Health inspection·December 17, 2025

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 3:08 p.m. Staff H, CNA said on [DATE] she found Resident# 3's DNRO form in the Code Status Binders. Upon entering Resident #3's room, Staff B, RN was crawling off [Resident #3's] bed. Staff H, CNA stated [Staff B, RN] did not check if the resident had DNR orders.During an interview on [DATE] at 11:48 a.m. Staff E, LPN said on [DATE] she was standing by the medication cart when two or three CNAs came running around the corner and said Resident #3 was not breathing. She said the CNAs asked about the resident's code status. Staff E, LPN said she did not hear a code announced over the facility's overhead paging system. She stated she checked Resident #3's orders and found a Do Not Resuscitate (DNR) order in the electronic health record (EHR). She stated she immediately called staff. Staff E, LPN stated that upon entering Resident #3's room staff were looking in the CPR binder for the DNRO form.During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said her employment at the facility began mid-September of 2025. During orientation education and training was provided primarily through computer modules. Staff B, RN said during orientation, the facility did not provide education or training related to Code Blue procedures or DNR procedures. She was not trained how to locate a resident's code status in the computer. She did not know about the code blue binder until after Resident #3 was found not breathing and without a pulse on [DATE].During an interview on [DATE] at 3:27 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Nurse Coordinator (RNC) the DON said Staff B, RN did not check the resident's code status before initiating Cardiopulmonary Resuscitation (CPR). The DON said the facility's expectation is for two nurses to verify a resident's code status in the EHR and the Code Status Binders before initiating CPR. The DON confirmed Resident #3's wishes for DNR was not honored.A review of the facility policy titled Advanced Directives Code Status, issued 1/2024, showed the following:Standard : It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations.Definitions:Code Status: Listed in the resident's medical chart. Obtained upon admission and reviewed at least quarterly and/or upon resident/representative's request. Identifies resident's wishes for medical intervention should the resident heart stop beating and/or should the resident stop breathing.Do Not Resuscitate (DNR): A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally, if their heart stops beating and/or they stop breathing.Admission/ readmission: Code Status verified upon admission with resident/representative by admitting nurse.-Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD.)DNR: Admitting nurse must review with resident/resident representative with a witness present (preferably another nurse of social services).-Admitting nurse obtains order from physician (MD) [physician].-Initiates yellow DNR form.-Yellow DNR form will be signed by the resident/resident representative and the two nurses who obtained the order from physician (MD).-Order entered [Electronic Health Record] verbal physician order is recognized as the resident's code status.-Yellow DNR form will be copied and social services notified of the new DNR.-Yellow DNR form will be expedited to the physician for final signature.OR-Resident arrives to the facility with yellow DNR form in place either from hospital /community.-Admitting nurse must confirm with the resident/resident representative choice for DNR.-Nurse obtain orders from the physician.-Order entered into [EHR].-Yellow DNR form is scanned into the [EHR] by a designated facility representative .-Yellow DNR form is placed in the Code Status Binders at all nurses' stations .A review of the facility policy titled Resident Rights, revised 1/2024, showed the following:Policy: The facility will inform the resident both orally and in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 2 of 16 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 12/17/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Section-Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including2b. The right to participate in the development and implementation of his or her person-centered plan of care .2e. the right to request, refuse, and/ or discontinue treatment, to participate in experimental research, and to formulate an advance directive. The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional Interdisciplinary team (IDT) members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On 11/17-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] observed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education regarding two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 3 of 16 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 12/17/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE]. On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes. Event ID: Facility ID: 105320 If continuation sheet Page 4 of 16 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 12/17/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one resident (#3) out of three residents sampled.On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. The facility's failure to honor Resident #3's DNR status deprived her of a dignified death and likely resulted in severe pain and organ damage. Additionally, Resident #3 could not express her reaction to this event. Applying the reasonable person concept, Resident #3 would likely experience serious psychosocial harm by being resuscitated against her wishes. