Health inspection·February 11, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2/10/22 at 4:19 p.m., he confirmed the bed was not long enough for the resident and would be changed out. Observation of Resident #56 on 2/10/22 at 4:25 p.m., revealed the resident in bed with the bed now extended and the extender bolster in place. The resident stated he was happy with the extension and his feet no longer rubbed against the footboard. Review of Resident #56 record revealed the resident's height was 71 inches (5 foot 9 inches) lying down. He was admitted to the facility on [DATE]. 3. Observation and interview of Resident #74 on 2/08/22 at 11:25 a.m., revealed the resident lying in his bed with his feet hanging over the end of the footboard. The resident stated his feet hurt after pushing on the foot board or when they hung over the side of the bed. Resident #74 was observed with a brace to the right leg and was unable to bend his knee. Resident #74 stated that maintenance looked at his bed weeks ago and said there was nothing they could do to make it longer and that was the last he heard about his bed. The resident placed his bed in the flat position and scooted to the head of the bed and he did not touch the footboard. After getting himself in the sitting position his feet were back over the foot board. During an observation and interview on 2/10/22 1:18 p.m. with Staff I, LPN, she confirmed Resident #74 needed a longer bed and would put in a maintenance request. During an interview and observation of Resident #49's room with the Maintenance Director,on 2/10/22 at 4:20 p.m., he confirmed the bed was not long enough for the resident and would be changed out. During an interview on 2/10/22 at 11:19 a.m. with Staff L, admission Director, she confirmed she was responsible for getting the correct beds, air mattresses, regular or scoop mattress, for the residents when they come in to the facility based on height and weight. She confirmed maintenance also had extenders for the beds. Staff L, confirmed once the resident was on the unit the nursing staff were to confirm the resident's bed was appropriate then would notify maintenance if a change was needed. During an interview with the Maintenance Director,on 2/10/22 at 4:45 p.m., he confirmed the facility completed bed audits but did not look at the bed compared to the height of the resident as that would be nursing's responsibility. Review of facility policy related to bed maintenance and inspections, revised 11/17, The compliance store, one page revealed: It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify and avoid areas of possible entrapment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 2 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Random observations while walking down the main hallway located on the long term care unit on 02/08/22 at 2:00 p.m., revealed the door to the shower room was open and the curtain inside the shower room was open. Observation from the hallway revealed a resident could be seen in the shower being showered by two persons. On 02/08/22 at 2:17 p.m., in an interview with Staff X, Certified Nursing Assistant (CNA), she identified the resident as Resident #37, and identified the two persons in the shower room as Staff A, Registered Nurse (RN), Unit Manager and the resident's daughter. Residents Affected - Few A review of Resident #37's admission Minimum Data Set (MDS) dated [DATE] revealed she was totally dependent on one person physical assist for bathing and had a BIMS (Brief Interview for Mental Status) score of 6, which indicated the resident had severe cognitive impairment. Review of Resident #37's care plan dated 12/28/21 indicated the resident had a risk for decreased ability to perform Activities of Daily Living (ADL's) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, location and toileting related to terminal prognosis of severe protein calorie malnutrition, Alzheimer's, Dementia, and HTN In an interview on 02/10/22 at 10:20 a.m. with Staff A, RN, Unit Manager, she revealed that the resident's granddaughter took the resident into the shower and proceeded to shower her. Staff A said when she became aware, she was in a rush to ensure that the resident did not fall or have an incident, and she did not close the door or the curtain. She reported that all resident's privacy should be ensured. Based on observations, staff interviews, and record review, the facility failed to 1. ensure privacy of resident medical information for seven (Residents #4, #11, #50, #54, #55, #74, and #336) of 45 residents and 2. ensure privacy during a shower for one (Resident #37) of 45 residents. Findings included: 1. On 2/8/2022 at 10:30 a.m., the main dining room was observed with eight tables that were used for both activities and dining. The room door was wide open and two residents self propelled their wheelchairs into the room and positioned themselves at various tables. The first table when entering the room was observed with a stack of papers, a notebook electronic device, an electronic mobile phone device, and a computer mouse device. The stack of paperwork and electronic devices were found to be unattended by staff. The stack of papers