Inspection·December 22, 2022

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the Nursing Home Administrator on 12/22/22 at 12:25 p.m. She stated she was made aware of resident's personal health information being visible on the computer screens. She confirmed this is an issue and stated it would be addressed immediately. A review of the facility policy titled Patient/Resident Rights-Personal Privacy/Confidentiality of Records, dated 9/2019, was reviewed. The policy indicated following: Policy: It is the policy of [the facility] to provide the patient/resident and or legal representative person privacy and confidentiality of records in such a manner to acknowledge and respect patient/resident rights. Procedure: 1. The patient/resident has a right to personal privacy and confidentiality of his or her personal and medical records. 4. The patient/resident has a right to secure and confidential personal and medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 2 of 23 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 12/22/2022 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment was completed within the Resident Assessment Instrument (RAI) manual within the required timeframe for one resident (#54) out of 25 residents sampled for accuracy of assessments. Residents Affected - Few Findings included: A review of the medical record on 12/20/22 for Resident #54's revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The last completed MDS in the medical record revealed a Medicare-5 Day assessment dated [DATE]. There was not a completed discharge assessment listed in the MDS for Resident #54. The MDS Summary page in Resident #54's medical record indicated a discharge assessment was due on 12/07/22. Photogenic evidence obtained. During an interview on 12/20/22 at 2:15 p.m., Staff C stated the discharge MDS had not been completed. Staff C stated the discharge MDS was not completed because the responsible employee was out on vacation. Employee C stated the discharge MDS was late according to the Resident Assessment Instrument (RAI) procedure manual and should have been completed by 12/07/22. A record review of the facility policy titled, CMS's RAI Version 3.0 Manual, dated 10/2019, indicated the Discharge Assessment's MDS completion date should be no later than 14 calendar days after discharge date . During an interview on 12/22/22 at 12:30 p.m., the Administrator stated the discharge MDS for Resident #54 should have been completed by the required date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 3 of 23 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 12/22/2022 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure services were provided to meet professional standards related to 1) a failure to assess skin conditions for one resident (#233), and 2) a failure to obtain oxygen orders for one resident (#283) out of 25 resident sampled. Residents Affected - Few Findings included: 1) Resident #233 was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, lumbosacral region, repeated falls, and Type 2 Diabetes Mellitus. A review of a Medical Certification for Medicaid Long-Term Care services - Form 3008 for Resident #233, indicated the resident was admitted to the facility with skin tears on arms from falls. On 12/19/22 at 9:38 a.m. and on 12/20/22 at 11:47 a.m., Resident #233 was observed in his room. The resident stated he fell at home, was hospitalized , and discharged to the facility for recovery. Resident #233 was noted with undated bandages on the left and right hand, two undated dressings on the upper right arm, and one undated dressing on upper right leg. The resident stated the nurse had put on the bandages to the left and right hand because he had some skin tags that opened up due to friction. The resident stated the nurse only applied the bandages. He did not recall who the nurse was. The resident stated no one had looked at his wounds. He stated he came in with injuries, and he had obtained some skin shear during therapy. Photographic evidence was obtained. A review of a skin evaluation for Resident #233, dated 12/16/22, indicated an admission skin evaluation as follows: skin warm and dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. No current skin conditions noted at the time. Noted dressing on his Right upper arm x2 with multiple bruises and ecchymosis areas on both upper and lower extremities. Noted small abrasion on Rt knee. A review of the physician orders for Resident #233 indicated the following: Skin tear right lower leg. Cleanse with NS (normal saline) apply foam dressing today, then change 2 tines a week until healed. Every dayshift Tuesday and Friday, effective 12/20/22. Skin tear right upper arm x2 (present on admission), cleanse with NS apply foam dressing change twice a week until healed Every dayshift Tuesday and Friday, effective 12/20/22. A review of a progress note, dated 12/20/22 at 10:52 a.m., by Staff A, Licensed Practical Nurse (LPN) read [it was brought to this writer's attention by therapy that resident obtained a skin tear to his right lower extremity while working with therapy. Area was cleaned with saline, and clean dry dressing was applied. MD (medical director) aware as well as family. wound care notified as well will continue to monitor]. An interview was conducted on 12/20/22 at 1:345 p.m., with Staff A, LPN. Staff A stated Resident #233 was admitted on [DATE] with some skin issues. She confirmed she noticed he had some undated dressings. Staff A said, I can't speak of the nurse who did the admission, but the expectation is to unless indicated, open the dressing, assess the wound, document the measurements, clean, redress and date. Staff A stated she did not know why this was not done. She stated she noticed the bandage on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 4 of 23 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 12/22/2022 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right hand but did not know why the resident had it. She stated therapy reported a skin tear on right lower leg which she dressed and dated. She stated she did not know about the other wounds/skin conditions, but the wound care nurse would know. Staff A reviewed the resident's EMR (electronic medical record) with surveyor and confirmed there were no notes or assessments from wound care nurse. On 12/20/22 at 12:00 p.m., an interview was conducted with Resident #233's Primary Care Physician (PCP). The PCP stated if a resident had any kind of bandage or dressing, they should be dated, if they were applied prior to arrival, they should be dated with information obtained during admission. The PCP stated if they were applied at the facility, the nurse should date them to confirm someone has evaluated and treated the resident, and document when the treatment was applied. The PCP said, they should be dated otherwise how would they monitor. A wound care progress note dated: 12/20/22 at 13:42 read: [skin issue location: Right upper arm x 2 present on admission: length: proximal 3/distal width centimeters (cm): proximal 1/distal 2 depth. proximal no flap/ wound exudate: serosanguineous. Peri wound condition: Fragile dressing saturation: Less than 25%. Skin issue: skin tear location: RLE Patient admitted [DATE] after a fall at home, 2 skin tears RUE from fall at home, removed foam dressings, cleansed with NS applied foam dressing will change twice a week until healed. New skin tear found by nurse when patient returned from PT (Physical Therapy) possible hit leg on wheelchair triangle shaped tear cleansed by staff