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. The scope and severity of F600 was reduced from J to a D which is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings included:During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said on [DATE] at approximately 6:30 p.m. Resident #3 was observed non-responsive and without a palpable pulse. Staff B, RN stated she instructed the Certified Nursing Assistant (CNA) present to call a code. Staff B, RN said the staff response time was slower than expected and she initiated chest compressions. She stated after performing two chest compressions, she was informed the resident had a DNR order in place and she discontinued chest compressions.A review of Resident #3's admission record showed an initial admission date of [DATE], with diagnoses including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, Stage 2 chronic kidney disease, anxiety, depression, insomnia, hypertension and Hodgkin's Lymphoma.A review of Resident #3's order summary report as of [DATE], showed a Do Not Resuscitate (DNR) order, dated [DATE].A Review of Resident #3's medical record revealed the presence of a valid State of Florida Do Not Resuscitate Order (DNRO) (Form DH 1896), dated [DATE]. The DNRO was present and available to guide staff in honoring the resident's end-of-life wishes when discovered on [DATE] not breathing and without a pulse.A review of Resident #3's annual Minimum Data Set (MDS) assessment, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment.A review of Resident #3's care plan showed a focus area as follows: [Resident #3] has an established DNR (DO NOT RESUSCITATE) order in place, initiated on [DATE], created by the Social Worker.The interventions for this care plan focus included, Activate resident's advanced directives as indicated.On [DATE] at 11:33 p.m. a progress note authored by Staff A, Licensed Practical Nurse (LPN) showed the following: Staff approached me around 1830 [6:30 p.m.] and informed me that resident was not breathing fellow nurse and I pronounced time of death at 1838 [6:38 p.m.] as resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 12:30 p.m. Staff F, CNA stated upon entering Resident #3's room she [Resident #3] was passed out. Staff F, CNA said, Staff B, RN was on top of [Resident #3] giving two chest pumps, she got off quick. Staff B, RN directed me to call 911 and I hurried up to call. Staff F stated later Staff A, LPN told her CNAs are not allowed to call 911.During an interview on [DATE] at 11:36 a.m. Staff D, CNA, assigned to care for Resident #3 on [DATE], stated upon picking up Resident #3's dinner tray Resident #3 was not responding. Staff D, CNA called Staff B, RN to the resident's room. Staff D, CNA stated Staff B, RN provided one or two chest compressions before stopping. Staff D stated Staff B, RN appeared to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 5 of 16 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 12/17/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few having difficulty breathing and Staff B said she was having an asthma attack.During an interview on [DATE] at 11:48 a.m. Staff E, LPN said on [DATE] she was standing by the medication cart when two or three CNAs came running around the corner and said Resident #3 was not breathing. She said the CNAs asked about the resident's code status. Staff E, LPN said she did not hear a code announced over the facility's overhead paging system. She stated she checked Resident #3's orders and found a Do Not Resuscitate (DNR) order in the electronic health record (EHR). She stated she immediately called staff. Staff E, LPN stated that upon entering Resident #3's room staff were looking in the CPR binder for the DNRO form.During an interview on [DATE] at 1:25 p.m., Staff B, RN stated she began employment at the facility mid-[DATE]. She stated during orientation the facility provided general orientation through an online platform. Staff B, RN said the facility did not provide education or training related to CPR or DNR procedures, instruction on how to locate a resident's code status in the computer system, or the location and contents of the CPR binder. She stated after Resident #3 expired, she learned the DNRO forms were in the CPR Blue binders.During an interview on [DATE] at 3:27 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Nurse Coordinator (RNC) the DON said Staff B, RN did not check the resident's code status before initiating Cardiopulmonary Resuscitation (CPR). The DON said the facility's expectation is for two nurses to verify a resident's code status in the EHR and the CPR Blue book before initiating CPR. The DON confirmed Resident #3's wishes for DNR were not honored.During an interview on [DATE] at 12:40 p.m. Resident #3's APRN said on [DATE] was notified through a Health Insurance Portability and Accountability Act (HIPAA) compliant messaging line chest compressions were performed on Resident #3. The APRN said, If a resident is a DNR do what the family wishes.During an interview on [DATE] at 12:47 p.m. Resident #3's physician said the expectation for residents with DNR status, is no interventions should be performed if the resident is pulseless; no resuscitative measures no heroics are to be started.A review of the facility policy titled Cardiopulmonary Resuscitation (CPR), implemented 11/2020, showed the following:Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR).Policy Explanation and Compliance Guidelines:1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR.2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and:a. In accordance with the resident's advance directives, orb. In the absence of advance directives or a Do Not Resuscitate order; andc. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) .A review of the facility policy titled Resident Rights, revised 1/2024, showed the following:Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.Section - Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including2b. The right to participate in the development and implementation of his or her person-centered plan of care .2e. the right to request, refuse, and/ or discontinue treatment, to participate in experimental research, and to formulate an advance directive.A review of the facility policy titled Abuse, Neglect and Exploitation, revised [DATE], showed the following:Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 6 of 16 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 12/17/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few written policies and procedures that prohibit and prevent abuse, neglect Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation andCompliance Guidelines: The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect .The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On 11/17-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] observed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE].On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 7 of 16 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 12/17/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes. Event ID: Facility ID: 105320 If continuation sheet Page 8 of 16 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 12/17/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, interviews and record review, the facility failed to ensure the residents' wishes were honored related to Do Not Resuscitate (DNR) orders for one (#3) of three residents sampled.On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. The scope and severity of F678 was reduced from J to a D which is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings included:During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said on [DATE] at approximately 6:30 p.m. Resident #3 was observed non-responsive and without a palpable pulse. Staff B, RN stated she instructed the Certified Nursing Assistant (CNA) present to call a code. Staff B, RN said the staff response time was slower than expected and she initiated chest compressions. She stated after performing two chest compressions, she was informed the resident had a DNR order in place and she discontinued chest compressions.A review of Resident #3's admission record showed an initial admission date of [DATE], with diagnoses including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, Stage 2 chronic kidney disease, anxiety, depression, insomnia, hypertension and Hodgkin's Lymphoma.A review of Resident #3's order summary report as of [DATE], showed a Do Not Resuscitate (DNR) order, dated [DATE].A Review of Resident #3's medical record revealed the presence of a valid State of Florida Do Not Resuscitate Order (DNRO) (Form DH 1896), dated [DATE]. The DNRO was present and available to guide staff in honoring the resident's end-of-life wishes when discovered on [DATE] not breathing and without a pulse.A review of Resident #3's annual Minimum Data Set (MDS) assessment, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment.A review of Resident #3's care plan showed a focus area as follows: [Resident #3] has an established DNR (DO NOT RESUSCITATE) order in place, initiated on [DATE], created by the Social Worker.The interventions for this care plan focus included, Activate resident's advanced directives as indicated.A review of Resident #3's care plan meeting minutes, dated [DATE] showed: Advance Directive: DNR.On [DATE] at 11:33 p.m. a progress note authored by Staff A, Licensed Practical Nurse (LPN) showed the following: Staff approached me around 1830 [6:30 p.m.] and informed me that resident was not breathing fellow nurse and I pronounced time of death at 1838 [6:38 p.m.] as resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 11:36 a.m. Staff D, CNA, assigned to care for Resident #3 on [DATE], stated upon picking up Resident #3's dinner tray Resident #3 was not responding. Staff D, CNA called Staff B, RN to the resident's room. Staff D, CNA stated Staff B, RN provided one or two chest compressions before stopping. Staff D stated Staff B, RN appeared to be having difficulty breathing and Staff B said she was having an asthma attack.During an interview on [DATE] at 11:48 a.m. Staff E, LPN said on [DATE] she was standing by the medication cart when two or three CNAs came running around the corner and said Resident #3 was not breathing. She said the CNAs asked about the resident's code status. Staff E, LPN said she did not hear a code announced over the facility's overhead paging system. She stated she checked Resident #3's orders and found a Do Not Resuscitate (DNR) order in the electronic health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 9 of 16 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 12/17/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few record (EHR). She stated she immediately called staff. Staff E, LPN stated that upon entering Resident #3's room staff were looking in the CPR binder for the DNRO form.During an interview on [DATE] at 12:30 p.m. Staff F, CNA said when she entered Resident #3's room the she [Resident #3] was passed out. Staff F, CNA said, she saw Staff B, RN on top of [Resident #3] giving two chest pumps, she got off quick. Staff B, RN directed me to call 911 and I hurried up to call. Later Staff A, LPN told me CNAs are not allowed to 911.During a telephone interview on [DATE] at 3:05 p.m. Staff G, CNA said on [DATE] when Staff E, LPN said Resident #3 was a DNR, I started hollering, she [Resident #3] is a DNR.During an interview on [DATE] at 3:27 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Nurse Coordinator (RNC) the DON said Staff B, RN did not check the resident's code status before initiating Cardiopulmonary Resuscitation (CPR). The DON said the facility's expectation is for two nurses to verify a resident's code status in the EHR and the code status