Inspection·November 15, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled Care Plan Revisions Upon Status Change, with revision and implementation date 09/7/2022, Page 01 of 01 reads under Policy The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Residents Affected - Few Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing a revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident's representative if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to a new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 2 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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** 2) On 11/07/22 at 1:24 p.m., Resident #32 was observed in his room sitting in the wheelchair next to his bed. He did not speak and pointed to his ear during an attempt to interview him. Resident #32 had dry scabbed areas on both hands. Residents Affected - Few On 11/14/22 at 11:22 a.m., the resident was observed sitting in the wheelchair next to his bed watching TV. Resident #32 again did not say anything in an attempt to interview him. Dry scrabbed areas were observed on both hands. A review of the admission Record revealed Resident #32 was initially admitted into the facility on [DATE] with a primary diagnosis of cerebral infarction. Section C: Cognitive Patterns of the annual Minimum Data Set (MDS), dated [DATE], indicated Resident #32 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating the resident was cognitively intact. Section M: Skin Conditions revealed the resident did not have any ulcers, wounds, or skin problems. A review of the Order Summary Report for September 2022 to November 2022 revealed the following order related to wounds on the hand: Monitor wound appearance on right palm of hand for signs and symptoms of infection. Notify doctor for redness, warmth, pain, edema, drainage, or odor every shift. There was no order in place for the wound on the left hand. A review of the Skin Head to Toe Weekly Skin Checks from September 2022 to November 2022 revealed Resident #32 only had an abrasion on the right palm. There was no indication on the skin checks that he had an abrasion on the left palm. A review of the monthly Skin & Wound Evaluation dated 09/19/22 indicated the resident had an in house acquired abrasion on the right palm. There was no documentation related to the abrasion on the left palm. A review of the Care Plan related to diabetes initiated on 09/12/19 revealed interventions, that included but were not limited to, check all of body for breaks in skin and treat promptly as ordered by the doctor. On 11/15/22 at 10:00 a.m., the Director of Nursing (DON) stated she did not find any documentation related to the wound on the left hand. She stated it was a dry scabbed area, but it was not open. She stated the wound care doctor saw him yesterday and put in new orders for the wound after the concern was brought to her attention. The DON stated she would expect to see documentation on the skin checks related to the area on the left hand and he should have had orders in place for treatment. The Skin & Wound Evaluation dated 11/14/22 completed by the wound care doctor indicated the resident had an in house acquired abrasion on the left dorsum. The area of the wound was 0.4 cm, length was 1.1 cm, and the width was 0.7 cm. The wound bed was eschar and 100% of the wound filled. The surrounding tissue was dry/flaky. The notes section indicated the wound was assessed by the wound care doctor for callus like area to left hand over healed surgical site. The doctor assessed and diagnosed as abrasion. Order received for skin prep daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 3 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 The policy provided by the facility Skin Evaluations revised 08/22/22 revealed the following: Level of Harm - Minimal harm or potential for actual harm It is our policy to perform a full body skin evaluation as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Residents Affected - Few 7. Documentation of skin assessment a. Include date and time of the assessment, your name, and position title. b. Document observation (e.g., skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurement, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate. Based on observations, interviews, and record reviews, the facility failed to 1)provide care and services in accordance with physician's orders and the plan of care for one resident (#271) of three residents sampled for nutrition services and, 2) failed to document an alteration in skin integrity for one resident (#32) of one resident sampled for skin impairments. Findings included: 1) A review of Resident #271's medical record revealed Resident #271 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, encounter for attention to gastrostomy, and sepsis. A review of Resident #271's physician's orders revealed a dietary order, dated 10/20/2022, for a Nothing by Mouth (NPO) diet. A review of Resident #271's care plan revealed a problem, dated 10/21/2022, that Resident #271 was NPO and relied on tube feedings to meet 100% of estimated nutritional needs. A review of Resident #271's Progress Notes revealed a note, dated 10/25/2022 at 5:35 PM, documented by Staff G, Registered Nurse (RN) that read: Resident #271's Resident Representative (RR) observed Resident #271 eating a grilled cheese sandwich in his room and asked Staff G, RN if Resident #271's diet order had changed from NPO. Staff G, RN informed the RR that Resident #271's diet order had not changed and that the resident was