and devices were within reach and visible to anyone who entered the room. Observations revealed the paperwork included Medication Administration Records, Medication Order sheets, and other resident information for Residents #4, #11, #50, #54, #55, #74, and #336. The papers included drug names, diagnoses, room numbers, and resident's date of birth . There were no staff in the room from at least 10:30 a.m. through 10:50 a.m. Photographic evidence was taken. On 2/8/2022 at 10:50 a.m., the Assistant Director of Nursing (ADON) came into the main dining room. She indicated there was supposed to be a team meeting in the dining room but it had been canceled. She was not aware that the information had been left on the table. The ADON confirmed residents were in the room, there were no other staff in the room, and the information was in an area where it could be easily seen. She verified the information had resident names, names of various medications, diagnosis, and room numbers. The ADON revealed they were to always follow HIPPA (Health Insurance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 3 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Portability and Accountability Act) rules and supervise resident information to keep it secure from non medical staff, visitors, and residents. On 2/10/20221 at 10:20 a.m., in an interview with Staff A, [NAME] Unit Manager, she said if it [medical information] was in an electronic device, the device was to be closed and locked when not in use. If there were paper files or documents that had resident medical information on it, they were not to be kept in the open, and should be within the employee's immediate area and away from anyone to see. She said she thought there was going to be a team meeting in the dining room and left the electronic devices and various papers on the table. She confirmed there were residents in the room but were not near the table where she left the information. She confirmed the table where she left the resident information was at the very first table when coming in the only entrance/exit door of the room. On 2/11/2022 at 10:30 a.m. the Assistant Director of Nursing (ADON) provided the HIPPA Security Measures Policy and Procedures with no implementation, or revision date for review. The policy indicated: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable and/or records that are in electronic format. Policy Explanation and Compliance Guidelines: #2 The facility will designate a security official who is responsible for the development and implementation of the facility's security policies and procedures. #3 Only appropriate employees will have access to electronic protected health information. These employees will receive appropriate training related to the security of the information for which they have access. #7 Assures the business associate will appropriately safeguard the information and agrees to report any security incident to the facility. #8 Physical safeguards will be implemented that limit physical access to its electronic information and agrees to report any security incident to the facility. #9 The facility will implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access EPHI. All workstations that access EPHI will have restricted access. On 2/11/2022 at 3:30 p.m., an interview with the Nursing Home Administrator, who was responsible for the Quality Assurance program, confirmed that staff should not leave resident medical information unattended and out in the open for anyone to view. He said all staff upon hire were provided with HIPPA training and resident information security. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 4 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to response to a grievance in a timely manner for one (Resident #61) of forty five sampled residents. Finding Included: An interview on 02/08/22 at 10:37 a.m. with Resident #61 revealed that when she went to the hospital back in December, came back to the facility, and was in isolation for 2 weeks, she wrote a check for $450. She reported that she gave the check to social services in December 2021, and had been given multiple excuses like because of COVID they were not going to the bank. She stated she had been relying on her friend to get things for her because she had not been able to get her money. The resident reported that she spoke with the Business Office Manager (BOM) about her money in January 2022 who stated that she had no money. The resident reported that her statement indicated that the check had been cashed on January 13th 2022. Resident #61 said the Assistant Business Office Manager (ABOM) recently had come to apologize to the resident and stated it was her fault. The resident reported there was nothing the facility could do to fix the problem. She reported that she found it embarrassing that she had to order things she needed through her friend. She reported that when she got a meal outside of the facility, she could only afford to get a kids meal. When the staff brought back her meal from an outside source, the staff stated she did not have enough money and the facility had to cover the taxes. Review of the resident's record revealed