binder before initiating CPR. The DON confirmed Resident #3's wishes for DNR was not honored. The DON said since [DATE] the facility has implemented additional education and training to prevent recurrence. Interventions include instructing staff to Stop, Think, Perform prior to initiating emergency interventions, conducting Code Blue drills, completing one-to-one Code Blue competency validations, and administering post-tests to assess staff understanding. Education was provided to all staff members and included the following topics: abuse, neglect, and exploitation; resident rights; Code Blue procedures; two-nurse verification of code status; adherence to the resident's care plan and physician orders; and timely physician notification. The facility will continue to monitor staff compliance through ongoing audits and competency evaluations.During an interview on [DATE] at 4:16 p.m. with the NHA, Regional Nurse Consultant (RNC), and the Regional Director of Operations (RDO). The NHA said on [DATE] Resident #3's code status was not checked before compressions were performed.During an interview on [DATE] at 12:40 p.m. Resident #3's APRN said on [DATE] was notified through a Health Insurance Portability and Accountability Act (HIPAA) compliant messaging line chest compressions were performed on Resident #3. The APRN said, If a resident is a DNR do what the family wishes.During an interview on [DATE] at 12:47 p.m. Resident #3's physician said the expectation for residents with DNR status, is no interventions should be performed if the resident is pulseless; no resuscitative measures no heroics are to be started.A review of the facility policy titled Cardiopulmonary Resuscitation (CPR), implemented 11/2020, showed the following:Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR).Policy Explanation and Compliance Guidelines:1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR.2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and:a. In accordance with the resident's advance directives, orb. In the absence of advance directives or a Do Not Resuscitate order; andc. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) .A review of the facility policy titled Resident Rights, revised 1/2024, showed the following:Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.Section - Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including2b. The right to participate in the development and implementation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 10 of 16 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 12/17/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few of his or her person-centered plan of care .2e. the right to request, refuse, and/ or discontinue treatment, to participate in experimental research, and to formulate an advance directive.A review of the facility policy titled Abuse, Neglect and Exploitation, revised [DATE], showed the following:Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation andCompliance Guidelines: The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect .A review of the facility policy titled Advanced Directives Code Status, issued 1/2024, showed the following:Standard : It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations.Definitions:Code Status: Listed in the resident's medical chart. Obtained upon admission and reviewed at least quarterly and/or upon resident/representative's request. Identifies resident's wishes for medical intervention should the resident heart stop beating and/or should the resident stop breathing.Do Not Resuscitate (DNR): A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally, if their heart stops beating and/or they stop breathing.Admission/ readmission: Code Status verified upon admission with resident/representative by admitting nurse.-Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD.)DNR: Admitting nurse must review with resident/resident representative with a witness present (preferably another nurse of social services).-Admitting nurse obtains order from physician (MD).-Initiates yellow DNR form.-Yellow DNR form will be signed by the resident/resident representative and the two nurses who obtained the order from physician (MD).-Order entered [Electronic Health Record] verbal physician order is recognized as the resident's code status.-Yellow DNR form will be copied and social services notified of the new DNR.-Yellow DNR form will be expedited to the physician for final signature.OR-Resident arrives to the facility with yellow DNR form in place either from hospital /community.-Admitting nurse must confirm with the resident/resident representative choice for DNR.-Nurse obtain orders from the physician.-Order entered into [EHR].-Yellow DNR form is scanned into the [EHR] by a designated facility representative .-Yellow DNR form is placed in the Code Status Binders at all nurses' stations .The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 11 of 16 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 12/17/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On [DATE]-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] reviewed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE].On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes. Event ID: Facility ID: 105320 If continuation sheet Page 12 of 16 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 12/17/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure nursing staff were competent in identifying and honoring cardiopulmonary resuscitation wishes for one (#3) of three residents sampled On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. The scope and severity of F726 was reduced from J to a D which is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings included:During an interview on [DATE] at 1:25 p.m., Staff B, Registered Nurse (RN), said on [DATE] at