still NPO. Staff G, RN then removed the food and a beverage cup from Resident #271's room. A telephone interview was attempted on 11/8/2022 at 9:24 AM with Staff G, RN. The telephone call was not answered and a voicemail message was left, but Staff G, RN did not return the call. A telephone interview was conducted on 11/8/2022 at 9:28 AM with Staff B, Certified Nursing Assistant (CNA). Staff B, CNA stated she was Resident #271's CNA on 10/25/2022 and it was the first time she had worked with the resident. Around 4:30 PM, while delivering dinner trays to the floor, Staff B, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 4 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 Residents Affected - Few CNA went into Resident #271's room and noticed he did not have a dinner tray in his room. Staff B, CNA observed a beverage cup and a container of pudding in Resident #271's room and assumed Resident #271 had an order for a regular diet. Staff B, CNA stated she did not see any signage in Resident #271's room indicating the resident had dietary restrictions but she did not confirm Resident #271's diet order before going to the kitchen to retrieve a meal tray. Staff B, CNA went to the kitchen and told a cook Resident #271 was not served a dinner tray. The cook, who Staff B, CNA was not able to name, informed her Resident #271 had an order for a regular diet and provided her with a grilled cheese sandwich to serve the resident. Staff B, CNA then served the grilled cheese sandwich to Resident #271 and the resident consumed half of the sandwich. Later, Resident #271's RR then asked Staff B, CNA for a spoon for the pudding in the resident's room, which was provided by Staff B, CNA. Staff B, CNA stated the resident's diet order was not correctly entered so, to the best of her knowledge and the fact that Resident #271 had a beverage cup and pudding at the bedside, the resident was ordered a regular diet. Staff B, CNA also stated the facility did not have a system in place for CNA's to verify resident diets at that time. A telephone interview was conducted on 11/8/2022 at 12:09 PM with Resident #271's RR. The RR stated on 10/25/2022, she arrived at the facility during dinner meal service and noticed Resident #271 had two halves of a grilled cheese sandwich on a tray at his bedside and Resident #271 had consumed one sandwich before her arrival. Resident #271 also had a container of pudding on the meal tray and the RR activated the call light to speak with the nurse on duty. After approximately 45 minutes, the nurse responded to the room and was not aware of Resident #271's order of NPO. The RR was not able to state if Resident #271 had received regular food or beverages before 10/25/2022. An interview was conducted on 11/8/2022 at 2:48 PM with the facility's Nursing Home Administrator, Staff C, Regional Director of Clinical Services (RDCS) and Staff D, RDCS. The NHA stated on 10/25/2022, Staff B, CNA provided a meal tray to Resident #271 that had a grilled cheese sandwich and a container of pudding on it. Staff B, CNA did not realize Resident #271 had an order for NPO and provided the tray because she saw the resident did not have any food during dinner service. Staff C, RDCS stated Staff B, CNA did not verify Resident #271's diet order and should have checked the resident's plan of care before serving them food. Resident #271's RR was present at the time and asked Staff G, RN if the resident's diet order had changed. Staff G, RN informed the RR Resident #271's diet order was NPO and removed the food and beverages from the resident's room. Staff C, RDCS stated Staff B, CNA received the grilled cheese from Staff F, Cook, who also did not verify Resident #271's diet order before providing the food. A telephone interview was conducted on 11/9/2022 with Staff F, Cook. Staff F, [NAME] stated on 10/25/2022, Staff B, CNA approached him in the facility kitchen and stated Resident #271 was missing a dinner tray. Staff F, [NAME] asked what the diet order was for Resident #271 and Staff B, CNA did not know. Staff B, CNA then requested some grilled cheese sandwiches for Resident #271, which Staff F, [NAME] provided. Staff F, [NAME] stated the facility did not have a process for kitchen staff to check diet orders at the time of the incident and he was not aware that Resident #271 had a diet order for NPO. A review of the facility policy titled Therapeutic Diet Orders, revised on 10/29/2022 revealed under the section titled Policy, the facility provides all residents with food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. The policy also stated under the section titled Policy Explanation and Compliance Guidelines dietary and nursing staff are responsible for providing therapeutic diets in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 5 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 appropriate form and/or the appropriate nutritive content as prescribed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 6 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to monitor behaviors and side effects for psychotropic medications for one resident (#63) out of five residents sampled for unnecessary medications. Findings included: A review of the admission Record for Resident #63 revealed he was initially admitted into the facility on [DATE] with diagnoses that included major depressive disorders and unspecified dementia. Section C: Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was rarely/never understood. Section N: Medications of the MDS indicated he received antipsychotics and antidepressants for