that she was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included fracture of the right tibia, Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, and had a Brief Interview for Mental Status (BIMS) dated 12/14/21 with a score of 14 (Cognitively intact). On 02/11/22 at 01:24 p.m., the Social Service Director said a grievance was completed but she was not aware of how long the incident had been pending. Interview on 02/11/22 at 1:34 p.m. with the BOM revealed that the resident came to her a week ago saying that she gave a check to the ABOM a month ago and that she did not have any money in her trust account. She reported that she checked the residents trust account and found no funds. She told the resident that she would check into it. She reported that she found out that the ABOM put the money in the wrong account. An interview on 02/09/22 at 2:29 p.m. with the BOM revealed she was aware of an issue related to the resident and her funds, but she was unsure of the date. She reported that the check was for $450 and it was put into the resident's liability account instead of her trust account. She reported that the check was going to be sent back to the facility. The BOM reported that the corporate office did the billing and AP Accounts payable. She reported that as of right now Resident #61 had $8.08 in her account. She reported that the resident got $130 a month from Medicare. The resident took care of her own finances and wrote the facility the check for the trust account, so she could get funds out when she needed it. She reported that the check in the amount of $450 was overnighted this morning. An interview on 02/09/22 at 2:41 p.m. with the BOM revealed that the ABOM, took over when she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 5 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out, and was the one who cashed the check. She reported that the check was given to a staff member for delivery to the business office, however the ABOM was unsure as to which employee delivered the check. The BOM reported that herself and the ABOM were responsible to receive the resident's checks and cashing them. She reported that the statement was emailed to her which indicated what funds were going into the liability account. The BOM said the resident alerted her and the ABOM of the issue at the end of January when she tried to pull money out of the trust account and the $450 was not there but, her statement indicated that the check had been cashed. The BOM reported that she contacted the person at corporate who handled facility's cash posting and she told them they had to do a refund request form. The BOM reported that the conversation for the refund with corporate happened on 02/03/22 and that she completed an audit but was unable to provide documentation of an audit to Resident #61's funds. In an interview on 02/09/22 at 2:59 p.m. with the BOM and the ABOM, the ABOM said she did not recall the staff member that gave her the resident's check. She deposited the check on the first or second week of January. When she got the checks, she put them in the safe and would then deposit the checks into the accounts. The ABOM reported that she put the check into the account. She reported that the residents state what account they want the checks placed into. She did not know what account to place this check into, because it was not personally given to her by the resident. The ABOM reported that she assumed it was for the resident's liability account. For this particular resident the BOM reported that she knew if the check was under $2800 it went into the trust account. She reported that the resident had her own checking account, debit card, and did her own shopping. The BOM reported that the expectation was to go check with the resident to confirm which account the check was going into. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 6 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide Activities of daily Living (ADL) tasks for one (Resident #41) of 45 sampled residents related to unwanted facial hair. Residents Affected - Few Findings included: Review of Resident #41's medical record revealed that the resident was admitted to the facility on [DATE] and had diagnoses that included Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, dementia without behavioral disturbances, and traumatic amputation at level between knee and ankle. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident required extensive assist of 1-person physical assist to complete personal care. Review of the quarterly MDS dated [DATE] revealed that the resident required extensive assist of 2-person physical assist to complete personal care. Review of Resident #41's care plan dated 6/24/20, with the most recent revision date of 3/9/21, indicated a risk for ADL related declines or complications due to hx DM (Diabetes Mellitus), hx Depression. She needs extensive to total assist with her ADL's. Future decline is expected due to Dementia. Observations of Resident #41 on 02/08/22 at 10:54 a.m. revealed the resident lying in bed. The resident was noted to have white facial hair on her chin. Observations of Resident #41 on 02/09/22 at 3:45 