Inspection·January 25, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of the Minimum Data Set (MDS) dated [DATE] noted no documentation in Section A1500 that acknowledged a Level II PASARR was completed for a diagnosis of Mental Retardation/Developmental Delay (MR/DD). A record review of the Annual MDS Assessment for Resident #1 dated 3/3/2011 noted no documentation in section A1500 acknowledging a diagnosis of MR/DD and/or the completion of a Level II PASARR screen. A record review of the Annual MDS Assessment for Resident #1 dated 6/4/2022 noted in section A1500 documented that Resident #1 was not considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability or related condition. An interview on 1/23/2023 at approximately 2:35 PM with Staff B, RN MDS Coordinator, acknowledged that a Level II screening was in the medical record from 2010, and that the MDS in section A did not acknowledge a Diagnosis requiring a Level II screen, and that a Level II screen had been completed. Staff B, RN MDS Coordinator stated the individual who did the annual MDS Screen dated 6.4.2022 was no longer at the facility. Resident #92 A record review performed on 1/24/2023 at approximately 2:34 PM of current and discontinued medications for Resident #92 noted that Resident #92 had not been prescribed a medication considered to be an anticoagulant. Resident #92 was prescribed Plavix (Clopidogrel Bisulfate) 75 mg on 8/9/2022, which is considered an antiplatelet medication. A review of the quarterly MDS of Resident #92 dated 11/10/2022 noted in Section N that Resident #92 received an anticoagulant for 7 of 7 days of the lookback period. In an interview on 01/25/23 at approximately 9:26 AM, the MDS Coordinators Staff B (a Registered Nurse) and Staff C (a Licensed Practical Nurse) were asked what medications are coded in MDS as an anticoagulant. Staff C stated that anticoagulants include Eliquis and Coumadin. Staff C stated that Plavix and Aspirin are not to be considered anticoagulants. Staff B and C were asked to pull up the records for Resident #92 and Resident #68. It was noted that both residents were noted to have been coded for an anticoagulant for 7 of 7 days. A review of the medications noted that neither resident #92 nor Resident #68 were prescribed a medication considered to be an anticoagulant. Both residents were prescribed Plavix which is not an anticoagulant. Staff B stated she had made that error. She stated she is recently new to the process and is learning. Resident #78 The record review of resident #78 documented diagnoses of Alzheimer's disease and Depression. The Level I PASARR for resident #78 was inaccurate, as it did not identify any serious mental disease or related conditions. On 01/23/2023, at approximately 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON indicates it is her responsibility to do a final review of all PASARRs. The DON indicates she performs the final review to determine if a Level II PASARR is needed. The DON verbally agreed that a Level II PASARR should have been completed for resident #78. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105295 If continuation sheet Page 2 of 5 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 105295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Walton Rehabilitation Center, LLC 1 Lbj Sr Drive Fort Walton Beach, FL 32547 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 01/23/2023, a review of the PASARR policy was completed. The Preadmission Screening and Resident Review policy (revised 11/18/2017) defined the federal requirement to complete a PASARR review to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. The policy requires that 1) all applicants to a Medicaid-certified nursing center be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing center, or acute care setting); and 3) receive the services they need in those settings. Event ID: Facility ID: 105295 If continuation sheet Page 3 of 5 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 105295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Walton Rehabilitation Center, LLC 1 Lbj Sr Drive Fort Walton Beach, FL 32547 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate a Level II Preadmission Screening and Resident Review (PASARR) assessment for 1of 1 residents sampled. (Resident #97) The findings include: A review of the PASARR form for Resident #97 dated 9/26/2021 noted no diagnosis of Serious Mental Illness (SMI) or Intellectual Disability (ID), or a primary diagnosis of dementia. A medical record review for Resident #97 noted a diagnosis of Generalized Anxiety Disorder added on 11/1/2021. In addition, on 9/13/2022, Resident #97 was prescribed Buspar tablet 7.5 mg by mouth three times a day for anxiety. On 