seven days. A review of the Order Summary Report with active orders as of 09/01/22 to 11/01/22 revealed the following orders: Donepezil HCL Tablet 10 milligrams (MG)- Give 1 tablet by mouth at bedtime related to down syndrome, unspecified dementia without behavioral disturbance Mirtazapine Tablet 7.5 MG- Give 1 tablet by mouth at bedtime related to major depressive disorder Olanzapine Tablet 5 MG- Give 1 tablet by mouth two times a day for mood disturbance related to unspecified dementia without behavioral disturbance There was no order in place related to behavior monitoring or side effect monitoring for psychotropic medications. A review of the Medication Administration Record for 09/01/22 to 11/01/22 revealed no documentation related to behavior monitoring or side effect monitoring for psychotropic medications. A review of the Care Plan focus area related to psychotropic medications, indicated the following interventions: Monitor/document for side effects and effectiveness; Monitor/document/report as needed any adverse reactions of psychotropic medications; Monitor/record occurrence of target behavior symptoms; and Monitor for side effects and effectiveness On 11/14/22 at 10:21 a.m., the Director of Nursing (DON) stated Resident #63 did not have an order in place for side effect and behavior monitoring related to psychotropic medications. She stated both orders were discontinued due to a medication change. She stated Resident #63 was taken off Risperidone on 06/26/22 and a new psychotropic medication was added on 10/05/22, and the order for side effect and behavior monitoring was not added. She stated the nurses should be monitoring side effects and behaviors every shift for residents who are prescribed psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 7 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record reviews, and interviews, the facility failed 1) to maintain the ceiling in a safe and sanitary manner in one of one kitchen observed and, 2) failed to store food in accordance with professional standards, related to storing opened food without a date, in the kitchen and in one of two nourishment refrigerators. Findings included: An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 11/07/22 at 10:30 a.m. A hole was observed in the ceiling near the dish washing area with exposed wires. The CDM stated that's where they removed the ceiling fan from. An opened bag of grits was observed next to the stove without an opened date. This was confirmed by the CDM, and she immediately labeled the opened bag of grits. The refrigerator in the nourishment room on the east wing was observed to contained an opened gallon of ice cream undated and an opened bag of chicken nuggets without an opened date. The CDM immediately discarded the items. She reported the nursing staff were responsible for labeling and dating foods in the nourishment refrigerators. The policy provided by the facility Nourishment Refrigerator/Freezer Storage with a revised date of 10/29/22 revealed the following: Policy Explanation and Compliance Guidelines: 2. All items should be dated with date of storage. 4. Follow manufacturer's guidelines for unopened times in their original packaging using Use-By date. 6. Food from outside sources for residents must be labeled with the resident's name, date item placed and a Use-By date. Monitor for freshness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 8 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The following observations were made of staff members wearing surgical masks inappropriately: Residents Affected - Some - On 1/31/23 at 11:09 a.m., identified Staff D, Housekeeper, standing in the entrance to room [ROOM NUMBER] with a surgical mask below the chin. - On 1/31/23 at 11:42 a.m., observed Staff I, Personal Care Assistant (PCA) enter the kitchen from the dining room wearing surgical mask below the nose. The staff member left the kitchen and returned a moment later continuing to wear surgical mask below the nose. - Staff H, Hospice Certified Nursing Assistant (CNA) was observed, on 1/31/23 at 12:05 p.m., standing in the middle hallway of the East wing. The staff member was wearing a surgical mask below the chin as she looked into the units shower room. A few moments later Staff H was observed at the end of the north hallway speaking with a resident with the surgical mask below the nose and propelled the resident from that area toward the nursing station with the mask below the chin. - On 1/31/23 at 12:07 p.m., Staff F, CNA, was observed wearing surgical mask below the nose as passing out lunch trays to residents. - On 1/31/23 at 12:07 p.m., Staff C, CNA was observed entering room [ROOM NUMBER] with a lunch tray while wearing surgical mask below nose. - During the passing of lunch trays on 1/31/23 at 12:09 p.m., Staff C, CNA, was observed removing a tray from the meal cart and enter room [ROOM NUMBER] wearing a surgical mask below the nose. The staff member continued to observed as leaving the room, at 12:13 p.m. on 1/31/23 to be wearing the mask below the nose. - On 1/31/23 at 12:28 p.m., Staff C and Staff G, agency Licensed Practical Nurse (LPN), were observed behind the [NAME] wing nursing station wearing surgical masks below their noses. - On 2/1/23 at 7:45 a.m., Staff J, agency LPN was observed sitting behind the [NAME] wing nursing station without a mask. The staff member reported working at the facility frequently. - Staff M, CNA, was observed, on 2/1/23 at 9:03 a.m., passing water cups to room [ROOM NUMBER] while wearing a surgical mask below nose. - On 2/1/23 at 11:13 a.m., Staff E, CNA, was standing at the East wing nursing station speaking with Staff O while wearing surgical mask below nose. An interview was conducted on 1/31/23 at 4:13 p.m., with Staff L, CNA. The staff member stated the blue door caddies were just to hold supplies (Personal Protective Equipment, PPE) and the yellow door caddies were for (residents with) COVID. On 2/1/23 at 9:05 a.m., Staff N, Registered Nurse (RN) reported not knowing why residents were on Enhanced Precautions. The staff member stated just to prevent the spread of anything. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 9 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/1/23 at 7:35 a.m., an observation was made of Resident #16 sitting on the front porch of the facility. The resident was sitting in a wheelchair, wearing oxygen in nares, wearing a non-slip sock on left foot, and the right foot was wrapped with rolled gauze. Resident #16 reported being on the way to an appointment to have fluid removed from abdomen. The rolled gauze was stained a tan-brown color, the end of the gauze was unattached approximately 6 inches, colored a wet-looking brown color and lying on the ground. The resident confirmed there was a wound (underneath the gauze) and reported asking for the dressing to be changed but they're having a hard time in there today. The Staffing Coordinator and Staff B, Certified Nursing Assistant (CNA) arrived to the area and the Coordinator asked for the resident to wear a sock on the right foot. Resident #16 reported not wanting to wear a sock because it drained so much and was so big. An unknown staff member arrived and the resident allowed a large royal blue sock to be placed over the stained dressing. The coordinator and unknown staff member went inside the facility and Staff B and the resident moved toward the transportation van. The admission Record identified Resident #16 was admitted on [DATE]. The record included diagnoses not limited to acute hematogenous osteomyelitis of right ankle and foot, alcoholic cirrhosis of liver with ascites, Type 2 Diabetes Mellitus with foot ulcer, and cellulitis of right lower limb. The Order Summary Report for Resident #16 identified the following orders: - Monitor appearance of Right foot diabetic ulcers, rash to right lower abdominal fold, surgical site to right intercostal, redness left shin and blister to right shin for signs/symptoms (s/s) of infection. Notify MD for redness, warmth, pain, edema, drainage, or odor every shift, started 1/24/23. - Monitor for dressing placement to right medial and lateral foot, right shin, and right intercostal area every shift, started 1/24/23 - Right shin open blister: Cleanse with normal saline, pat dry, apply xeroform and cover with bordered gauze dressing as needed for dressing not intact, started on 1/23/23. - Right shin open blister: Cleanse with normal saline, pat dry, apply xeroform and cover with bordered gauze dressing every day shift every other day, ordered on 1/23/23. - Collagenase Ointment 250 unit/gram (gm). Apply to right lateral foot topically as needed for dressing not intact. Cleanse with normal saline (NS), pat dry, apply Santyl, apply Calcium alginate, cover with 4x4 gauze, wrap with kerlix and secure with tape. This order was to start on 1/24/23. - Collagenase Ointment 250 unit/gram (gm). Apply to right lateral foot topically every day shift for wound care. Cleanse with normal saline (NS), pat dry, apply Santyl, apply calcium alginate, cover with 4x4 gauze, wrap with kerlix and secure with tape. This order was to start on 1/24/23. - Collagenase Ointment 250 unit/gram (gm). Apply to Right Medial foot topically as needed for Dressing not intact. Cleanse with normal saline (NS), pat dry, apply Santyl, apply Calcium alginate, cover with 4x4 gauze, wrap with kerlix and secure with tape. This order was to start on 1/24/23. - Collagenase Ointment 250 unit/gram (gm). Apply to Right Medial foot topically every day shift for Wound care. Cleanse with normal saline (NS), pat dry, apply Santyl, apply Calcium alginate, cover with 4x4 gauze, wrap with kerlix and secure with tape. This order was to start on 1/24/23. The January Treatment Administration Record (TAR) for Resident #16 indicated on 1/31/23 staff had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 10 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed dressing changes to the residents right lateral foot, right medial foot, had monitored the appearance of the right foot diabetic ulcers, the blister to right shin, redness to left shin, and had monitored the dressing placement to the right medial and lateral foot, right shin, and right intercostal area. The TAR indicated staff had completed wound care to the residents' right shin open blister on 1/30/23. The January TAR did not indicate the staff had completed as needed dressing changes to Resident #16's right lateral foot, right medial foot, or right shin open blister. The February TAR for Resident #16 did not indicate as needed dressing changes had been completed on 2/1/23 to the residents' right medial foot, right lateral foot, or the right shin open blister. A review of the progress notes for Resident #16 indicated on 2/1/23 at 7:30 a.m., Staff Q, Licensed Practical Nurse (LPN) had documented the Resident was offered socks and shoes prior to appointment this morning by CNA. Resident refused saying he prefers to not wear socks or shoes. Respected resident's wishes. A progress note, dated 2/1/23 at 7:50 a.m., identified Resident #16 had left the facility to attend an appointment and was not