p.m. revealed the resident lying in bed and was noted with white facial hair on her chin. Observations of Resident #41 on 02/10/22 at 8:36 a.m. revealed the resident lying in bed. The resident was noted to still have white facial hair on her chin. An interview with the resident at this time revealed that she did not like the hair and had to get it shaved. Observations of Resident #41 on 02/10/22 at 10:48 a.m. revealed the resident sitting up in her wheelchair in the day room watching TV. The resident was noted to be dressed and groomed for the day. It was noted that the resident still had white facial hair on her chin. An interview on 02/10/22 at 10:50 a.m. with Staff S, Licensed Practical Nurse (LPN), revealed that her expectation was that staff provide ADL's to include making sure the resident's face was clean, washed, face shaved, and nails filed. She reported that this needed to be done every morning with shaving done on shower days and as needed. An interview on 02/10/22 at 11:02 a.m. with Staff P, Certified Nursing Assistant (CNA), (Agency Staff), revealed that she had worked in the facility for three weeks and was familiar with the resident. She reported that she got the resident up this morning and provided ADL's. She reported that the resident did have facial hair and the resident declined for the hair to be shaved as it would grow back thicker. She reported that she did not ask the resident if she would like the facial hair tweezed as the facility did not have or use tweezers only razors for shaving. Staff P reported that she did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 7 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 not report this to the nurse but knew she should have. Level of Harm - Minimal harm or potential for actual harm An interview on 02/10/22 at 11:07 a.m. with Staff S, LPN revealed that she was not aware that the resident had facial hair and was not aware of the resident's refusal. She reported that the CNA should have shared that information to allow for alternate interventions to ensure that the resident was appropriately groomed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 8 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 one (Resident #74) of 45 residents observed received care and services related to a brace and dry flaky feet. Residents Affected - Few Findings Included: During observation and an interview with Resident #74 on 2/9/22 at 1:00 p.m., he stated he had not had a shower in a couple of weeks and no one took his socks off or checked his skin under his brace. Resident #74 stated that the therapist put something under his brace at the bottom of his leg to assist with the rubbing he was getting from the brace, but it had not been checked since then and his feet were extremely itchy. During an interview with Staff F, CNA on 2/9/22 at 1:10 p.m., she confirmed she had not given the resident a shower and had not removed his socks to check his feet or apply lotion as he had not asked her do that. Staff F, CNA removed his socks and white flaky skin dropped to the floor. Staff F, CNA confirmed the residents feet were really dry and needed lotion. During an interview and observation on 2/10/22 at 1:18 p.m. with Staff I, LPN and Resident #74, Staff I, LPN confirmed the resident's feet were extremely dry. Staff I, LPN confirmed the resident's skin was checked weekly with the brace, not daily and stated the resident did not have orders for care of the brace. Staff I, LPN confirmed the resident should have showers or baths weekly and his feet should not be this dry. Staff I, LPN removed the brace to look at the resident's skin. She removed the pad from the resident's lower leg and stated she was unsure why it was there or where it came from. The resident stated the pad was from therapy to relieve pressure from the brace. Staff I, LPN placed the brace on the right leg incorrectly. The resident tried to tell the nurse she had the brace on wrong but the nurse strapped the brace on with the hinge below the knee and the strap across the residents scabbed knee. During an interview on 2/10/22 at 2:00 p.m. with the Director of Rehab (DOR), she stated the resident was off case load and that he was taught how to apply and remove his brace by the therapist. The DOR stated the nurses should have been given an inservice on how to apply and remove the hinged brace but did not find any information confirming the inservice. The DOR confirmed the resident was off caseload for about 7 days. On 2/10/22 at 4:17 p.m., Resident #74 was observed sitting in his wheel chair with the right leg brace not in the correct position. The resident stated the nurse nor therapy had come back to adjust the brace. The hinge of the brace was observed below the knee and should be at the bend of the knee. During observation and interview of resident #74 on 2/11/22 at 10:58 a.m. with the DOR, she confirmed the residents brace was in the wrong place and would rub the scab off the wound since the strap was placed over the healing scab. The DOR adjusted the resident's brace and confirmed the resident's brace should have been corrected yesterday. The DOR stated the nurses were inserviced on how to put on a