nurse with NS and foam dressing applied. Will change twice a week until healed. Clinical suggestions: Dressing changes/treatments performed as ordered.] A care plan for Resident #233, dated 12/20/22, indicated a focus skin/ skin risk, initiated 12/20/22 showing the resident is at risk for skin breakdown, irritation, surgical wound infection, worsening skin issues AEB (as evidenced by) impaired mobility, Diabetes diagnosis, skin tear to right upper arm and right lower arm. Goal indicates skin will be intact free of redness, blisters, discoloration by review date. Interventions were treatment as ordered, monitor for side effects and effectiveness of treatments, inform resident/family and care givers of any new area of skin breakdown, monitor nutritional status, standard pressure redistribution mattress and WC(wheelchair) cushion to help prevent breakdown. On 12/20/22 at 2:02 p.m., an interview was conducted with Staff B, Registered Nurse (RN)/ Infection control and wound care nurse. Staff B stated if they have seen the resident, it should be documented. She stated if a resident comes in with skin conditions, they are assessed, and orders are put in place upon admission. Staff B stated she would review the resident's EMR. A follow -up interview was conducted with Staff B on 12/20/22 at 3:39 p.m. Staff B stated she spoke with the wound care nurse who saw the resident today [12/20/22] and noted the skin tears and assessed the wounds. She stated the nurse had done an initial skin check, noting the skin tears, had changed the dressings, but could not remember if they were dated or not. Staff B was shown photographic evidence related to the undated dressings and bandages. Staff B stated she did not know about the bandages on the right and left hand. She stated she could not confirm if the admitting nurse opened the dressings on the right hand and redressed and forgot to date or not. She confirmed they did not have physician orders prior to today. Staff B stated typically the admitting nurse would notify wound care there is a skin tear or wound so they can assess the patient. Staff B said, the expectation would have been to assess the resident upon admission and contact the physician and obtain orders to treat it. Staff B confirmed the resident came in with skin conditions that were not assessed or treated per their policy. Staff B stated she would follow up with the admitting nurse and figure out what went wrong. Staff B stated someone should have dated the dressings per their policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 5 of 23 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 12/22/2022 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/21/22 at 9:46 a.m., an interview was conducted with Resident #233. The resident was noted with dressings dated 12/20/22. Resident #233 stated a nurse had come in yesterday, cleaned his wounds and reapplied dressing. The resident confirmed this was the first time he received this treatment since admitting to the facility on [DATE]. Review of the MAR (Medication Administration Record) for Resident #233, revealed no documented entries indicating skin tears were treated on 12/16/22, 12/17/22, 12/18/22 and 12/19/22. The MAR indicated orders were initiated on 12/20/22. A review of a facility policy titled, Altered skin integrity guidelines, dated 10/2022, indicated the following: Policy: An expectation to observe all skin surfaces for tissue tolerance and signs of alterations in skin integrity on admission/readmission and weekly. Document licensed nurse skin check per policy. Pg. 5. Skin tear guidelines showed skin tears are a traumatic break in the skin that may present as a superficial tear in the epidermis or may penetrate to subcutaneous tissue. Expectation showed: notify physician, complete skin evaluation, obtain diagnosis of a skin tear, recommend, and obtain treatment orders based on condition. Notify therapy, dietary, and other team members as appropriate of risk factors impeding healing, discuss plan of care with patient, family, health care decision maker and CNA (certified nurse's aide). Under treat, implement prevention interventions, evaluate for pain, and medicate as indicated, cleanse area with normal saline and apply treatment as ordered, monitor site daily for placement of dressing , status of surrounding tissue, and pain. Document order, date - cleanse skin tear, apply specific treatment, change how often, transcribe order and document and update care plan to reflect daily monitoring, any new factors, and interventions. 2) An observation was made of oxygen tubing with a nasal cannula in the room of Resident #283 on 12/19/22 at 3:49 p.m. The oxygen tubing was on the right upper side rail of the resident's bed. Photographic evidence was obtained. An observation was made on 12/21/22 at 9:35 a.m. of oxygen tubing with nasal cannula labeled, dated 12/20/22, and placed in a bag hanging at Resident #283's bedside. Photographic evidence was obtained. The resident stated his oxygen measurements have been good, but every now and then he will need the oxygen. A review of orders for Resident #283 indicated the resident did not have an order for oxygen therapy. The following respiratory orders were noted in the resident's record: Respiratory evaluation as needed for pulmonary dysfunction PRN daily as needed. Dated 12/7/22 Ipratropium-Albuterol 0.5-2.5 mg/3 ml. 1 applicator orally q 12 hours as needed for asthma. Dated 12/10/22 Advair Diskus-Aerosol Power breath activated 100-50 mcg/act. 1 puff inhale orally 2 x day for COPD. Dated 12/7/22 Albuterol Sulfate HFA Aerosol solution 108 mcg/act. 2 puffs inhale orally every 4 hours as needed for wheezing. Dated 12/7/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 6 of 23 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 12/22/2022 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 0658 Level of Harm - Minimal harm or potential for actual harm A review of admission records indicated Resident #283 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Chronic Diastolic Heart Failure. A review of care plan revealed a focus area in place for Emphysema/COPD. An intervention listed was to provide oxygen therapy as ordered by the physician. Residents Affected - Few A review of Resident #283's vital signs summary indicated the resident's oxygen saturation was checked while the resident was being administered oxygen via nasal cannula on 12/7, 12/8, and 12/12/22. The vital sign summary show the resident's oxygen saturation on 12/19/22 was 96%, 12/20/22 was 94%, 12/21/22 was 100%, and 12/22/22 was 98%. An interview was conducted on 12/22/22 at 9:56 a.m. with Staff R, Registered Nurse (RN.) Staff R stated Resident #283 gets short of breath when he is pushing around his room in his wheelchair and will use the oxygen occasionally. Staff R was observed reviewing Resident #283's medical record. She stated she was unable to find an order for oxygen use. Staff R stated the resident had a discontinued order from 2020, but no current order. Staff R stated the resident does currently need oxygen due to an emergency, therefore he should have an oxygen order. An interview was conducted with Staff B, RN/Unit Manager (UM) on 12/22/22 at 10:02 a.m. Staff B reviewed Resident #283's medical record and confirmed there was no current order for oxygen. She stated, she was calling the provider and he will have a current order. Staff B stated if oxygen is being used the resident should have an order. An as needed oxygen order was put in the resident's record on 12/22/22. A facility policy