in acute distress upon leaving the facility. The progress note, dated 2/1/23 at 12:15 p.m., indicated Resident #16 had returned to facility following paracentesis. A progress note, on 2/1/23 at 3:05 p.m., identified after returning from an appointment Resident #16 had refused to having dressings changed, wishing to rest. The note indicated the nurse had returned and had completed the dressing changes. An interview was conducted, on 2/2/23 at 7:59 a.m., with Staff U, LPN. The staff member reported being told by an aide Resident #16 did not want to wear socks and shoes. The staff member stated she had spoken with the resident regarding this and during the conversation she had not looked at the dressing on the residents' right lower leg. Staff U stated the resident reported the socks were tight and uncomfortable. The staff member stated the facility had not spoken with the physician regarding changing the dressing more frequently and confirmed the wound does drain a lot. She stated the resident should have looked presentable to leave for an appointment and the dressing should have been addressed prior to the appointment. The Director of Nursing reported, on 2/1/23 at 5:54 p.m., of being aware of the observation of Resident #16's dressing and the expectation would be the dressing would be redone prior to the resident leaving (for appointment) and the physician be notified if the drainage was more than normal. During an interview with Resident #16, on 2/2/23 at 9:01 a.m., the resident was observed wearing a royal blue sock on the right foot covering to mid-leg. Above the sock was a dressing dated 2/1/23 and discolored with brownish/tan coloring. The resident stated the wound was almost closed and not draining, the drainage came from the leg itself, and the floor should be wet where the leg drains. A small amount of wetness was observed on the floor. Resident #16 stated the wounds were saturated yesterday when returning from the appointment. Resident #16's care plan indicated the resident had a diabetic ulcer of the right foot related to (r/t) diabetes (and) renal disease. The interventions indicated staff were to monitor/document/report as needed (prn) changes in wound color, temp, sensation, pain, or presence of drainage and odor. The policy - Wound Treatment Management, implemented 8/25/22, indicated To promote wound healing of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 11 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The guidelines indicated that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The guidelines indicated dressing changes may be provided outside the frequency parameters in certain situations: feces has seeped underneath the dressing, the dressing has dislodged, and the dressing is soiled otherwise or is wet. On 2/1/23 at 9:29 a.m., an observation was conducted with Staff O, Licensed Practical Nurse (LPN) and Staff P, LPN of the medication administration for Resident #6. Staff O dispensed the following medications: - Levetiracetam 100 milligram/milliliter (mg/mL) liquid - 30 mL's - Atropine sulfate opthalmic drops orally - Potassium Chloride 20 milliequivalent/15 milliliter (meq/mL) - 15 mL's - Metoprolol Tartrate 25 milligram (mg) tablet - 1/2 tablet - 12.5 mg The staff members entered Resident #6's room and Staff O unhooked the nutritional liquid from the residents percutaneous endoscopic gastrostomy (PEG) and obtained 250 mL's of tap water. Staff O flushed the PEG with 60 mL's of water, administered Potassium, flushed the tube with 5 mL's of water, administered Levetiracetam, flushed with 5 mL's of water, mixed 5 mL's of water with the crushed half tablet of Metoprolol prior to administering it, then flushed the tube with 5 mL's of water. Staff O used the remaining water to flush the residents PEG tube. Staff O completed tracheostomy care then administered the residents' Atropine drops. A review of Resident #6's February Medication Administration Record (MAR) identified staff were to administer 12.5 mg's of Metoprolol Tartrate via PEG twice a day related to Benign Intracranial Hypertension and to hold for a systolic blood pressure (BP) less than 100 or a pulse less than 60. The order was started on 6/14/21. The spaces where staff were to document the blood pressures and pulses for the administration of Metoprolol was X on 2/1/23 for 9:00 a.m. and 9:00 p.m. and X on 2/2/23 at 9:00 a.m., and indicated staff had administered Metoprolol on those days and those times. A review of the Advanced Practitioner Registered Nurse (APRN) note, dated 6/14/21, indicated the Assessment/Plan was to hold Metoprolol systolic (sys) < 100 for the diagnosis of essential (primary) hypertension. The February MAR for Resident #6 indicated a physician order that instructed staff to obtain vital signs (BP, temperature, pulse, respirations, and oxygen saturations) every evening shift on Sundays. A review of Resident #6's January MAR identified the BP and Pulse sections of the residents' Metoprolol was X with no vital signs documented. The January MAR for Resident #6 identified the following blood pressures and pulses were obtained on Sunday evenings: - 1/1/23: 107/65, 69 pulse; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 12 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 - 1/8/23: 124/78, 92 pulse; Level of Harm - Minimal harm or potential for actual harm - 1/15/23: 124/78, 92 pulse; - 1/22/23: 124/78, 92 pulse; Residents Affected - Some - 1/29/23: 124/78, 95 pulse. The review of Resident #6's Weights and Vitals Summary identified two blood pressures documented for January