brace and confirmed an order should be in the computer as of 2/11/22. Review of Resident #74's record revealed the resident was admitted for presence of right artificial knee joint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 9 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the physician orders revealed the resident was weight bearing as tolerated to right lower extremity with hinge knee brace dated 12/1/21. Weight bearing as tolerated with hinge knee brace locked in extension dated 12/15/21. Review of the physician orders did not include to check skin under brace or orders for the care of the brace. Residents Affected - Few Review of the care plan, last review date 1/31/22, revealed the resident was at risk for alterations in comfort related to a diagnosis of ankylosing spondylitis of the spine. Interventions include to assist with activities of daily living and comfort measures. Assist to a position of comfort utilizing pillows as appropriate. Provide assist and comfort measures such as repositioning. Therapy as ordered. The resident is at risk for falls related to injury related to difficulty walking related to weight bearing as tolerated to right lower extremity and use of immobilizer. Interventions included anticipate needs, provide prompt assistance. The resident is at risk for decreased ability to perform activities of daily living in bathing, grooming, personal hygiene, and bed mobility. Interventions include assist with immobilizer to right lower extremity as needed. Assist of one for personal hygiene and grooming. Weight bearing as tolerated with knee brace. Resident is at risk for skin break down related to impaired mobility needing assistance with transfers and mobility to right lower extremity impairment with use of immobilizer. Interventions include to complete weekly skin assessment. Monitor skin during bathing and daily, especially over bony prominence's. Monitor skin for signs and symptoms of skin breakdown, related to cracking. Off load heels while in bed as resident allows. Review of minimum data set (MDS) dated [DATE] for Section C, revealed a Brief Interview of Mental Status (BIMS) score of 15, representing no cognitive impairment. Review of section G, functional status revealed the resident's bed mobility required extensive assistance and two person assist. Dressing requires extensive assistance and two person assist. Bathing requires total assistance and one person assistance. During an interview with Staff K, Unit Manager on 2/11/22 at 11:30 a.m., she confirmed the resident should be bathed as scheduled and the staff should know how to apply his brace appropriately and skin should be checked under the brace as ordered. Review of facility policy titled, Provision of physician ordered services from The Compliance store revised 11/17, one page, revealed: The purpose of this policy is to provided a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 10 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident #49) of three sampled residents received catheter care related to a urinary catheter that was cloudy with sediment observed stuck to the tubing. Findings Included: On 2/8/22 at 12:00 p.m., an observation of Resident #49 revealed his urinary catheter tubing was cloudy, gray, and not dated. The resident stated it had not been changed for at least two months and he was currently being treated for a urinary tract infection. The resident said his catheter had not been flushed or changed and he was worried about the way the tubing looked. Observation of Resident #49's tubing on 2/10/22 at 1:10 p.m. revealed the tubing cloudy and gray with sediment. The resident stated no one had looked at the catheter or flushed it. During an interview and observation on 2/10/22 at 1:18 p.m. with Staff I, LPN, she confirmed the catheter did not have orders as to when to change it and she was unaware of the facility policy. Staff I, LPN confirmed the catheter was cloudy and should be changed. Staff I, LPN confirmed she could not see where the catheter had been changed since readmission on [DATE]. During an interview with Staff F, CNA on 2/10/22 at 10:39 a.m., she stated the resident's catheter was cleaned with soap and water on her shift and stated his catheter tubing looked like it needed to be changed but the nurses had not changed it. Review of physician orders revealed: catheter bag: may convert drainage system to leg bag while up and as needed dated 12/29/21. Catheter care with soap and water dated 12/29/21. Change catheter drainage bag as needed for blockage or leakage as needed dated 12/29/21. Change catheter size 16 french and 10 ml, as needed if dislodged, clogging or leaking as needed, dated 12/29/21. Change catheter size 16 french and 10 ml, every 30 days and as needed if dislodged, clogged or leaking as needed, dated 2/10/22. Change catheter size 16 french and 10 ml, every 30 days as needed if dislodged, clogged or leaking every evening shift for urinary retention dated 2/10/22. Irrigate Foley catheter with 30 ml normal saline as needed for blockage or sluggishness as needed dated 12/29/21. Review of treatment administration record since 12/24/21 did not show the catheter was changed or