Inspection·February 10, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete misappropriation of resident/guest property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and physical or chemical restraints not required to treat the resident/guest(s) medical symptoms . This policy addresses the acts and occurrences that constitute abuse, neglect, exploitation and misappropriation of resident/guest property and suspicious injuries of unknown source; this includes but is not limited to: freedom from corporal punishment, involuntary seclusion, and physical or chemical restraints not required to treat the resident/guest(s) medical symptoms of any type, by anyone; when such acts and occurrences transpire, it must be reported to agencies and officials outside of the facility; the proper reporting procedures to be used in such instances; training of employees regarding such acts and occurrences and reporting procedures; and the investigation of such acts and occurrences and reporting procedures. The policy also addresses the proper investigation and documentation of incidents and accidents involving resident/guest(s) that are not caused by abuse, exploitation and misappropriation of resident/guest property. For purpose of this Policy, the following terms shall have the following meanings: A. Abuse. The definition of abuse encompasses a broad scope of behavior. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. In addition, abuse includes depriving the resident/guest of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial well-being irrespective of any mental or physical condition. Any act considered abusive towards an alert and oriented resident/guest should also be considered abusive to the cognitively impaired or non-responsive. Willful means the individual must have acted deliberately (not inadvertently or accidentally), not that the individual must have intended to inflict injury or harm. A cognitively impaired resident/guest that intentionally hits another resident/guest, may be considered abusive. The following are definitions of specific types of abuse: 1. Verbal- Verbal abuse is the use of oral, written or gestured communication or sounds that includes disparaging and derogatory terms to resident/guest(s) or their families/representatives, or within their hearing distance, regardless of their ages, abilities to comprehend, or the nature of their disabilities. Examples of verbal abuse could include, but are not limited to: threatening to hurt and saying things to frighten a resident/guest, such as telling a resident/guest that: he/she will never be able to see his/her family again, will take to shower room and leave for hours, will leave a bed all day to soil yourself, if you don't eat fast enough food will be taken away, isolating a resident/guest from social interaction or activities. Using profanity to a resident/guest, blaming the resident/guest for their condition and employee altercations in front of a resident/guest, mocking, insulting, or ridiculing the resident/guest are also examples that could be abuse . VI. Investigations and Facility Response to Incidents or Accidents: a) The facility will report all instances of alleged or suspected abuse, including verbal and mental abuse, neglect, suspicious injuries of unknown origin, exploitation and misappropriation of resident/guest property in the following manner, b) Investigation and Reporting Steps: - Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately. - The Administrator/Designee will report to the State Agency and all other required agencies, per regulations. All allegations of abuse and instances that result in serious bodily injury must be reported within 2 hours. Event ID: Facility ID: 105317 If continuation sheet Page 2 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care services received such care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen administration, Resident #8, in a total sample of 54 residents. Residents Affected - Few Findings: Review of Resident #8's records revealed the resident was admitted on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (a lung disease that blocks airflow and makes it difficult to breathe), left sided hemiplegia (paralysis on one side of the body), dementia, hypertension (high blood pressure), and major depression. During an observation on 2/6/2022 at 10:43 AM, Resident #8 was receiving oxygen at 4 liters per minute via oxygen concentrator, with the oxygen humidification bottle on the floor. During an observation on 2/7/2022 at 7:55 AM, Resident #8 was receiving oxygen at 4 liters per minute via oxygen concentrator, with the oxygen humidification bottle on the floor. During an observation on 2/7/2022 at 1:52 PM, Resident #8 was receiving oxygen at 4 liters per minute via oxygen concentrator, with the oxygen humidification bottle on the floor. Review of the physician order dated 1/25/2022 for Resident #8 revealed oxygen at 2 liters per minute as needed for shortness of breath. During an interview on 2/7/2022 at 2:12 PM, Staff G, Licensed Practical Nurse (LPN), stated, The oxygen is not supposed to be on 4 liters. She has doctor's orders for 2 liters. I'm not sure why she is on 4 liters. The humidification bottle should not be on the floor and needs to be changed right away. During an interview on 2/7/2022 at 2:45 PM, the Director of Nursing (DON) stated, Oxygen should be administered according to the doctor's orders. I can't believe that the humidification bottle was on the floor. It needs to be in the holder. I expect that the nurses are assessing every shift and making sure that it is being administered according to the doctor's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 3 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the medications used in the facility were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable in 5 of 6 medication carts reviewed. Findings: On 2/6/2022 at 9:25 AM, the surveyor observed Medication Cart #1 with Staff A, Licensed Practical Nurse (LPN), and found one opened Lantus insulin pen with no opened or expiration dates, one opened Lispro insulin pen with no opened or expiration dates, one opened bottle of Lantus insulin with no opened or expiration dates, and one opened bottle of Ofloxacin eye drops with no opened or expiration dates. During an interview on 2/6/2022 at 9:25 AM, Staff A, LPN, stated, All insulin and eye drops should be labeled when they are opened. I'm not sure why they aren't. This is not my cart. On 2/6/2022 at 9:30 AM, the surveyor observed Medication Cart #2 with Staff B, Registered Nurse (RN), and found one opened Levemir insulin pen with no opened or expiration dates, one opened Novolog insulin pen with no opened or expiration dates, one opened bottle of artificial tears with an expiration date of 12/23/2021, one opened bottle of Refresh artificial tears with an opened date of 8/22/2021, one opened bottle of Brimonidine eye drops with an expiration date of 5/30/2021, one opened bottle of Latanoprost eye drops with an opened date of 9/5/2021 and pharmacy instructions to discard after 42 days, one opened bottle of polymyxin eye drops with no opened or expiration dates, two opened bottles of artificial tears with no resident identifiers and no opened or expiration dates, and one opened bottle of Dorzolamide eye drops with no opened or expiration dates. During an interview on 2/6/2022 at 9:35 AM, Staff B, RN, stated, I'm not sure why the expired medications are still on the cart. They should be thrown out. All eye drops and insulin should have the date opened and when they expire. On 2/6/2022 at 9:40 AM, the surveyor observed Medication Cart #3 with Staff C, LPN, and found one opened Tresiba insulin pen with no opened or expiration dates, one opened Levemir insulin pen with no opened or expiration dates, one Novolog insulin pen with an expiration date of 2/3/2022, one opened Aspart insulin with no opened or expiration dates, one opened bottle of Lantus insulin with no opened or expiration dates, one opened bottle of Timolol with an expiration date of 1/16/2022, and one opened bottle of Systane eye drops with no opened or expiration dates. During an interview on 2/6/2022 at 9:45 AM, Staff C, LPN, stated, The insulin and the eye drops are expired, and they should not be on the cart. They should have been removed. All insulin and eye drops should be labeled when they are opened. On 2/6/2022 at 9:50 AM, the surveyor observed Medication Cart #4 with Staff D, LPN, and found one opened Lantus insulin pen with no opened or expiration dates, one opened bottle of Humalog insulin with an expiration date of 1/24/2022, one opened Lantus insulin pen with no opened or expiration dates, one opened bottle of artificial tears with an expiration date of 12/18/2021, one opened bottle of Brimonidine 0.2% eye drops with no opened or expiration dates, one opened bottle of Timolol eye (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 4 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many drops with an expiration date of 1/1/2022, and one opened bottle of Latanoprost eye drops with an opened date of 12/12/2021 and pharmacy instructions to discard after 42 days. During an interview on 2/6/2022 at 9:55 AM, Staff D, LPN, stated, That insulin and those eye drops are expired, and we should have discarded them and gotten new ones. All eye drops and insulin need to be labeled when they are opened and when they expire. On 2/6/2022 at 10:05 AM, the surveyor observed Medication Cart #5 with Staff E, LPN, and found one opened bottle of Latanoprost 0.005% eye drops with no opened or expiration dates, one opened bottle of Lumigan 0.01% eye drops with no opened or expiration dates, one opened bottle of Refresh eye drops with no opened or expiration dates, and one opened bottle of Visine eye drops with no resident identifier and an opened date of 10/29/2021. During an interview on 2/6/2022 at 10:10 AM, Staff E, LPN, stated, We should not have any expired meds on the cart. Review of the facility policy number 5.3 titled Storage and Expiration of Medications, Biologicals, Syringes and Needles with the last revision date of 1/1/2013, reads, Procedure: . 4. Facility should ensure that medications and biologicals: 4.1 Have an expiration date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines . 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 5 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility administration failed to ensure the facility was administered in a manner to maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents reviewed for facility response to abuse allegations, Residents #10, #59, and #69. Residents Affected - Many Findings: Review of the job description for the Administrator with an effective date of 10/1/1994 and review date of 6/30/2003 reads, General Purpose: To direct the day-to-day functions of the facility in accordance with current Federal, State and local standards governing long-term care facilities to ensure that the highest practicable level of care is provided to the residents. Review of the job description for the Director of Nursing with an effective date of 10/1/1994 and review date of 9/1/2009 reads, General Purpose: Under the direction of the Administrator, plans, organizes, develops and directs the overall operation of the Nursing Services Department in accordance with current federal, state and local standards governing the facility. Ensure that the highest practicable level of quality of care is maintained at all times. Review of the facility grievances report dated September 2021 revealed Resident #10 had voiced an allegation of verbal abuse that a Certified Nursing Assistant had called him a name. Review of the facility grievances report dated October 2021 revealed Resident #69 had voiced