was on 1/8/23 of 124/78 and 1/1/23 of 107/65. The pulse summary indicated on 1/28/23 the residents' pulse was 95, on 1/8/23 the pulse was 92, and the third most recent documented pulse was 69. The Weight and Vital Summary did not identify any blood pressure or pulse was obtained in February. The latest progress note, dated 1/31/23, for Resident #6 indicated the blood pressure was 124/78, obtained on 1/8/23, and pulse was 95, obtained on 1/28/23. A progress note, dated 1/29/23, identified the residents blood pressure of 124/78 was obtained on 1/8/23 and the pulse of 95 was obtained on 1/28/23. The care plan for Resident #6 identified Resident #6 was at risk for fluctuating/unstable blood pressure related to (r/t) hypertension (HTN), initiated 9/16/18. The interventions instructed staff to Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. The policy - Medication Administration, implemented 9/7/22, indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The guidelines instructed staff to Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. The policy identified that medications requiring vital signs prior to administration included Anti-hypertensives per physicians orders. On 2/2/23 at 10:31 a.m., Staff O, Licensed Practical Nurse (LPN) stated to be honest with you, did not take it (blood pressure) yesterday. The staff member reviewed the order for Metoprolol, confirmed that the order did have parameters, and stated Normally don't take it. The Director of Nursing (DON) stated, on 2/2/23 at 10:39 a.m., if parameters for blood pressure and pulse, staff are to take them prior to administering the medications. The DON reported if parameters were needed the expectation would be the MAR would have a special indicator to document. The DON reviewed Resident #6's record and confirmed the latest evaluation, antibiotic progress note on 1/31/23 recorded a BP from 1/8/23 and blood pressures could change during that time and when vitals are placed on the MAR they should be transferred to the Weights/Vitals tab of the electronic medical record. Based on observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice identified during a recertification survey conducted on 11/15/2022, and a comparative survey conducted on 12/15/2022. The facility was cited during the recertification survey for F656, and F684. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 13 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 Level of Harm - Minimal harm or potential for actual harm The facility was cited during the comparative survey for F644, F656, F658, F842, and F880. On 2/02/2022 a revisit survey was conducted and the facility was recited at F644, F656, F658, F684, F842, and F880. The facility had developed a Plan of Correction with a completion date by 01/15/2023. The facility had not comprehensively implemented the Plan of Correction for the identified quality deficiencies. Residents Affected - Some Findings Included: 1) A review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, including but not limited to, cerebral infarction, muscle weakness, abnormalities of gait and mobility, dementia, vitamin D deficiency, protein calorie malnutrition, and lack of coordination. On 6/04/2022 Resident #2 was hospitalized after a fall at the facility and diagnosed with a right femur fracture, and cognitive communication deficit. On 11/03/2022 Resident #2 was sent to the hospital for swelling and edema to the right lower leg and was diagnosed with a right tibial fracture. The resident did not return to the facility. A review of the Order Summary Report revealed orders dated 6/09/2022 as: Activity: Up as tolerated unless otherwise specified, and May use assistive devices (pillow/wedge cushion/positioner) for positioning. Device in use direction. A review of the Minimum Data Set (MDS) quarterly assessment completed on 9/15/2022, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A review of Section G: Functional Status indicated Resident #2 required extensive assistance (resident involved in activity, staff provide weight-bearing support), by two+ persons for physical assistance during transfers. Resident #2 was assessed to require total dependence with the support of two+ persons for physical assistance during bathing. A review of the Comprehensive Care Plan revealed a focus area as follows: Resident #2 has an ADL (activates of daily living) self-care performance deficit related to weakness (Initiated on 6/27/2022). Goal: Resident #2 will maintain current level of function through the review date. Interventions/Tasks: the resident requires total assistance by 2 via mechanical total lift staff to transfer between surfaces. A review of the October 2022 nursing task documentation for Resident #2 indicated the following: ADL (Activities of Daily Living) bathing Monday and Thursday 7-3 shift documented as 4,2 (Total Dependence, One-person physical assist) six times, 3,2 (Physical help in part of bathing activity, One-person physical assist) one time, 0,2 (Independent, One-person physical assist) one time, and RR (resident refused) one time. ADL Transferring for day shift documented as 4,3 (Total Dependence, Two-person physical assist) 24 times, 3,2 (Extensive assist, One-person physical assist) four times, and 2,2 (Limited assistance, One-person physical assist) one time. A review of the November 2022 nursing task documentation for Resident #2 indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 14 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 ADL bathing Monday and Thursday 7-3 shift revealed no documentation for the