so we started her on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 11 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ativan 0.25 mg every six hours. She has been on these drugs for quite awhile. We can't just stop the benzos (benzodiazepines) because they are addictive. So we try to get them on the lowest dose. She has been on it since February. They have to be on them for a time for the therapeutic benefit. I do review them every month. This month she has had 0 Lorazepam IM. It's every twelve hours prn and she is not on any others. That's a different order than I recommended, so they have changed it. It does not have a stop date on it. Resident #1 was just admitted and I may have reviewed her at the beginning of April. She had two doses in March. It was started March 27th. It's twenty days (since it was ordered). He confirmed there was only a start date on it. He confirmed it was prn. He said it looks like she has requested it at night. 2. The admission Record for Resident #5 indicated that the resident was admitted into the facility on [DATE] with diagnoses that included but were not limited to Dementia, persistent mood disorder, restlessness and agitation, anxiety disorder, and major depressive disorder. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 07 out of 15 indicating severe impairment. Section N indicated that Resident #5 received antipsychotics seven days a week and antianxiety medications one time a week. A review of the Order Summary Report with active orders as of 04/16/2021 revealed the following orders: Clonazepam Tablet 1 MG- Give 1 mg po (by mouth) every 12 hours as needed for anxiety with a start date of 11/02/20 and no end date Lorazepam Solution 2 MG/ML(milliliter) - Inject 0.5 ml intramuscularly every 12 hours PRN (as needed) for agitation with a start date of 08/21/20 and no end date. The Medication Administration Record (MAR) for March 2021 revealed that Clonazepam was administered on March 3rd, 7th, 9th, and 11th. The MAR reflected that Lorazepam was not administered. The MAR for April 2021 revealed that Clonazepam was administered on April 7th, 10th, and 14th. The MAR reflected that Lorazepam was not administered. A review of the progress notes from 03/01/21 to present did not reflect a rational to extend the medications. A review of the Consultant Medications Therapy Review with an effective date of 03/05/21 and 04/08/21 did not reflect a rational to extend the medications. On 04/16/21 at 12:08 p.m., the DON reported that each month the pharmacist reviews the medications. The physician would make the determination for the stop date. The policy provided by the facility titled, Pharmacy Services- Drug Regimen Free from Unnecessary Drugs, issued on 06/2020, revealed the following: Purpose: The intent of this policy is each patient's/resident's entire drug/medication regimen is managed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 12 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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 0758 Level of Harm - Minimal harm or potential for actual harm and monitored to promote or maintain the patient's/resident's highest practicable mental, physical, and psychosocial wellbeing: the facility implements gradual dose reductions (GDR) and nonpharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Residents Affected - Few Procedure: 3. Based on a comprehensive assessment of a patient/resident, the facility will ensure that: c. Patients/Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and d. PRN orders for psychotropic drugs are limited to 14 days. Except, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the patient's/resident's medical record and indicate the during for the PRN order. e. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the patient/resident for the appropriateness of that medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 13 of 14 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 105128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Plant Rehabilitation Center 400 Corbett St Belleair, FL 33756 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, record review, and interviews, the facility failed to ensure a staff member (M) used sanitary practices to prevent cross contamination when taking food temperatures and failed to perform hand hygiene in one of one kitchen. Findings included: On 04/15/21 at 11:19 a.m. an observation was conducted in the kitchen of Staff M, Cook, taking the temperature of the foods to be served for the lunch meal with the same thermometer. After taking the temperature of the hamburgers, Staff M used a dry paper towel to clean the thermometer. She then took the temperature of the fish and used a dry paper towel to clean the thermometer. Staff M then took the temperature of the chicken, and used a dry paper towel to clean the thermometer. She took the temperature of the turkey gravy and used a dry paper towel to clean the thermometer. Staff M took the temperature of the beef gravy and used a dry paper towel to clean the thermometer. She took the temperature of the ground turkey gravy and used a dry paper towel to clean the thermometer. Staff M took the temperature of the squash and continued wiping the thermometer with the same paper towel. At this time, Staff M was observed adjusting her mask twice with her left hand. She did not change her gloves or use hand hygiene. Staff M stated, The mask keeps falling. She continued to take the temperature of the mashed potatoes, and then the baked potatoes without cleaning the thermometer. She then took the temperature of the sweet potatoes and used the same dry paper towel to clean the thermometer. Staff M took the temperature of the puree turkey and used a dry paper towel to clean the thermometer. Following the observation an interview was conducted at 11:26 a.m. with the Certified Dietary Manager (CDM) related to the method of cleaning the thermometer. The CDM then instructed Staff M to use the wipes to clean the thermometer. The alcohol wipes were observed sitting on the steam table in a box. Staff M reported that she usually uses the alcohol wipes. On 04/15/21 at 12:23 p.m., the CDM stated they (kitchen staff) know the protocol for taking temperatures. They should sanitize the thermometer in between taking the temperatures. Staff had been educated on appropriate hand hygiene several times stated the CDM. At 12:44 p.m., the CDM stated staff were educated to use alcohol wipes to clean the thermometer. A review of the Program Report Form dated March 2021 revealed that Staff M was educated on hand hygiene on 03/30/21. A policy provided by the facility titled, Food Storage, revised 01/21, did not reflect the procedure for taking food temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 14 of 14