approximately 6:30 p.m. Resident #3 was observed non-responsive and without a palpable pulse. Staff B, RN stated she instructed the Certified Nursing Assistant (CNA) present to call a code. Staff B, RN said the staff response time was slower than expected and she initiated chest compressions. She stated after performing two chest compressions, she was informed the resident had a DNR order in place and she discontinued chest compressions.A review of Resident #3's admission record showed an initial admission date of [DATE], with diagnoses including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, Stage 2 chronic kidney disease, anxiety, depression, insomnia, hypertension and Hodgkin's Lymphoma. A review of Resident #3's order summary report as of [DATE], showed a Do Not Resuscitate (DNR) order, dated [DATE].A Review of Resident #3's medical record revealed the presence of a valid State of Florida Do Not Resuscitate Order (DNRO) (Form DH 1896), dated [DATE]. The DNRO was present and available to guide staff in honoring the resident's end-of-life wishes when discovered on [DATE] not breathing and without a pulse. A review of Resident #3's annual Minimum Data Set (MDS) assessment, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment. A review of Resident #3's care plan showed a focus area as follows: [Resident #3] has an established DNR (DO NOT RESUSCITATE) order in place, initiated on [DATE], created by the Social Worker.The interventions for this care plan focus included, Activate resident's advanced directives as indicated.On [DATE] at 11:33 p.m. a progress note authored by Staff A, Licensed Practical Nurse (LPN) showed the following: Staff approached me around 1830 [6:30 p.m.] and informed me that resident was not breathing fellow nurse and I pronounced time of death at 1838 [6:38 p.m.] as resident was apneic (not breathing) and without heartbeat. Informed Advanced Practice Registered Nurse, (APRN) and Director of Nursing, (DON) of resident's death. Contacted resident's [family member] .During an interview on [DATE] at 1:25 p.m., Staff B, RN stated she began employment at the facility mid-[DATE]. She stated during orientation the facility provided general orientation through an online platform. Staff B, RN said the facility did not provide education or training related to CPR or DNR procedures, instruction on how to locate a resident's code status in the computer system, or the location and contents of the CPR binder. She stated after Resident #3 expired, she learned the DNRO forms were in the Code Status Binders.During an interview on [DATE] at 4:16 p.m. with the Nursing Home Administrator (NHA) the Regional Nurse Consultant (RNC), and the Regional Director of Operations (RDO). The NHA said Resident #3 was a DNR and she was told compressions were performed. The NHA read Staff A, LPN's witness statement. Staff A, LPN wrote [on [DATE]] Resident #3 was assessed with Staff E, LPN and they verified no heartbeat and death was pronounced at 6:38 p.m. messaged the ARNP . informing her of resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 13 of 16 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 12/17/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few passing around 1900 [7:00 p.m.]. The NHA said on [DATE] Resident #3's code status was not verified before chest compressions were performed. Staff did not follow the procedure to overhead page there was a code blue emergency. Licensed nurses are expected to notify EMS and a CNA notified EMS. The RNC said since incident all staff members have participated in code blue drill and licensed nurses have completed the code blue checklist. The RNC said the facility has provided additional education to CNAs regarding their role during a code blue emergency.During an interview on [DATE] at 1:46 p.m. Staff C, Licensed Practical Nurse, (LPN) Unit Manger UM) said new employee orientation consist of education/training using a collaboration platform and licensed nurses receive a minimum of three days orientation in the nursing unit. Staff C, LPN, UM said code blue checklist and mock Code Blue drills were implemented after the [DATE] event.During an interview on [DATE] at 4:00 p.m. the RNC said the Code Blue Response Worksheet is used as a training tool during drills.Review of facility Job Description, Position: Director of Nursing (DON), showed the following: Summary provide direct nursing care to the residents and provide clinical oversight of the day-to-day nursing activities performed by Licensed Practical Nurses and or Certified Nursing Assistants Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility.Essential Duties and responsibilities: .direct the day-to-day functions of the LPN's, nursing assistants .in accordance with rules, regulations, and guidelines that govern the long-term care industry.Ensure that all nursing personnel assign to you comply with the written policies and procedures established by the facility .Confirm that LPN's and CNAs ae aware of the resident care plan. Review of facility Job Description Position: Registered Nurse, showed the following:Summary: Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility.Provide direct nursing care to the residents and provide clinical oversight of the day-to-day nursing activities performed by Licensed Practical Nurses and or Certified Nursing Assistant Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility. Essential Duties and responsibilities: Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.Review of facility Job Description Position: Charge Nurse (LPN) showed the followingSummary: Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern facility .Essential Duties and responsibilities: Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.A review of the facility's General Orientation Agenda undated, . showed on