task on 11/3/2022. Level of Harm - Minimal harm or potential for actual harm ADL Transferring for day shift documented as 2,2 (Limited assistance, One-person physical assist) on 11/1/2022, and 4,2 (Total Dependence, One person physical assist) on 11/2/2023. No documentation for the task was noted for 11/3/2023. Residents Affected - Some A review of the progress notes revealed the following documentation: 11/2/22 2300: PT [Physical Therapist] notified nurse that right leg appears shorter than left leg and that right foot is externally rotated. PT educated that pillow was propped on right side of right foot and should be positioned that way. Pillow in place. No signs of distress noted. Scheduled pain med's administered. S/P [status post] 1 hour pain pill in effect. Call light within reach. Res [Resident] is able to make needs known. Will continue to monitor. This was a Late entry note created on 11/5/2022 at 1:50:19 A review of a SBAR (situation, background, assessment, response) Communication Form dated 11/03/2022 revealed the following documentation: Pain evaluation: resident has new pain to right lower leg in the front. Resident showing non-verbal signs of pain described; Repeated troubled calling out loud moaning or groaning, Crying, Sad/frightened/frown, Tense, Distressed pacing, Fidgeting, Distracted or reassured by voice or touch. Transfer to ER [Emergency Room] for further evaluation. On 2/1/22 at 4:36 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated she was notified by the DON of Resident #2 being diagnosed with a right tibial fracture on 11/3/2022. She stated the nurse caring for the resident had reported to the DON the resident went to the hospital for edema and redness to the right lower extremity. The NHA stated the first sign of edema and redness noticed by the nursing staff occurred on 11/3/23 when the resident complained of pain. The DON stated there was no indication of a problem with the right leg for Resident #2 prior to 11/3/23. The NHA stated the nurse was notified by an aide about pain and swelling to the right lower leg after the morning shower at 8:30 a.m. on 11/3/23. The DON stated the nurse gave the resident some pain medication at the time and did not notice any problems with the leg that seemed urgent. The DON stated later in the day, the nurse noticed a discoloration to the lower leg, and the leg was warm to the touch, so the nurse immediately notified the doctor and sent the resident out to the hospital around 1:00 p.m. on 11/3/23. The NHA stated she was not sure of what had caused the injury but she believed the fracture was pathological and any sudden movements could have caused a break due to the resident's condition. The NHA stated the resident had gone to meals during the day of the incident and had no complaints of pain during that time. The NHA stated the resident had all of her normal activities that day. The DON stated Resident #2 was a Hoyer lift for all transfers at the time of the incident. The DON stated the resident always had some pain every day so it was not unusual for her to complain of pain and the resident was getting a routine medication for pain. The DON stated the resident was in pain when she went out and confirmed the type of pain described was not like every day pain Resident #2 usually had. The NHA stated they did competencies related to proper use of the Hoyer lift, abuse, and neglect training, and how to assure staff are following the care plan and Kardex related to transfers and lifts. The NHA stated she never felt there was any abuse/neglect or a fall associated with the injury. She stated she felt it was the Resident's condition that was the root cause of the injury. On 2/2/23 at 11:25 a.m. an interview was conducted with the MDS Coordinator. She stated she recalled the incident with Resident #2 on 11/3/23. She stated she was asked by Staff N, Registered Nurse (RN) to take a look at Resident #2's leg due to some swelling. She stated when she went into the room she observed the resident's right lower leg to be swollen, warm to touch, and red with a purplish-blue color starting to appear. She stated she thought the resident could possibly have a blood clot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 15 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and she told the nurse to call the doctor to inform him. She stated Staff N, RN and Staff Q, RN were caring for the resident at the time. On 2/2/23 at 12:25 p.m. a telephone interview was conducted with Staff R, CNA (Certified Nursing Assistant). Staff R confirmed she was providing care for Resident #2 on 11/3/23 on the day shift (7am to 3pm). She stated she had taken care of the resident a few times a week on a regular basis. She stated Resident #2 required total care and required the use of a Hoyer lift for all transfers. She stated Resident #2 previously had a brace on her right leg, but therapy said it was fine to have it off and she did not wear it anymore. She stated after breakfast on 11/3/23 she gave Resident #2 a shower. Staff R, CNA stated a Hoyer pad was under the resident in her wheelchair so she put the resident into the shower chair and undressed her and gave her a shower. She stated she noticed her right leg was swollen and the resident was complaining of pain in her leg during the shower. She stated when she finished the shower she dressed Resident #2 and put her back in the wheelchair. She stated she was the only one using the Hoyer lift to transfer the resident because she could not find anyone to help her, so I did it by myself. She stated she was the