an allegation that he was told to urinate in his brief, and he was not getting water. Review of the facility grievances report dated November 2021 revealed Resident #59's daughter had voiced an allegation that Resident #59 had been locked in the shower and was screaming. During an interview on 2/8/2022 at 9:27 AM, the Social Worker verified that the facility had not reported the allegations of abuse involving Resident #10, Resident #69, and Resident #59. During an interview on 2/8/2022 at 10:22 AM, the Administrator acknowledged the requirement for the incidents involving Resident #10, Resident #69, and Resident #59 to have been reported. During an interview on 2/8/2022 at 11:42 AM, the Social Worker stated Resident #10 had voiced the allegation on 9/23/2021, Resident #69 had voiced the allegation on 10/21/2021, and Resident #59's daughter had voiced the allegation on 11/3/2021. During interview on 2/9/2022 at 1:14 PM, the Director of Nursing confirmed the abuse/neglect allegations of 3 residents (Resident #10, Resident #69, Resident #59) were not reported because no one stated they were abused, no one stated they were hit, and someone stated they were called a name. During an interview on 2/10/2022 at 8:30 AM, the Administrator stated he knew that the incidents involving Resident #10, Resident #59, and Resident #69 had occurred and he had signed off on them. He stated, After I reviewed these, we really should have reported them. I'm aware we have an obligation to report. These seemed so subtle, we just didn't realize. But we really should have identified them after the second occurrence and come up with a plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 6 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation reviewed on 1/5/2022, read, Purpose: This Policy (the Policy) is concerned with all incidents and accidents involving resident/guest(s). The facility will investigate and document all incidents and accidents involving resident/guest(s). Certain incidents and accidents involving residents/guests must also be reported to the appropriate agencies. All of our resident/guest(s) have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and physical or chemical restraints not required to treat the resident/guest(s) medical symptoms . This policy addresses the acts and occurrences that constitute abuse, neglect, exploitation and misappropriation of resident/guest property and suspicious injuries of unknown source; this includes but is not limited to: freedom from corporal punishment, involuntary seclusion, and physical or chemical restraints not required to treat the resident/guest(s) medical symptoms of any type, by anyone; when such acts and occurrences transpire, it must be reported to agencies and officials outside of the facility; the proper reporting procedures to be used in such instances; training of employees regarding such acts and occurrences and reporting procedures; and the investigation of such acts and occurrences and reporting procedures. The policy also addresses the proper investigation and documentation of incidents and accidents involving resident/guest(s) that are not caused by abuse, exploitation and misappropriation of resident/guest property. For purpose of this Policy, the following terms shall have the following meanings: A. Abuse. The definition of abuse encompasses a broad scope of behavior. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. In addition, abuse includes depriving the resident/guest of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial well-being irrespective of any mental or physical condition. Any act considered abusive towards an alert and oriented resident/guest should also be considered abusive to the cognitively impaired or non-responsive. Willful means the individual must have acted deliberately (not inadvertently or accidentally), not that the individual must have intended to inflict injury or harm. A cognitively impaired resident/guest that intentionally hits another resident/guest, may be considered abusive. The following are definitions of specific types of abuse: 1. Verbal- Verbal abuse is the use of oral, written or gestured communication or sounds that includes disparaging and derogatory terms to resident/guest(s) or their families/representatives, or within their hearing distance, regardless of their ages, abilities to comprehend, or the nature of their disabilities. Examples of verbal abuse could include, but are not limited to: threatening to hurt and saying things to frighten a resident/guest, such as telling a resident/guest that: he/she will never be able to see his/her family again, will take to shower room and leave for hours, will leave a bed all day to soil yourself, if you don't eat fast enough food will be taken away, isolating a resident/guest from social interaction or activities. Using profanity to a resident/guest, blaming the resident/guest for their condition and employee altercations in front of a resident/guest, mocking, insulting, or ridiculing the resident/guest are also examples that could be abuse . VI. Investigations and Facility Response to Incidents or Accidents: a) The facility will report all instances of alleged or suspected abuse, including verbal and mental abuse, neglect, suspicious injuries of unknown origin, exploitation and misappropriation of resident/guest property in the following manner, b) Investigation and Reporting Steps: Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately. - The Administrator/Designee will report to the State Agency and all other required agencies, per regulations. All allegations of abuse and instances that result in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 7 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0835 serious bodily injury must be reported within 2 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 8 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain accurately documented medical records for 2 of 4 residents reviewed for Preadmission Screening and Resident Review (PASRR), Residents #126 and #127, in a total sample of 54 residents. Findings: Review of Resident #127's admission records revealed the resident was admitted on [DATE] with diagnoses to include dementia (a group of symptoms affecting memory, thinking, and social abilities severe enough to interfere with daily life), psychosis (a mental disorder characterized by a disconnection from reality), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #127's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 9/15/2021 reads, E. Medical Condition. Primary Diagnosis: Dementia. Review of Resident #127's Preadmission Screening and Resident Review (PASRR) completed on 9/16/21 revealed depressive disorder was not selected under Section I: PASRR Screen Decision-Making, Subsection A. MI [Mental Illness] or suspected MI, and the question for primary diagnosis of dementia was answered as No in Section II: Other Indications for PASRR Screen Decision-Making, Subsection 5. During an interview on 2/7/2022 at 9:45 AM, the Director of Nursing (DON) stated Resident #127's PASRR was not correct and the answer to the question in Section II-5 should have been checked as Yes. Review of Resident #126's admission records revealed the resident was admitted on [DATE] with diagnoses to include altered mental status (general changes in brain function such as confusion, memory loss, disorientation, defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception) and auditory hallucinations (false perceptions of hearing sounds without any real sensory stimuli). Review of Resident #126's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/27/2022 reads, E. Medical Condition. Primary Diagnosis: Acute Psychosis. Review of Resident #126's hospital records dated 1/24/2022 revealed the resident was brought to the emergency room after wandering the apartment complex and having auditory hallucinations. The resident was evaluated by telemetry psychiatry who recommended the resident be admitted for observation under a [NAME] Act and evaluated by psychiatry and neurology for acute delirium (disturbed consciousness, cognitive function, or perception usually developed over a short period of time). Review of Resident #126's hospital discharge instructions dated 1/27/22 revealed discharge diagnosis of acute psychosis and mania (a psychological condition causing a person to experience unreasonable euphoria, very intense moods, hyperactivity, and delusions). Review of Resident #126's PASRR completed on 1/27/2022 revealed that in Section I: PASRR Screen Decision-Making, Documented History is selected under Finding is based on, and in Section II: Other Indications for PASRR Screen Decision-Making, Subsection 3: Is there an indication that the individual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 9 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following, No was selected for both A: Psychiatric treatment more intensive than outpatient care (e.g., partial hospitalization or inpatient hospitalization), and B: Due to the mental illness, the individual has experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials. During an interview on 2/8/2022 at 11:45 AM, the DON stated, I usually only have the resident's name and maybe a medication list at the time the PASRR is filled out. I don't know why I checked based on documentation. I usually select the one for individual or family report. The form is filled out prior to admission, usually before I have any information. Review of the facility policy number SS.III-2 titled Pre-admission Screening for Mental Retardation [MR] and Mental Illness [MI] with an effective date of July 15, 2009 and last review date of 1/5/2022 reads, Purpose: To ensure that individuals with mental retardation or mental illness receive the care and services they need, in the most appropriate setting and have medical needs that outweigh their mental needs . Process: - Level I Determinations must be signed and dated by an RN at the admitting nursing facility on or before the date of admission. - The nursing facility is responsible for ensuring that a Level I screening is completed, submitted and has a Level I Determination and/or a Level II if indicated, on or before nursing home admission and regardless of payment source. - Residents identified through the PASRR process as having an MI or MR diagnosis must be assessed by the nursing facility on an ongoing process to identify any significant changes. Those residents identified as having a significant change must have an updated Level I screening within 14 days of the significant change. - The original documents for the Level I and/or Level II determinations will be retained in the medical chart behind the Social Services tab. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 10 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility quality assurance and performance improvement committee failed to identify and implement a performance improvement plan related to the failure to report allegations of abuse as required for 3 of 3 residents reviewed for facility response to abuse allegations, Residents #10, #59, and #69. Residents Affected - Many Findings: Review of the facility grievances report dated September 2021 revealed Resident #10 had voiced an allegation of verbal abuse that a Certified Nursing Assistant had called him a name. Review of the facility grievances report dated October 2021 revealed Resident #69 had voiced an allegation that he was told to urinate in his brief, and he was not getting water. Review of the facility grievances report dated November 2021 revealed Resident #59's daughter had voiced an allegation that Resident #59 had been locked in the shower and was screaming. During an interview on 2/8/2022 at 9:27 AM, the Social