titled Oxygen Use and Delivery Methods Protocol, dated 3/2021, was reviewed. The policy stated the following: Oxygen use Procedure: 1. Check patient medical record chart for oxygen order. If there is no specific oxygen order or oxygen titration order, follow protocol below. b. Initiate oxygen via nasal cannula as ordered by the physician. If there is no order and SpO2 on room air is less than 90%, initiate oxygen via nasal cannula at 2 liters per minute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 7 of 23 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 12/22/2022 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure one resident (#27), who required Eating supervision, 1) was supervised timely by staff out of twenty-five sampled residents, and 2) failed to ensure the resident received eating utensils in a manner where they could be reached during three (12/19/22 and 12/20/22) of four meals observed. Residents Affected - Few Findings included: On 12/19/2022 at 12:58 p.m. Resident #27 was observed in her room lying in bed under the covers with the over the bed table placed in front of her. Staff H, Certified Nurse Aide (CNA) brought in a meal tray and placed it on the table in front of the resident. The aide picked up the lids on the plates, positioned a plate guard at the back end of the plate, and left the room within two minutes. The plate guard device was positioned on the left side of the plate, allowing the resident to scoop away from her rather than scoop towards her. The silverware, to include a metal fork and metal spoon, were placed on the table on the resident's right side and set under a plate, out of reach of the resident. Resident #27's right hand was positioned under the covers and under the linen napkin, the resident could not use her right hand. The table was placed close to her and she could not reach the eating utensils with her left hand. An interview was attempted with Resident #27, she was not able to be interviewed related to her care and services. Resident #27 was observed at 1:05 p.m. grabbing at her grilled cheese sandwich with her left hand, setting it down, and grabbing vegetables with her left hand and bringing them to her mouth to eat. Resident #27 was unable to reach the utensils to eat with them. At 1:15 p.m. Resident #27 still trying to grab mechanical textured food items with her left hand and place them in her mouth. She set the food back down on the plate and proceeded to grab the grilled cheese sandwich with her left hand and brought it up to her mouth and took bites. Staff were not observed to come in the room and check on the resident to offer assistance. At 1:24 p.m. Resident #27 was still observed using her left hand to try to pick up vegetables and then mashed potatoes from her plate. She still had not been able to access and use the eating utensils. At 1:30 p.m. a floor nurse Staff G, walked into the room, assisted the resident with medications, and left the room. The nurse did not offer any assistance with the meal or place the utensils within reach for the resident. At 1:40 p.m. Resident #27 consumed less than half of her sandwich, a bite or two of her vegetables, and couple of helpings with her hands of mashed potatoes. She still had not used her eating utensils. The utensils were still positioned on the right side of the table and under the plate lip. The resident's right hand and arm were still positioned under the linen napkin and covers. The resident could not move her right hand and or arm after being asked to. At 1:50 p.m. Staff D, CNA was observed to walk into the room and removed the roommate's meal tray. The aide did not check on Resident #27 or ask if she needed any assistance with her meal. Staff D stated, ok you are still eating and then walked out of the room. At 1:50 p.m. Staff H, CNA was observed in the hallway informing Staff D, CNA she was going on break. During the meal observation, no supervision or assistance was offered to Resident #27 for one hour and two minutes. On 12/20/2022 at 7:48 a.m. the breakfast meal tray cart arrived on the floor. Staff began to serve and set up trays immediately. At 7:58 a.m. Staff F, CNA brought Resident #27 her breakfast tray and set it up by taking off the plate warmer lid, and placing a plastic plate guard on the back of the far end of the plate. Staff F also placed silverware on the left side of the tray and plate, within the resident's reach. The aide did not explain the use of the plate guard, she just said to the resident in a polite manner, Ms. #27 you gonna eat? She then left the room at 7:49 a.m. From 7:49 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 8 of 23 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 12/22/2022 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few through to 9:02 a.m. there were no visits from staff to check on Resident #27 during the meal. The tray was removed from the room at 9:02 a.m. There were no staff visits for one hour and three minutes during this meal service. On 12/20/2022 at 1:15 p.m. Resident #27's room was visited. While entering the room, Resident #27 was observed lying in bed with the head of the bed at approximately 45 degrees. She was observed with the over the bed table placed in front of her and the lunch meal tray positioned in front of her. Resident #27 was observed with her right hand and arm positioned under the covers. The left hand and arm were placed on top of the covers. The lunch meal tray was observed with two plates. One plate had a chicken salad sandwich, at regular consistency. The other plate had mechanical textured baked potato, bowl of soup, and vegetables. The plate lid was observed on the left side of the table and the silverware placed inside the lid. The resident was not be able to reach the silverware from the position she was lying in. A bowl of soup was observed to not have a spoon in it and no spoons were observed within reach of the resident. The sandwich appeared to have several bites from it, but other food items ,that required a spoon or fork, were not touched. Resident #27 was not able to speak related to her care and or services. At 1:39 p.m. Resident #27 was still noted in her room, with the meal in front of her and with no staff direction on where her silverware was located. She was not able to eat her soup or other non hand held items. At 1:50 p.m. Resident #27 was observed in bed with eyes closed and her lunch meal tray still in front of her. No staff had visited her to provide supervision or assistance since at least 1:15 p.m. At 1:54 p.m. Staff E, CNA was observed to walk in the room and remove the meal tray minus the plate with the sandwich. He indicated the resident was still working on the sandwich but was not eating anything else. The tray he was putting back revealed most of her non sandwich items not touched. Staff E confirmed Resident #27 would only be eating the sandwich. He stated he did not know if Resident #27 required any assistance or supervision for meals because the resident is not on my assignment and I am just helping picking up trays. Resident #27 was not visited from staff or checked/supervised with eating from 1:15 p.m. through to 1:54 p.m., over forty-nine minutes. On 12/21/2022 at 7:46 a.m. the breakfast meal cart arrived on the floor. At 7:51 a.m. Staff K, CNA was observed to take the tray from the cart and bring it to Resident #27's room and set the tray on the over the bed table. The over the bed table was positioned over the resident as she was seated upright in bed. Resident #27 was awake, and ready to receive her breakfast