12/16/2022, Resident #97 was additionally prescribed Lorazepam tablet 0.5 mg two tablets at bedtime for anxiety. A medical record review of thirteen psychiatry evaluations from 11/29/2021 through 11/15/2022 documented a diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder. A medical record review of the Annual Minimum Data Set (MDS) assessment dated [DATE] for resident #97 noted in Section A: Section 1500 that the resident is currently considered to not have a serious mental illness and/or intellectual disability or related condition. In an interview on 1/24/2023 at approximately 11:59 AM with the MDS Coordinators, Staff B (a Registered Nurse) and Staff C (a Licensed Practical Nurse) were asked what the process was if the resident has a SMI added after they are admitted . Staff C stated that, when the consultant provides a new diagnosis, the Director of Nursing (DON) will let them know to add this to the MDS. In an interview with the Administrator, Director of Nursing (DON), and the Regional Clinical Director on 1/24/23 at 12:03 PM, they were asked what the process was to get a Level II PASARR screening completed when a resident gets a new diagnosis of a serious mental illness. They expressed confusion over what needed to be referred for a Level II, what qualified as a serious mental illness, and whether or not the resident had dementia. They produced guidance from the Level II contractor who provides their training and guidance. A review of the memo noted documentation that the Level II evaluation may be terminated if the evaluator determines at any time during the evaluation that the individual: 1. Does not have an SMI or ID. 2. Has a primary diagnosis of dementia; or 3. Has a non-primary diagnosis of dementia without a primary diagnosis of SMI or ID. They acknowledge that Resident #97 did not have a primary diagnosis of dementia and had been later given a diagnosis of anxiety disorder. They were then asked who does the referral for a Level II PASARR screening if there is an updated diagnosis or change. The DON stated that it would be her. A review of the facility policy titled Pre-admission Screening and Resident Review (PASARR) dated as 11/28/2017 states that Referral to the Stated Mental Health (SMH)/Intellectual Disability (ID) authority should be made as soon as the criteria indicative of a significant change are evident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105295 If continuation sheet Page 4 of 5 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 105295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Walton Rehabilitation Center, LLC 1 Lbj Sr Drive Fort Walton Beach, FL 32547 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews, and policy review, the facility failed to ensure staff effectively disinfected shared blood glucose meters during 1 of 1 random observations of blood glucose sampling for resident #43. Residents Affected - Few The findings include: An observation of Employee A (Licensed Practical Nurse) checking resident #43's blood sugar was conducted on 1/23/23 at 4:41 PM. Employee A obtained the blood glucose meter from the medication cart, then placed the machine on the bedside table in resident #43's room. She obtained the blood sample from resident #43 and applied it to the strip in the machine then laid the machine in resident #43's bed. Afterwards, Employee A picked up the machine and placed it back on the bedside table. Employee A then disposed of the blood sampling strip and placed the blood glucose meter on top of the medication cart with no barrier under the machine. Employee A then cleansed the blood glucose meter with an alcohol wipe. An interview was conducted with employee A on 1/23/23 at 4:48 PM. She stated she had training to clean the blood glucose meter with bleach wipes. She stated she had to check 5 resident blood sugars and it was sometimes more convenient to use alcohol wipes to clean the machine. She then confirmed she was supposed to clean the machine with bleach wipes between each resident and stated the supervisor told her she could use alcohol. An interview was conducted with the Director of Nursing (DON) on 1/23/23 at 4:53 PM. The DON stated the staff are to use bleach wipes to clean the blood glucose meter, not alcohol. Review of the undated facility policy regarding Guidelines for Cleaning and Disinfecting Blood Glucose Meter revealed the meter should be disinfected with a germicidal wipe before and after each use. The policy states, Disinfect the meter with a germicidal wipe, place the meter on a clean barrier, and allow to air dry for a full 3 minutes. The policy includes a photo of bleach germicidal wipes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105295 If continuation sheet Page 5 of 5