orientation day #2 the Life Safety/ Codes includes: Code Blue, CPR, DNR, and Stop, Think, PerformA review of the facility checklist titled Code Status Competency showed staff competency verifications include the following:1. Verbalizes Understanding and acknowledges process with New admission New DNR responsibilities.2. Verbalizes Understanding and acknowledges process with New admission New DNR time implementation3. Verbalizes Understanding and acknowledges process with New admission New DNR obtaining order from physician, entering order into Point Click Care.4.Verbalizes Understanding and acknowledges process with New admission New DNR initiating Yellow DNR Form with resident/representative signature.5.Verbalizes Understanding and acknowledges process with New admission New DNR copies placed in all code status binders.6. Verbalizes Understanding and acknowledges process with New admission New DNR copy to Social Services for physician signature.7.Verbalizes Understanding and acknowledges process with re-admission New DNR responsibilities. 8. Verbalizes Understanding and acknowledges process with re-admission New DNR time implementation.9. Verbalizes Understanding and acknowledges process with re-admission New DNR obtaining order from physician, entering order into Point Click Care.10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 14 of 16 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 12/17/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Verbalizes Understanding and acknowledges process with re-admission New DNR initiating Yellow DNR Form with resident/resident representative signature . A review of the facility policy titled Advanced Directives Code Status, issued 1/2024, showed the following:Standard : It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations.A review of the facility policy titled Cardiopulmonary Resuscitation (CPR), implemented 11/2020, showed the following:Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives.In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Compliance Guidelines:1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR.2.If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and:1a. In accordance with the resident's advance directives .The facility's immediate actions to remove the Immediate Jeopardy included:An audit of the code status binders to validate DNR forms were in the appropriate binder was completed on [DATE].An audit to verify residents DNR forms were present in the electronic medical record, physician orders were in place and care plans were reflective of residents' code status was completed on [DATE].Staff education was provided between [DATE] and [DATE] instructing licensed nurses to evaluate residents for absence of vital signs, if vital signs are noted to be absent, follow residents Advanced Directive. If the resident has DNR orders, immediately notify the provider for further orders.From [DATE] to [DATE], staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status. Education was completed by 100% of staff, excluding those on leave from work. A process was initiated for newly hired facility staff will receive the above education during orientation and prior to working any assignment.On [DATE] an ad hoc [when necessary or needed] Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.On [DATE] the QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results. No discrepancies or concerns were identifiedXXX[DATE] the QAPI committee reviewed the same areas and education completion: licensed nurses 97%, all other staff 98%. Staff on leave will be educated upon return. No discrepancies noted.On [DATE] the QAPI committee discussed ongoing monitoring audits including education validation; 100% of staff interviewed answered questions appropriately. Code Blue drills continue until 100% of nursing staff participate.On [DATE]-[DATE] the QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.Between [DATE] and -[DATE] the QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.On [DATE] reviewed completed audits titled, Code staff education validation. No issue identifiedOn [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text for orders and to clearly document in the medical record.On [DATE], the Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff were instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified immediately for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105320 If continuation sheet Page 15 of 16 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 12/17/2025 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.100% of the nurses received an electronic copy of the education. To date, 25 of 30 licensed nurses have completed the education, with the remaining 5 scheduled to complete it prior to starting their next shift. Licensed nurses are required to sign the education acknowledgment sheet before working.Verification of the facility's removal plan was conducted by the survey team on [DATE] through [DATE].On [DATE], interviews were conducted with 19 CNAs working across all shifts to verify education related to their role during a Code Blue (the code called when a resident is discovered to be non responsive), the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.On [DATE], licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.On [DATE], licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to immediately notify the physician or Medical Director for additional orders. On [DATE] interviews were conducted with 11 licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills. In-service attendance signature sheets and a log of electronic communications were reviewed, which confirmed that 25 out of 30 nurses received the in-service training about the new processes. Event ID: Facility ID: 105320 If continuation sheet Page 16 of 16