meal. Staff K removed the plate lid and the meal consisted of two waffles soaked in syrup, and chopped sausage pieces. Staff K set up the plate guard and took out plastic eating utensils and placed them within the resident's left hand/arm reach. The right hand and arm were positioned on her lower body, under the covers. Staff K left the room at 7:53 a.m. after completing set up. No staff were observed to return to the room to supervise the meal for Resident #27 until 8:26 a.m. Staff M, CNA stated she came in the room to check on the resident and she had not been in there since she was served and set up with her meal from by Staff K and Staff M. Staff K and Staff M, stated during an interview, Resident #27 had a contracture on her right arm and she only uses her left hand to eat. They both confirmed the resident does require some supervision and some cueing during meals. They both stated when they set up the meal tray, they appropriately place the plate guard on the far end of the plate, and place eating utensils on the left side of the tray/plate for the resident to easily reach. An interview with the floor nurse, Staff L, revealed she knows Resident #27 and has her on her assignment routinely. She confirmed Resident #27 has a contracted right arm and she only uses her left hand during activities of daily living (ADL) tasks to include eating. Staff L stated Resident #27 does use her left hand and grabs at food at times and does not use her utensils. Staff L, Staff K, and Staff M all stated Resident #27 was to be set up and provided supervision during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 9 of 23 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 12/22/2022 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meals every so often. The staff could not tell what the specific timeframe would be to come and check on the resident. Staff K and M stated 45 minutes to one hour would be too long to wait to check on a resident during a meal and they would check on the resident a lot more frequently than that. Staff L, nurse also stated forty-five minutes to an hour is way too long to wait to check and supervise the resident when eating. A review Resident #27's medical record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to: Hemiplegia affecting right dominant side, morbid obesity, contracture right forearm, weakness, dysphagia, aphasia, muscle weakness, and anemia. A review of the following Minimum Data Set (MDS) assessments revealed: 1. 8/16/2022 (Significant Correction MDS): (Cognition/Brief Interview Mental Status (BIMS) score - No score however Long Term/Short Term memory problems with severely impaired decision making skills); (Activities of Daily Living or ADL - Bed Mobility - Extensive assist with two person assist, Eating Independent set up only, Range Of Motion or ROM - Impaired one side upper/lower extremity). 2. 10/28/2022 Quarterly MDS: (Cognition/BIMS score - Not scored however Long Term/Short Term memory problems with severely impaired decisions making skills); (ADL - Bed Mobility - Extensive with two person assist, Eating - Supervision/One person assist, ROM - Impaired one side upper/lower extremity). A review of progress notes revealed the following: -dated 11/1/2022 10:35 - N Adv - Long Term Care Evaluation - Right hand: Weakness, Left Hand: Weakness, Right leg: Weakness, Left leg: Weakness, Right foot: Weakness, Left foot: Weakness. -dated 11/6/2022 11:47 (Nurse Note), revealed pleasant and compliant with care. Required full assistance with ADLs. Right sided weakness, however resident able to feed self, appetite fair. -dated 12/1/2022, revealed uses communication board, and uses picture book. Function section, Functional limitation Range of Motion (FN 2 - Upper extremity range of motion marked for Impairment on one side); (FN3 - Lower extremity range of motion marked for Impairment on one side) -dated 12/4/2022 08:01 Nurse Note, revealed Alert and oriented x 1, remains aphasic. Assisted with meal tray set up, feeding and ADLs. Appetite good. A review of the current care plans with next review date 2/6/2023 revealed areas to include: -Nutrition risk related to: Overweight, Swallowing/Chewing difficulty, TP/TPN, Physiological causes, Mech altered diet, mental status, with interventions to include but not limited to: Provide regular diet level 7 easy to chew texture, likes chicken salad sandwiches, provide normal entrée plus sandwich so resident can choose updated 11/16/2022. -At risk for missed communication history of CVA (Cerebral Vascular Accident), BIMS score 0, Aphasia, Unable to consistently communicate wants/needs, with interventions in place -ADL and physical declines, skin breakdown, UTI (urinary tract infection), and falls right (R) side hemiparesis, impaired mobility/balance, Hemorrhagic CVA with R sided weakness, with interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 10 of 23 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 12/22/2022 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 0676 Level of Harm - Minimal harm or potential for actual harm in place to include but not limited to: Podus boots as tolerated while in supine for contracture management, R edema glove and resting hand splint on after breakfast and of after lunch as tolerated for edema and contracture management. For Eating interventions included: Set up and encourage her to eat herself. Assistance as indicated. Residents Affected - Few -Risk for fall and fall related injuries with interventions in place On 12/22/2022 at 9:00 a.m. an interview with Minimum Data Set (MDS )Coordinators Staff C and Staff I revealed they knew of Resident #27 and what her care needs were. They both confirmed Resident #27 has a right hand/arm contracture and does not use her right hand/arm for any ADL tasks. Both Staff C and I confirmed Resident #27 does not eat with her right hand at all and currently staff are to set up the tray, assist with cutting food items if needed, and set up hydration for her as well. MDS Coordinator Staff I indicated she was more familiar with Resident #27 and an interview was continued with her. Staff I explained Resident #27 has had a decline in Eating ADL activities recently and confirmed in the Significant Correction MDS assessment dated [DATE], Resident #27 was assessed at Independent with Set up assistance only. She further confirmed the most recent Quarterly MDS assessment dated [DATE] shows a decline with Eating ADL with Resident #27 now requiring Supervision with One person physical assist. Staff I revealed the reason for the decline is because there were several days during the assessment period CNAs documented supervision with assist for Eating. She revealed even if the CNAs documented one time during the assessment period of the decline, they would also need to reflect that in the MDS to show the decline. Staff I revealed the expectations and interpretations for Supervision, with One person physical assist, means for staff to serve and set up the meal tray, set up any items so the resident could self feed, pour drinks into cups if need be, place silverware within reach of the resident. Staff I revealed it would be expected staff return to the room frequently as part of supervision. Staff I stated frequently meant perhaps every fifteen minutes or so, depending on the need of that meal service. Staff I confirmed over an hour and near an hour of staff not returning to the room would not be an acceptable time frame to visit for supervision. She confirmed staff should have visited more frequently. MDS coordinators I and C were