Health inspection·October 13, 2022

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/10/22 at 5:30 PM, CNA A acknowledged resident #111's fingernails were not acceptable. She said, Absolutely too long and dirty. CNA A stated no one should have to eat with their hands that dirty. Resident #111's dinner tray was in front of him and the resident was eating. He stated no staff checked his hands or cleaned them before dinner. 3. Resident #665 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, urinary tract infection, and atrial fibrillation. Review of the MDS assessment dated [DATE] revealed he a BIMS score of 12 indicating he had moderate cognitive impairment. He required extensive assistance of one person for personal hygiene, dressing, and was totally dependent for his bathing needs. On 10/10/22 at 1:00 PM, the resident was observed in bed. His fingernails to both hands were long and dirty with dark brown substance under all fingernails. He had a full beard and moustache, that was uneven and unkempt. Resident #665 stated he liked to be shaved but he needed someone to do it for him. On 10/10/22 at 5:21 PM, CNA B stated today was her first time caring for the resident. She confirmed that his fingernails were long and dirty. She said it was the CNAs responsibility to ensure the resident was shaved and his nails cleaned and trimmed. On 10/10/22 at 5:24 PM, the UM observed resident #665's fingernails and acknowledged no one should be eating with fingernails like that. She confirmed staff should assist residents with hand hygiene before and after every meal and nailcare should be provided at least on shower days. Resident #665 reiterated he required assistance with shaving. The Unit Manager stated it was the responsibility of all nursing staff to provide hygiene care for the residents. A review of the facility's CNA Job Description dated April 2020 Essential Duties & Responsibilities: Provide personal care (i.e., grooming, bathing, dressing, oral care, etc.) of residents daily and as needed. Review of the facility's Nail Care Policy, revised 6/07/21 noted, Routine cleaning and inspection of nails will be provided during ADL care and on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule and as need arises. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105377 If continuation sheet Page 2 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longwood Health and Rehabilitation Center 1520 S Grant St Longwood, FL 32750 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place for 4 of 6 residents reviewed for falls out of a total sample of 51 residents, (#32, #45, #26, and #67). Findings: 1. Review of resident #32's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, anemia, and anxiety. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 8/6/22 revealed a Brief Interview for Mental Status interview was not conducted because the resident was rarely or never understood. The MDS showed resident #32 depended on staff for transfers and toileting and required extensive assistance from staff for bed mobility. Review of resident #32's care plan for falls, revised 4/30/21, identified she was at risk for falls related to weakness, unsteadiness, decreased safety awareness, medication side effects, impaired vision, and history of falls. The care plan included interventions of bed bolsters, bed in low position, and bilateral floor mats. Review of a Post-Fall Evaluation dated 10/10/22 revealed resident #32 had an unwitnessed fall without injury. The nurse wrote, Observed resident on floor next to right side of bed. The evaluation specified resident #32 was not using footwear or an assistive device and there were no environmental factors present at the time of the fall. The immediate new measure put in place after the fall was frequent checks to coincide with neuro checks. On 10/11/22 at 9:43 AM, resident #32 was observed lying in bed with her eyes closed. Her bed was placed against the wall, with bolsters on the right side of the bed and there were no floor mats present. On 10/11/22 at 12:58 PM, she was sitting in a wheelchair in her room and there were no floor mats visible in her room. On 10/11/22 at 1:07 PM, Certified Nursing Assistant (CNA) C indicated she was not sure if resident #32 was supposed to have floor mats. She stated she used to have floor mats and her bed was always against the wall with bolsters on both sides of the bed to prevent her from falling. CNA C stated she was not aware of any recent falls for resident #32. CNA C noted resident #32 was not able to use her call light for assistance. CNA C reviewed the resident's care plan and noted floor mats was one of the interventions listed. She reported she did not know where the floor mats were and confirmed there were not in resident #32's room. On 10/12/22 at 10:05 AM, Registered Nurse (RN) D stated resident #32 required total care and 2-staff for transfers. RN C indicated resident #32 had not sustained any recent falls. She stated resident #32 did not use her call light when she needed help. RN D explained it was the CNA's responsibility to place floor mats by the bed when the resident was in bed. On 10/13/22 at 10:30 AM and 1:53 PM, the Director of Nursing (DON) explained it was her expectation the CNAs and nurses reviewed and familiarized themselves with the resident's care plan. The DON indicated CNAs and nurses performed rounding at change of shift and discussed residents' care. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105377 If continuation sheet Page 3 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longwood Health and Rehabilitation Center 1520 S Grant St Longwood, FL 32750 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 0689 Level of Harm - Minimal harm or potential for actual harm explained it was important to discuss any recent changes to interventions to the resident's care. The DON reviewed the details surrounding resident #32's fall on 10/10/22 and stated the incident occurred at 2:35 AM. The DON said according to the report, resident #32 was observed on the floor by her assigned nurse. She explained she obtained witness statements from staff assigned to resident #32, and the resident had not sustained any injuries. Residents Affected - Some On 10/13/22 at 2:23 PM, during a telephone interview, Licensed Practical Nurse (LPN) E explained she was seated at the nurses' station working on documentation when she heard someone talking words she couldn't understand coming from resident #32's room located across from where she was seated. She indicated she went in the room and found resident #32 lying supine on the floor, looking up. LPN E stated there was no mat on the floor. She stated resident #32 was in bed sleeping when she performed her rounds at the start of her shift at 11:00 PM. LPN E explained resident #32 did not sustain any injuries and she was assisted back to bed. She stated she knew resident #32 was supposed to wear a crisscross belt when up in the wheelchair and recalled she had floor mats before but did not know why the mats were not in the room that night. LPN E stated she did not review residents' care plan routinely and could not confirm if the floor mats were listed under the fall interventions. On 10/13/22 at 2:37 PM, the DON stated this incident was unfortunate and she was not aware LPN E had not reviewed the resident's care plan. The DON indicted it was her expectation for the nursing staff to be knowledgeable of care plan interventions for their residents. Review of the facility's policy titled Fall Prevention Program revised on 4/9/21 read, Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. Review of the facility's policy titled Comprehensive Care Plans revised on 7/27/22 revealed qualified staff responsible for carrying out interventions specified in the care plan to be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses that included cerebral atherosclerosis, Alzheimer's Disease, maxillary fracture, emphysema, dementia and compression fracture of T11-T12 vertebrae. Review of the MDS quarterly assessment with assessment reference date (ARD) 8/10/22 revealed resident #45's BIMS score was 6 which indicated she had severe cognitive impairment. She required extensive assistance for activities of daily living (ADLs) and had unsteady balance. A care plan initiated 2/15/22 indicated resident #45 was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension and was unaware of safety needs. Interventions included bilateral fall mats while in bed. Review of resident #45's medical record revealed a physician order dated 6/13/22 for bilateral floor mats while in bed. On 10/10/22 at 12:59 PM, 10/10/22 at 4:25 PM and 10/11/22 at 8:31 AM, resident #45 was observed in bed. Bilateral floor mats were not in place at bedside as ordered. 3. Resident #67 was admitted to the facility on [DATE] with diagnoses of cerebral vascular disease, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105377 If continuation sheet Page 4 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longwood Health and Rehabilitation Center 1520 S Grant St Longwood, FL 32750 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 0689 Alzheimer's disease, insomnia and delusional disorders. Level of Harm - Minimal harm or potential for actual harm Review of the MDS quarterly assessment with ARD 8/18/22 revealed resident #67 had a BIMS score of 3 which indicated she had severe cognitive impairment. She required extensive assistance with ADLs and had unsteady balance. Residents Affected - Some A care plan initiated 2/23/21 and revised 5/23/22 indicated resident #67 was at risk for falls related to cognitive loss/decline, medication side effects, impaired balance and history of falls. Interventions included bilateral fall mats. Review of resident #67's medical record revealed a physician order dated 8/04/22 for floor mats. On 10/10/22 at 11:25 AM, 10/10/22 at 2:44 PM and 10/11/22 at 8:30 AM, resident #67 was observed in bed. Bilateral floor mats were not in place as ordered. 4. Resident #26 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, dementia, repeated falls, transient ischemic attack and osteoporosis. Review of the MDS significant change assessment with ARD 7/25/22 revealed resident #26 had a BIMS score of 3 which indicated she had severe cognitive impairment. She required extensive assistance with ADLs and had unsteady balance. A care plan initiated 1/28/22 and revised 8/05/22 indicated resident #26 was at risk for falls related to confusion, gait/balance problems, incontinence, repeated falls, psychoactive drug use and was unaware of safety needs. Interventions included bilateral fall mats. Review of resident #26's medical record revealed a physician order dated 8/24/22 for floor mats at bedside while resident was in bed. On 10/11/22 at 8:31 AM, resident #26 was observed in bed. One floor mat was observed on the left side of resident's bed between the bed and the wall. There were no floor mats on the other side of the bed. On 10/11/22 at 9:08 AM, the Assistant Director of Nursing (ADON) stated bilateral floors mats were one of the interventions used for a resident identified as a fall risk resident. He observed resident #45 in bed and confirmed she had no floor mats at beside. He stated he was unsure whether or not she required bilateral floor mats. The ADON observed resident #67 in bed and confirmed she did not have floor mats in place. He stated he was unsure if she was identified as a fall risk. The ADON observed resident #26 in bed and confirmed she only had one floor mat in place. On 10/11/22 at 9:13 AM, the B-Wing UM stated she did not think resident #67 was identified as a fall risk. The UM reviewed resident #67's Electronic Medical Record (EMR) and confirmed there was a physician order for floor mats. The UM reviewed resident #26's EMR and confirmed a physician order for floors mats. She reviewed resident #26's care plan and confirmed she should have bilateral floor mats. The UM reviewed resident #45's EMR and confirmed a physician order for floor mats. She reviewed resident #45's care plan and confirmed she should have bilateral floor mats. The ADON was present and informed the UM resident #45 and resident #67 did not have any floor mats in place and resident #26 only had one floor mat in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105377 If continuation sheet Page 5 of 5