Worker verified that the facility had not reported the allegations of abuse involving Resident #10, Resident #69, and Resident #59. During an interview on 2/8/2022 at 10:22 AM, the Administrator acknowledged the requirement for the incidents involving Resident #10, Resident #69, and Resident #59 to have been reported. During an interview on 2/8/2022 at 11:42 AM, the Social Worker stated Resident #10 had voiced the allegation on 9/23/2021, Resident #69 had voiced the allegation on 10/21/2021, and Resident #59's daughter had voiced the allegation on 11/3/2021. During interview on 2/9/2022 at 1:14 PM, the Director of Nursing confirmed the abuse/neglect allegations of 3 residents (Resident #10, Resident #69, Resident #59) were not reported because no one stated they were abused, no one stated they were hit, and someone stated they were called a name. During interview on 2/10/2022 at 8:23 AM, the Director of Nursing stated the facility quality assurance committee had not identified and implemented a performance improvement plan related to facility failure to submit a federal report related to allegations of staff abuse/neglect of residents. During an interview on 2/10/2022 at 8:30 AM, the Administrator stated he knew that the incidents involving Resident #10, Resident #59, and Resident #69 had occurred and he had signed off on them. He stated, After I reviewed these, we really should have reported them. I'm aware we have an obligation to report. These seemed so subtle, we just didn't realize. But we really should have identified them after the second occurrence and come up with a plan. Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation reviewed on 1/5/2022, read, Purpose: This Policy (the Policy) is concerned with all incidents and accidents involving resident/guest(s). The facility will investigate and document all incidents and accidents involving resident/guest(s). Certain incidents and accidents involving residents/guests must also be reported to the appropriate agencies. All of our resident/guest(s) have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property. This includes but is not limited to freedom from corporal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 11 of 12 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete punishment, involuntary seclusion, and physical or chemical restraints not required to treat the resident/guest(s) medical symptoms . This policy addresses the acts and occurrences that constitute abuse, neglect, exploitation and misappropriation of resident/guest property and suspicious injuries of unknown source; this includes but is not limited to: freedom from corporal punishment, involuntary seclusion, and physical or chemical restraints not required to treat the resident/guest(s) medical symptoms of any type, by anyone; when such acts and occurrences transpire, it must be reported to agencies and officials outside of the facility; the proper reporting procedures to be used in such instances; training of employees regarding such acts and occurrences and reporting procedures; and the investigation of such acts and occurrences and reporting procedures. The policy also addresses the proper investigation and documentation of incidents and accidents involving resident/guest(s) that are not caused by abuse, exploitation and misappropriation of resident/guest property. For purpose of this Policy, the following terms shall have the following meanings: A. Abuse. The definition of abuse encompasses a broad scope of behavior. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. In addition, abuse includes depriving the resident/guest of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial well-being irrespective of any mental or physical condition. Any act considered abusive towards an alert and oriented resident/guest should also be considered abusive to the cognitively impaired or non-responsive. Willful means the individual must have acted deliberately (not inadvertently or accidentally), not that the individual must have intended to inflict injury or harm. A cognitively impaired resident/guest that intentionally hits another resident/guest, may be considered abusive. The following are definitions of specific types of abuse: 1. Verbal- Verbal abuse is the use of oral, written or gestured communication or sounds that includes disparaging and derogatory terms to resident/guest(s) or their families/representatives, or within their hearing distance, regardless of their ages, abilities to comprehend, or the nature of their disabilities. Examples of verbal abuse could include, but are not limited to: threatening to hurt and saying things to frighten a resident/guest, such as telling a resident/guest that: he/she will never be able to see his/her family again, will take to shower room and leave for hours, will leave a bed all day to soil yourself, if you don't eat fast enough food will be taken away, isolating a resident/guest from social interaction or activities. Using profanity to a resident/guest, blaming the resident/guest for their condition and employee altercations in front of a resident/guest, mocking, insulting, or ridiculing the resident/guest are also examples that could be abuse . VI. Investigations and Facility Response to Incidents or Accidents: a) The facility will report all instances of alleged or suspected abuse, including verbal and mental abuse, neglect, suspicious injuries of unknown origin, exploitation and misappropriation of resident/guest property in the following manner, b) Investigation and Reporting Steps: - Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately. - The Administrator/Designee will report to the State Agency and all other required agencies, per regulations. All allegations of abuse and instances that result in serious bodily injury must be reported within 2 hours. Event ID: Facility ID: 105317 If continuation sheet Page 12 of 12