informed Resident #27 had her silverware placed on the right side of the tray and plate, and out of reach from her left hand. They were also informed the resident had to resort to picking up mixed vegetables and mashed potatoes with her left hand rather than an eating with utensil. Staff I and C stated that was unacceptable and though she could use her left hand to pick up the sandwich, she should have been more supervised so staff could assist with eating utensils placed in a reachable area. On 12/22/2022 at 9:20 a.m. an interview with the first floor unit manager Staff B revealed she had Resident #27 on her assigned floor and knows the resident and her care and service needs. Staff B confirmed Resident #27 has been at the facility for a few months and she has been assessed with a right hand/arm contracture. She further stated Resident #27 does not use her right hand/arm for ADL tasks to include eating. Staff B stated staff should have visited more frequently and confirmed the silverware should have been placed on the left side of the tray and not the right. Unit Manger Staff B confirmed Resident #27 would not have been able to reach the silverware with her left hand, when placed on right side of the tray. Staff B explained on 12/19/2022 and 12/20/2022 there were staff on the unit who generally do not work the unit and they did not know Resident #27 and her eating needs, to include supervision. Staff B nor the Nursing Home Administrator provided a policy and procedure related to resident supervision while eating for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 11 of 23 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 12/22/2022 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 - Some 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 observation, interview and record review, the facility failed to ensure behavioral monitoring related to psychotropic medications was performed for three residents (#19, #26, and #183) of five residents reviewed for unnecessary medications. Findings included: A review of admission records indicated Resident #19 was admitted on [DATE] with diagnoses including dementia, anxiety disorder, and major depressive disorder. A review of the Medication Administration Record (MAR) and the Physician Order Summary as of 12/21/22 indicated the following: Buspirone HCL tablet 5 milligrams(mg.) Give 1 tablet by mouth two times a day related to anxiety disorder. Start date: 9/8/22 A review of the MAR and the Treatment Administration Record (TAR), dated 12/2022, revealed no behavioral monitoring, or monitoring for medication side-effects, or effectiveness. A review of Resident #19's care plan revealed a focus area, created 6/17/21 and revised 2/4/22, for psychotropic medication. The interventions included: Monitor for side effects and effectiveness; Monitor occurrence of target behavior symptoms associated with anxiety and depression; Monitor/report to MD prn side effects and adverse reactions of psychoactive medications. A review of admission records indicated Resident #26 was admitted on [DATE] with diagnoses including dementia, generalized anxiety disorder, and major depressive disorder. A review of the Medication Administration Record (MAR) and the Physician Order Summary as of 12/21/22 indicated the following: Depakote ER tablet Extended Release 24 hr 250 mg. Give 1 tablet by mouth two times a day for generalized mood disorder. Start date: 11/11/22; Sertraline HCL tablet 100 mg. Give 1 tablet by mouth one time a day related to major depressive disorder. Start date: 11/11/22; Donepezil HCL tablet 10 mg. Give 1 tablet by mouth one time a day for dementia. Start date: 11/3/22; Alprazolam tablet 0. 25mg. Give 1 tablet by mouth two times a day for anxiety. Hold for sedation. Start date: 11/2/22. A review of the MAR, dated 12/2022, revealed no behavioral monitoring, or monitoring for medication side-effects, or effectiveness. A review of Resident #19's care plan revealed a focus area, created 11/4/22 and revised 11/14/22) for psychotropic medication. The interventions included: Monitor for side effects and effectiveness; Monitor occurrence of target behavior symptoms associated with diagnosis/indication; Monitor/report to MD prn side effects and adverse reactions of psychoactive medications. A review of admission records indicated Resident #183 was admitted on [DATE] with diagnoses including anxiety disorder and major depressive disorder. A review of the Medication Administration Record (MAR) and the Physician Order Summary as of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 12 of 23 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 12/22/2022 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 - Some 12/21/22 indicated the following: Paroxetine HCL tablet 40 mg. Give 0.5 tablet by mouth one time a day for depression. Start date: 12/6/22; Xanax tablet 0. 25mg (Alprazolam). Give 1 tablet by mouth every 6 hours as needed for anxiety for 14 days. Start date: 12/5/22. End date: 12/19/22. A review of the MAR, Dated 12/2022, revealed no behavioral monitoring, or monitoring for medication side-effects, or effectiveness. A review of Resident #183's care plan revealed a focus area, created 12/6/22, for diagnoses of anxiety and depression per doctor hospital notes, has been prescribed psychotropic medications. Interventions included: Monitor for side effects and effectiveness; Monitor/report to MD prn side effects and adverse reactions of psychoactive medications. An interview was conducted on 12/21/22 at 12:06 p.m. with Staff S, Registered Nurse (RN). When asked where behavior or side effect monitoring is being charted for residents on psychotropic medication, the nurse was confused. She stated if there was an issue, they would just create a progress note. She said if it was bad, they could do a change of condition. An interview was conducted on 12/21/22 at 1:55 p.m. with Staff T, RN. Staff T stated when a PRN (as needed) medication is given, the medical record triggers the nurse to enter its effectiveness. She said any behavior problems would just be put in a progress note. An interview was conducted on 12/21/22 at 2:04 p.m. with Staff B, RN/Unit Manager (UM.) When asked if behavior and side effect monitoring is being completed for residents on psychotropic medications she stated, I don't believe there is an actual form for that. Staff B was observed going through a resident record that is currently on a psychotropic medication. She even attempted to chart a medication as if it was being given. She stated the PRN (as needed) medications trigger a follow up for effectiveness but scheduled psychotropic medications do not. She reviewed the resident's chart to see if behavior or side effects were documented anywhere else. She confirmed she was unable to find any documentation related to behaviors, side effects, or effectiveness or psychotropic medications. A telephone interview was conducted with the Consultant Pharmacist on 12/22/22 at 10:30 a.m. He stated when a resident is taking a psychotropic drug, staff are looking for a reaction from the drug and stabilization of the resident. He said they are also looking for behaviors they should get from the drug. He confirmed there should be documented outcomes on the behaviors. When asked if there should be behavior monitoring for psychotropic medication he stated, sure, absolutely. He stated I do think staff document if there is an abnormal behavior, like agitation, but I don't know that they are actually doing more than that. The Pharmacist also stated he feels like the every