flushed. Review of the care plan revealed the resident had a suprapubic urinary catheter due to neurogenic bladder. Interventions included catheter care twice a day and as needed. Keep catheter off the floor. Monitor for signs and symptoms of infection and report to physician. Monitor urine for sediment, cloudy, odor, blood and amount. Review of the Minimum Data Set (MDS) section C for cognitive patterns dated 12/31/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which meant no cognitive impairment. Section H bladder and bowel included indwelling catheter. During an interview with Staff K, Unit manager (UM) on 2/11/22 at 11:35 a.m., she confirmed she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 11 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete observed the cloudy tubing of the urinary catheter and that the order should have been put in the computer to change the catheter every 30 days. Staff K, UM confirmed the resident had a urinary tract infection and the stated the orders were put in on 2/10/22 to get a new catheter. Review of facility policy titled, Catheter Care revised 11/17, The compliance store, revealed: It is the policy of this facility to ensure the residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 1. Catheter care will be performed every shift and as needed by nursing personnel. Event ID: Facility ID: 105320 If continuation sheet Page 12 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 one (Resident # 81) of three residents observed on oxygen, received oxygen as ordered and in a sanitary manner Residents Affected - Few Findings Included: On 2/8/22 at 10:15 a.m., an observation of Resident #81 revealed her sitting in a wheel chair with her oxygen tubing stuck under her wheel chair and dragging across her bedroom floor. On 2/10/22 at 3:05 p.m., an observation of Resident #81 revealed her oxygen tubing bunched up under the wheel chair wheel and under her feet. The resident stated she was unsure why she had so much tubing and said she got stuck in the tubing with her wheel chair. The oxygen setting was observed set at three liters. During an interview with Staff member F, CNA on 2/10/22 at 10:43 a.m., she confirmed the extra long tubing was new for the resident and stated Resident #81 usually did not use the oxygen but had been lately. Staff F, CNA confirmed the setting at 3 liters. Review of the physician's order dated 1/20/22 revealed change oxygen tubing and bag cover every Sunday 11:00 a.m. to 7:00 p.m., label tubing with tape every Sunday. Check oxygen filter every Sunday dated 1/20/22. Oxygen 2 liters via nasal cannula as needed for shortness of breath dated 12/21/21. Review of treatment administration orders dated 12/21/21 revealed oxygen at 2 liters via nasal cannula as needed for shortness of breath. Review of the minimum data set (MDS), dated [DATE], section O, respiratory treatments did not reveal the resident on oxygen therapy. During an interview with Staff K, Unit Manager (UM) on 2/11/22 at 11:31 a.m., she confirmed the resident used a long oxygen cord due to not leaving her room and only going to her doorway. Staff K, UM stated they attached a long cord to the resident's oxygen concentrator so she could self propel in her room with the tubing following her. Review of facility policy titled, Oxygen administration, The compliance store, revised 11/17, revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. the type of oxygen delivery system. b. When to administer such as continuous or intermittent and or when to discontinue. Equipment setting for prescribed flow rates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 13 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 #238) of one resident sampled for Dialysis was monitored pre and post Dialysis services. Residents Affected - Few Findings included: Resident #238 was admitted on [DATE]. The admission Record identified diagnoses not limited to End Stage Renal Disease, Type 2 Diabetes Mellitus with hyperglycemia, and chronic pulmonary edema. Resident #238 was observed, on 2/9/22 at 2:57 p.m. lying in bed and was able to reposition self without assistance. The resident was observed, on 2/10/22 at 1:51 p.m., sitting on the side of the bed speaking on the telephone. The Order Summary Report, active as of 2/10/22, indicated Resident #238 was to receive Dialysis treatments on Tuesday, Thursday, and Saturdays at 4:00 p.m. A review of the calendar for February 2022 indicated that the resident was to receive Dialysis on 2/8 and 2/10/22. The Assessments tab of the electronic record indicated that a skilled nurse's note was last completed on 2/8/22. The skilled nursing note that corresponded with the assessment was completed at 9:00 p.m. on 2/8/22. The note indicated that the resident's temperature was 97.3 F on 2/8, pulse 78 on 2/6/22 at 7:04 a.m., respiration was 20 on 2/6/22 at 7:04 a.m., blood pressure was 132/72 on 2/6/22 at 7:04 a.m. The note did not indicate the condition of the Dialysis access site in the upper right chest. The progress notes identified that the resident returned from Dialysis at 11:02 p.m. on 2/8/22, was alert and oriented, voiced all needs, no signs of distress, and denied pain. The review