only staff member in the shower room with Resident #2 during the shower. She stated she notified the nurse because the leg looked extra swollen and the resident was complaining of a lot of pain. She stated she had another aide help get the resident back in bed and she elevated the leg and sent the nurse in to see the resident. She stated the leg was pinkish/purple and very swollen and Resident #2 was in pain. She stated Resident #2 was yelling in pain. She stated the pain Resident #2 was exhibiting was much more than usual. She stated the resident did go to breakfast and lunch during the day. She stated Resident #2 had never complained of that intense of pain before. Staff R stated she had given a statement to the DON and NHA. On 2/2/23 at 12:45 p.m. a telephone interview was conducted with Staff Q, RN. Staff Q stated he was familiar with Resident #2. He stated the resident was located in the area he was assigned and he had a lot of contact with the resident. Staff Q, RN stated Resident #2 had dementia and a very involved family. He stated the family wanted the resident to participate in activities and be out of the bed as much as possible especially or meals. The RN stated Resident #2 required extensive to total assistance for all ADL's. He stated the resident required a Hoyer lift for transfers. The nurse stated the aides did most of the transfers and they would close the doors during the transfers. Staff Q, RN stated he was caring for Resident #2 on 11/3/23 when the incident occurred. He stated early in the morning the resident was taken to the shower by an aide. He stated after the shower Resident #2 was laid down and he was informed the resident was complaining of pain to her right lower leg. Staff Q stated he assessed the resident and noted some swelling with some discoloration to the leg. He stated he provided pain medication and notified the doctor about the swelling and the resident was transferred to the hospital for evaluation. He stated he was notified by the hospital the resident had a fracture and he notified the DON, the doctor, and the family. Staff Q stated he was not notified of any fall or accident by anyone. On 2/2/23 at 1:00 p.m. a telephone interview was conducted with Staff S, CNA. Staff S verified she was the aide caring for Resident #2 on the night shift of 11/3/23 (11p to 7a). She stated she did not recall any complaints from Resident #2 during the night about pain in her leg. She stated she provided care and did not notice any swelling in her right leg while performing incontinence care. On 2/2/23 at 1:30 p.m. a telephone interview was conducted with Staff T, Physical Therapist (PT). Staff T stated he saw Resident #2 on the afternoon of 11/2/23 for therapy. He stated the resident was having discomfort in her right leg so she did not want to get out of bed. He stated he noticed the right leg was in external rotation with a pillow underneath. He stated he repositioned the leg and informed the nurse on how to position the leg in the future. He stated the resident had normal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 16 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 swelling due to the previous fracture and he did not notice any other problems with the leg. Level of Harm - Minimal harm or potential for actual harm On 2/2/23 at 1:45 p.m. a telephone interview was conducted with the Primary Care Physician (PCP). The PCP stated the resident had dementia and she had a previous fracture to the right femur. The PCP stated there was a question about how the new fracture occurred and he thought it was probably associated with her bone density condition. He stated he could not recall what was said related to the 11/22 fracture. He stated he was notified but he did not have a recollection of what happened. He stated he knew there was new education and training done at the facility after the incident. Residents Affected - Some A review of the policy titled Comprehensive Care Plans, implemented 9/7/22, indicated the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. .8. Qualified staff responsible for carrying out interventions specified in the car plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. A review of the policy titled Accidents and Supervision, implemented 9/7/22, indicated the following: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks 2. Evaluating and analyzing hazards and risks 3. Implementing interventions to reduce hazards and risks 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanations and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. .3. Implementation of interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 17 of 18 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0867 a. Communicating the interventions to all relevant staff Level of Harm - Minimal harm or potential for actual harm b. Assigning responsibility c. Providing training as needed Residents Affected - Some d. Documenting interventions e. Ensuring the interventions are put into action .i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions A review of the policy titled Safe Resident Handling/Transfers, implemented 10/3/22, indicated the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. .Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. .3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting excepts in medical emergencies. .10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually, and as the need arises or changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practice[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 18 of 18