shift system becomes a check in the box instead of documenting when something actually happens, making it not effective. He stated he feels like they document when there is an issue, but they need a spot that is easily reachable. A facility policy titled Psychotropic: Unnecessary Drugs, dated 9/2022, was reviewed. The policy stated the following: Purpose: The intent of this policy is each patient's/resident's entire drub/medication regimen is managed and monitored to promote or maintain the patient's/resident's highest practicable mental, physical, and psychosocial wellbeing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 13 of 23 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 12/22/2022 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 Procedure: Level of Harm - Minimal harm or potential for actual harm 1. Each patient's/resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: Residents Affected - Some a. In excessive does, b. for excessive duration, c. without adequate monitoring, d. without adequate indications for its use, e. in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or f. any combination of the reasons stated. 2. A psychotropic drug is any drug that affects brain activities associated with mental process and behavior. These drugs include, but are not limited to, drugs in the following categories: a. anti-psychotic b. anti-depressant c. anti-anxiety and d. hypnotic 3. Based on a comprehensive assessment of a patient/resident, the facility will ensure that: a. Patients/Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. b. Patient/Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 14 of 23 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 12/22/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two residents (#25, #7) of five residents observed. These errors constituted an 8.0 % medication error rate. Residents Affected - Few Findings Included: On 12/21/2022 a 9:18 a.m. medication observation was conducted alongside Staff L, Registered Nurse (RN). She prepared and administered the following medications to Resident #25 Gas relief 80 mg one tablet, Miralax 17 gram, Lorazepam 0.125 mg, Aspirin enteric coated 81 mg, Docusate 100 mg, Fluoxetine 10 mg, Lasix 40 mg, Metformin 500 mg, Spironolactone 100 mg, Lovastatin 40 mg, and Flonase. Medication reconciliation revealed Physician order for Simethicone tablet chewable 125 mg give 1 tablet by mouth with meals for gas dated 07/28/2022. On 12/21/2022 at 11:00 a.m. an interview was conducted with Staff L, RN, she confirmed she had administered Resident #25 Gas relief 80 mg tablet. She stated, It was the only dose available On 12/22/2022 at 10:31 a.m. a phone interview was conducted with the Consultant Pharmacist that stated, the facility has Simethicone 125 mg and 80 mg He went on to say I don't know why she would administer the wrong dose. On 12/22/2022 at 11:45 a.m. Staff L, RN was observed as she entered Resident # 7 bedroom with a Humalog KwikPen and informed Resident #7 she was due for her insulin injection. The RN attached the needle to the pen and turned the dose knob to 10 units. Then immediately administered the insulin to Resident #7 left upper quadrant. Review of the Physician orders Humalog KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Lispro) inject 10 units subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS dated 04/19/2021. The facility provided a copy of Insulin Lispro injection 100 units/mL 3 mL single -patient- use pen that did not contain a date read to Read the instruction for use before you start taking Humalog and each time you get another KwikPen. There may be new information. Priming your Pen, Prime before each injection. Priming you Pen means removing air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose knob to select 2 units. Step 7: Hold your pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with the needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the needle and repeat the priming steps 6 to 8. On 12/22/22 at 12:52 p.m. an interview was conducted with Staff B, Unit Manager and Staff L, RN on the process of priming Humalog KwikPen. Staff L confirmed she had not primed the pen prior to the administration of the ordered insulin. She indicated she was nervous when watched. Staff B confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 15 of 23 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 12/22/2022 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 0759 the pen should be primed prior to use. Level of Harm - Minimal harm or potential for actual harm Review of the Policy/ Procedure title: Medication, Administration of Intramuscular-Subcutaneous-Oral dated: 9/2012. Subcutaneous Injections: Procedure 4. Expel air from the syringe. Oral Medications: Procedure 1. Read the label three times before administering medication. Check again after administration. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 16 of 23 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 12/22/2022 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, interviews, and record review, the facility failed to 1) Ensure one of one kitchen dish washing machine was running effectively during one of four days observed on (12/19/2022); and 2) Ensure three of three walk in/reach in freezers with food items inside, were free from heavy ice and frost build up during two of four days observed (12/19/2022, and 12/21/2022). Findings included: 1) On 12/19/2022 at 9:20 a.m. the kitchen was toured with the facility's Registered Dietitian. The Registered Dietitian revealed the Dietary Manager would not be available during the length of survey and she would be the contact person for all kitchen and dietary questions. The Registered Dietitian was asked to tour the kitchen and she accommodated. The Registered Dietitian was asked if they were in process of washing dishes and she indicated they had already started using the machine this morning and was currently still in process of washing dishes. The Registered Dietitian revealed the facility had a High Temp dish washing machine and the staff to include Kitchen aides N, O, and P were in process of running it. Observations revealed Staff N. was standing to the left side of the machine and was inserting crates of soiled dishes to be cleaned. Prior to running a crate of dishes, Staff N was interviewed and asked about the machine. He confirmed the machine was a High Temp dish washing machine and the wash temperature should reach 150 degrees Fahrenheit (F) and above, and the final rinse should reach 180 degrees F and above. The Registered Dietitian confirmed the type of machine to be High Temp. An interview with the Registered Dietitian, and Staff N, O, and P all confirmed the machine is maintained by an outside sourced maintenance company and there had not been any issues with the machine within the past few months. The Registered Dietitian provided the last two months (11/2022, and 12/2022) of the Dish Machine Log-Hot Water Sanitizing sheets for review. An interview with Staff N. revealed he had not tested the wash and rinse temperatures and further confirmed he and Staff O and P, had been already running crates of dishes through the machine to be washed. No other employees stated they tested and logged the water temperatures for wash and rinse this a.m. The Registered Dietitian and Employees N, O, and P, again indicated the machine had been running effectively for the past few months and there has not been any times where the machine was running below wash and rinse requirements. Further observations of the