of nursing notes, on 2/10/22 at 2:47 p.m., did not include any further notes. The Weights/Vital Signs electronic tab indicated the last blood pressure, pulse, and respiration was taken on 2/6/22, two days prior to the residents dialysis treatment on 2/8/22. The care plan for Resident #238 indicated that the resident had potential for complications related to dialysis. Diagnosis: End Stage Renal Disease (ESRD). The interventions instructed staff to monitor/record/report to MD dialysis complications such as air embolism (hypotension, chest pain, cough, cyanosis, weak pulse), bleeding, decreased output (pulse weak and/or irregular, fluid overload, cerebral edema, local or systemic infection. Staff W, Licensed Practical Nurse (LPN) stated, on 2/10/22 at 2:00 p.m., the Dialysis center did not allow them [the facility] to send the communication form with Resident #238 due to COVID-19. The staff member stated the Dialysis center would send information with pre and post weights and other information a couple of days after the visit. On 2/10/22 at 3:28 p.m., Staff S, LPN, stated that vital signs were taken prior to the resident leaving for Dialysis. Staff S stated that a Dialysis Communication form was completed before and after Dialysis visits and did not know where the facility put the forms after the resident returned. An interview was conducted, on 2/10/22 at 5:39 p.m. with the Assistant Director of Nursing (ADON) and Staff U and V, Minimum Data Set Coordinators (MDS). The staff members stated dialysis should be sending a condition form from the visit which was uploaded into the record, and the facilty should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 14 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few conducting a pre and post assessment on the resident. Staff V reviewed Resident #238's clinical record and confirmed that there was no pre- or post progress notes regarding Dialysis. She informed the ADON that the facility should have an electronic Dialysis communication form. The policy, Hemodialysis, undated, indicated that the facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. The Compliance Guidelines indicated The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: - a. Timely medication administration (initiated, held, or discontinued) by the nursing home and/or dialysis facility; - b. Physician /treatment orders, laboratory values, and vital signs; - c. advance Directives and code status; specific directives about treatment choices; and any charges or need for further discussion with the resident/representative, and practitioners; - d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as orders; - e. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; - f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site. - g. Changes and/or declines in condition unrelated to dialysis. - h. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facilty. The Nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 15 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0885 Report COVID19 data to residents and families. 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 notify five (#22, #32, #41, #85, and #186) out of five sampled residents and their representatives in a timely manner of the positive COVID-19 results within the facility. Residents Affected - Some Findings included: A review of the positive COVID-19 cases within the facility identified that Resident #32 tested positive on 1/29/22. A review of Resident #22's Quarterly Minimum Data Set (MDS) identified a Brief Interview of Mental Status (BIMS) score of 10, indicating a moderate impairment of cognition. The clinical record indicated that a call had been placed, on 2/1/22 at 3:02 p.m., to family member to notify of the most recent COVID 19 number in the facility. A review of Resident #32's admission Record identified the residents' responsible party was a family member. The clinical record indicated that on 2/1/22 at 3:55 p.m. a message left for family member to notify of the most recent COVID-19 numbers in the facility. The review of Resident #41's Annual MDS, dated [DATE], identified that the resident did not have a BIMS score. The clinical record indicated that on 2/1/22 at 4:29 p.m., a call placed to family member to notify of the most recent COVID-19 numbers in the facility. The review of Resident #85's Quarterly MDS, dated [DATE], did not include a BIMS score for the resident as they were rarely or never understood. The clinical record indicated that on 2/1/22 at 4:28 p.m., call placed to family member to notify of the most recent COVID-19 numbers in the facility. On 2/8/22 at 10:38 p.m., the family member of Resident #186 was interviewed as the resident was deemed non-interviewable. The family member stated she had not been informed by the facility that a resident had tested positive for COVID-19 only that three staff members were recovering from the virus. She stated she came to visit almost daily. The clinical record identified that, on 2/1/22 at 3:51 p.m., call placed to family member to notify of the most recent COVID-19 number in the facility. No answer at phone number, unable to leave message. On 2/8/22 at 12:59 p.m., the