machine revealed a specifications plate affixed under and near where the temperature gauge was. The specification plate read, Hot Water Sanitizing; Wash temperature 150 degrees F. (66 degrees C.) minimum, Rinse temperature 180 degrees F. (82 degrees C.) minimum. At 9:30 a.m. Staff N was asked to provide a wash/rinse cycle demonstration. Staff N noted the machine did not need to be primed to ensure required heated water. It was determined per this demonstration that the wash cycle reached 144 degrees F., and the rinse cycle reached 189 degrees F. per the digital thermometer on the machine. The wash cycle reached 144 degrees F. and held there for approximately ten seconds until that cycle ended. Staff N and the Registered Dietitian confirmed the observed wash and rinse temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 17 of 23 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 12/22/2022 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 At 9:32 a.m. Staff N ran a second was/rinse cycle demonstration. Staff N pushed through a crate of soiled dishes and the machine's wash temperature reached 144 degrees F. and held there for approximately ten seconds until the cycle ended, and the rinse cycle reached 190 degrees F., per the digital thermometer on the machine. At 9:40 a.m. a third wash/rinse demonstration was made with Staff N and after he pushed a crate of dishes into the machine the wash cycle only reached 144 degrees F., and the rinse cycle reached 188 degrees F., per the digital thermometer on the machine. Staff N and the Registered Dietitian also confirmed the errant temperatures. Interviews with Kitchen Staff N, O, and P, and the Registered Dietitian revealed they did not know why the machine was not reaching the optimum and required wash cycle temperatures and would call the outside sourced maintenance company to come out and check and repair the machine. The Registered Dietitian revealed her staff will wash all the previously ran dishes through the three compartment sink and will continue to use the three compartment sink until the dish machine is looked at and repaired. In an earlier interview with the Registered Dietitian and Staff N, they both indicated there had not been any temperature issues with the dish machine in the past three months. A review of the 11/2022 and 12/2022 Dish Machine Log-Hot Water Sanitizing log revealed the following dates with errant temperatures: 1. November 2nd - Wash 145 degrees F. (after breakfast meal). 2. November 4th - Wash 147 degrees F. (after breakfast meal). 3. November 6th - Wash 146 degrees F. (after breakfast meal). 4. November 17th - Wash 147 degrees F. (after breakfast meal); no logged temps after the dinner meal). 5. November 18th - Wash 149 degrees F. (after the dinner meal). 6. November 19th - Wash 147 degrees F. (after the dinner meal). 7. November 23rd - Wash 148 degrees F. (after the dinner meal). 8. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 18 of 23 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 12/22/2022 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 November 24th - Wash 148 degrees F. (after the dinner meal). Level of Harm - Minimal harm or potential for actual harm 9. November 25th - Wash 147 degrees F. (after the dinner meal). Residents Affected - Some 10. November 26th - Wash 143 degrees F. (after the dinner meal). 11. November 27th - Wash 148 degrees F. (after the lunch meal). 12. December 6th - Wash 148 degrees F. (after the dinner meal). 13. December 10th - Wash 149 degrees F. (after the dinner meal). The Registered Dietitian and Staff N, O, and P. confirmed the required wash temperatures and did not know if the Dietary Manager was aware or not. Staff N, O, and P revealed they log the temperatures but did not notify the Dietary Manager or Registered Dietitian or Maintenance of the errant temperatures. They also confirmed most days in November, there was at least one wash cycle that did not reach 150 degrees F. and above. The Registered Dietitian provided the last maintenance work orders to include dates 1/8/2022, and the Dish Machine operations manual for review. She had no other recent work orders from the maintenance department or the outside sourced maintenance company. The last work order dated 1/8/2022 (over eleven months ago), revealed tech notes: E2 error removed object from drain and reprogrammed checks ok. There was no evidence of errant wash and or rinse temperatures during that visit. On 12/22/2022 at 10:00 a.m. an interview with the Maintenance Director revealed he does not maintain the machine and an outside sourced company comes out to ensure the machine is running appropriately and to ensure the wash and rinse temperatures are running per the machine's requirement. On 12/22/2022 at 10:45 a.m. the Nursing Home Administrator provided the facility's Equipment, use of policy and procedure, with effective date of 3/1/2012. The policy revealed that the facility will reference to packaged instructions for use of equipment. Policy further revealed, all equipment instruction manuals are kept in the infection control office or the facilities office. This policy did not include the daily use and wash and rinse requirement for the dish washing machine. However, review of the manufacturer's dishwasher operations manual, only included makers specs and features and did not indicate what the required wash temperature should reach. The manual did include the following: Rinse cycle gallons per rack at 20 psi flow and to run at 180 degrees F. minimum for hot water sanitizing. Again, the manual did not indicate what the wash temperature requirements. The specifications plate affixed to the machine did indicate High Temperature machine and that wash cycle temperature should reach at least 150 degrees F., and the rinse cycle temperature should reach at least 180 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 19 of 23 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 12/22/2022 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 degrees F. Level of Harm - Minimal harm or potential for actual harm 2) On 12/19/2022 at 9:20 a.m. during kitchen tour with the Registered Dietitian, the following observations were revealed: Residents Affected - Some a. The reach in Cook Freezer was observed with heavy ice build up on the metal shelving, and on various packaged food items. The temperature via internal thermometer read 15 degrees F. The food items appeared as thought he ice frosting had been built up over a long period of time. Photographic evidence was taken. The Registered Dietitian confirmed all the ice build up and was not aware of the icing on packaged food items. She also did not know how long the ice had been building in this freezer. b. The reach in Cook Refrigerator was observed with metal container approximately nine inches long, but five inches wide and approximately six to seven inches deep. The container was just over ½ full with what appeared to be water that was leaking from the inside back of the refrigerator. Further, there was a white towel on the bottom self of the unit. The Registered Dietitian confirmed that the container was catching leaking water from the inside of the unit. Photographic evidence was taken. The Registered Dietitian did not know how long the refrigerator had been leaking inside and confirmed there were no current work orders to show it has been worked on currently worked on by Maintenance. c. The Tray Line freezer was observed with approximately fifteen to twenty small full ice cream cups with heavy frosting and ice build