Director of Nursing (DON) stated that documentation of family notifications (related to COVID-19) were done by the Social Worker (SW) and that a note was put in the clinical record at that time. She stated that sometimes the SW would delegate to others for notifications. The Nursing Home Administrator reviewed Resident #22's clinical record regarding family notifications of COVID-19 and confirmed the documentation on 2/1/22. He reviewed a calendar and stated that 1/29 (the day Resident #32 tested positive) was a Saturday and that 2/1/22 was a Monday. The policy, Coronavirus Surveillance, implemented 12/4/20 and revised 11/15/21, indicated Residents and representatives will be kept up to date on the conditions inside the facility related to COVID-19. Minimum information to be reported: I. - Within 12 hours and subsequently: the occurrence of a single confirmed infection of COVID-19, or 3 or more residents or staff with new onset of respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 16 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0885 symptoms that occur within 72 hours. 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: 105320 If continuation sheet Page 17 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on review of test results, review of the staff schedule for 2/8/22, and interviews, the facility failed to test 26 out of 65 staff members twice weekly for COVID-19 per the community transmission rate (high) for the period of 2/3 - 2/9/22. Residents Affected - Some Findings included: A cross reference review of the staff roster, 2/7 and 2/8/22 staff COVID-19 test results, the working schedule for staff members in all departments for 2/8/22, and the logs of COVID positive staff from November 2021 through January 2022 indicated that the following staff members did not test on 2/7 or 2/8/22 prior to working their shift on 2/8/22: - Staff Member E, Licensed Practical Nurse (LPN) - Staff Member F, Certified Nursing Assistant (CNA) - Staff Member R, Maintenance Assistant - Staff Member T, Speech Language Pathologist (SLP) - Staff Member Y, Housekeeping - Staff Member Z, Housekeeping - Staff Member AA, Housekeeping - Staff Member BB, Certified Occupational Therapy Assistant/Director of Rehab (DOR) - Staff Member CC, Chef - Staff Member DD, Chef - Staff Member EE, Dietary - Staff Member FF, Dietary - Staff Member GG, Dietary - Staff Member HH, Dietary - Staff Member II, Dietary - Staff Member JJ, nurse - Staff Member KK, nurse - Staff Member LL, CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 18 of 19 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 105320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525 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 0886 - Staff Member MM, CNA Level of Harm - Minimal harm or potential for actual harm - Staff Member NN, CNA - Staff Member OO, CNA Residents Affected - Some - Staff Member PP, CNA - Staff Member QQ, CNA On 2/9/22 at 3:45 p.m., the Director of Nursing (DON) confirmed that the facility tested twice weekly, Monday and Thursday's due to the community transmission rate. The DON stated staff results from Monday had not been reviewed. She stated that the facility attempted to test 100% of staff but it was difficult as some staff only worked weekends and it was hard to get them to come in and test. The DON stated that the facility used to take untested staff off the schedule but because of staffing issues they were not able to do that anymore. On 2/9/22 at 3:58 p.m., the DON provided a testing log and stated that the log was what she used to mark who tested and test results. She stated changes to the log were not done per the staff rosters but off the top of my head. On 2/10/22 at 10:10 a.m., Staff T reported that testing was done once a week and she had tested negative today. On 2/10/22 at 10:22 a.m., Staff E stated staff were tested twice weekly, Monday and Thursday's. The staff member reported that the last time she tested was Monday, 2/7/22. A review of the test results from 2/7 and 2/8/22 obtained from the DON on 2/9/22 did not include test results for Staff E. On 2/10/22 at 10:25 a.m., Staff R reported that he was tested one time last week and had been tested this morning, 2/10/22. A review of the test results from 2/7 and 2/8/22 did not include test results for Staff R. During an interview on 2/11/22 at 11:40 p.m., the Assistant Director of Nursing stated that staff testing had been the responsibility of the DON. She reported that the DON did some of the tests, she did some of the tests, the Social Service Assistant did some tests, and the nurses on the weekends and nights also tested staff. The ADON stated that the previous DON ensured staff were getting tested. The policy, Coronavirus Testing, undated, identified All staff and residents that test negative will be retested every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The policy, COVID-19 Testing of Residents and Staff, reviewed/revised 8/20/21, identified that when the Community COVID-19 Activity was High, the county positivity rate in the past week was >10%, the minimum testing frequency for staff was twice a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 19 of 19