up. Further, the second and top shelf and the fan motor housing at the top of the inside of the unit were observed with heavy ice build up and appeared to have ice building for a long period of time. Other packaged food items were also observed with ice build up on them. Photographic evidence was taken. The Registered Dietitian revealed she was not aware of the ice build up in this unit and nobody had notified her of the frosted covered food. She also confirmed there were no current work orders from maintenance related to this unit. d. The main walk in freezer, which was inside and through the walk in refrigerator was observed with heavy ice buildup on the ground near both the right and left side door frames. Further, there was heavy ice build up on the door frames itself and on various shelving in the unit. Photographic evidence was taken and the Registered Dietitian confirmed the ice build up. She believed there were no work orders out with maintenance related to this unit. On 12/21/2022 at 1:30 p.m. during another kitchen tour, the reach in Tray Line freezer, and the reach in Cook Freezer were still both observed with some icing on the top and bottom shelves. The Registered Dietitian confirmed the ice build up. The reach in Cook Refrigerator was still observed with a white towel on the bottom of the inside shelf. The Registered Dietitian noted the towel was completely dry, but again confirmed it had been in there to catch a water leak and the leak had not been fixed yet. On 12/22/2022 at 10:00 a.m. the Nursing Home Administrator provided the facility's Equipment, use of policy and procedure, with effective date of 3/1/2012. The policy revealed that the facility will reference to packaged instructions for use of equipment. Policy further revealed, all equipment instruction manuals are kept in the infection control office or the facilities office. The policy did not contain information related to maintaining specific walk in and reach in refrigerators and freezers. On 12/22/2022 at 10:00 a.m. an interview with the Maintenance Director revealed he had not been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 20 of 23 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 12/22/2022 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 made aware of the ice building and water leaks in various identified freezer and refrigerator units. He confirmed he would have work orders for each job worked on or prior to being worked on. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 21 of 23 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 12/22/2022 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to ensure it had an effective pest control program during four of four days observed (12/19/2022, 12/20/2022, 12/21/2022, and 12/22/2022). It was observed the kitchen and first floor main hallways near resident rooms 121 - 134 had many small knat-like insects flying around. Residents Affected - Some Findings included: On 12/19/2022 at 9:30 a.m. during the initial kitchen tour, on 12/21/2022 at 1:30 p.m. during the comprehensive kitchen tour, the dish washing machine area and near food preparations stations near the hand washing sink were observed with ten to fifteen small knat like flying insects flying around the room. The area in the dish washing machine room near the floor drain and near the soiled dishes were observed with many flying knat like flying insects. Interview with Kitchen Staff N, and while he was swatting the insects away from his face, confirmed the insects and indicated they have been there a few days but could not remember when they were first spotted. Kitchen Staff O, and P, as well as the Registered Dietitian confirmed the small flying insects and could not say where they originated from and how long they have been in the area. On 12/19/2022 at 12:30 p.m. the first floor nurse station and hallway with rooms 121 - 134 were observed with approximately ten small knat like flying insects flying in, at and around the nurse station, the main hallways and also in the first floor lounge area. On 12/20/2022 at 7:30 a.m. 10:00 a.m. and 1:00 p.m. the first floor nurse station and main hallways and lounge area near hall with rooms 121 - 134 were observed with over five small knat like flying insects flying around these areas. At 10:00 a.m. interview with Nurse Staff G confirmed various flying insects at and around the first floor main hallway near the unit station and did not know exactly when they were originally started in that area. On 12/21/2022 at 7:15 a.m. and 9:00 a.m. the first floor nursing station was observed with over five small knat like flying insects. As residents were being assisted in this area while in wheelchairs, the flying insects would fly in the resident's general face area and were swatting them away. On 12/21/2022 at 12:38 p.m. The first floor main hallway accessing rooms 121 - 134, the first floor nursing station and the lounge room were observed with four to five small knat like flying insects. At 1:00 p.m. Staff D., L., J., and K., all confirmed they have seen and continually see small knat-like insects at and around the main hallways near the first floor unit station. They did not know if pest control was in to treat the area recently On 12/21/2022 at 12:00 p.m. the Registered Dietitian provided the Pest Control log book and contract for review. It was determined the facility had a current withstanding pest control contract. The contract revealed pest control visits include to treat the facility interior common areas, kitchen, 10 rodent bait stations, rooms upon request, all break areas once monthly. The last visit noted from the pest control company was on 12/9/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 22 of 23 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 12/22/2022 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The visit on 12/9/2022 included treatment services to 9 drains in the kitchen. The service schedule was changed to four times a month per review of the last commercial services agreement addendum dated 12/9/2022 On 12/22/2022 at 8:00 a.m. the Nursing Home Administrator provided the Pest Control policy and procedure, with original issue date of 7/2020, for review. The policy indicated the following: Purpose - This pest control policy applies to the facility. The policy further revealed, The purpose of this policy is to provide a framework for the facility to manage the pest prevention program and provide a safe and healthy workplace. Specifically, the policy aims to ensure: 1. A robust contract for pest control in place which incorporate regular and proactive monitoring of the facility in addition to timely and safe treatment and eradication. 2. There is a framework for reporting sightings of pests or evidence of their presence at the earliest opportunity. 3. The Manager of Environmental Services is responsible for coordinating pest control in the facility. 4. It is the specific department's responsibility to contact Environmental Services for their individual needs and communicate to Environmental Services any precautions that need to be addressed in specialized areas. 5. Service records are signed, dated and kept in the Environmental Services office, with the exception of Food and Nutrition which will keep their own set of records. 6 Pest control log will be maintained by the Environmental Services Department. 7. A 24 hour, 7 day a week, emergency number is available for emergency or immediate needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105128 If continuation sheet Page 23 of 23