Inspection·April 19, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some evaluate and treat as indicated. The record documented the family was notified but there was no indication the State Long Term Care Ombudsman was notified of the transfer. On 4/19/23 at 2:26 PM, the Director of Social Services explained she used to send the State Long Term Care Ombudsman a list of residents who were transferred to the hospital and residents that were discharged . She said, I would fax it to their office. I am not doing that currently. She reported she had not sent anything to the State Long Term Care Ombudsman regarding discharges or transfers since the pandemic and was not aware if any other facility staff notified the Ombudsman. On 4/19/23 at 2:43 PM, the Director of Nursing (DON) stated she believed the former Business Office Manager sent discharge and transfer information to the Long Term Care Ombudsman's office. She indicated the current Business Office Manager would not have any knowledge concerning where the information could be found. She did not explain who was responsible for sending the notifications to the Ombudsman's office. The policy for Transfer and Discharge(including AMA) implemented 1/22/21 and revised 1/06/23 read: Generally, the notice must be provided at least 30 prior to a facility initiated transfer. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because: An immediate transfer is discharge is required by the resident's urgent medical needs; In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate and the LTC Ombudsman as soon as practicable before the transfer or discharge. The facility will maintain evidence that the notice was sent to the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 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 105379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kissimmee Health and Rehabilitation Center 320 N Mitchell St Kissimmee, FL 34741 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 - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review, the facility failed to ensure Licensed Practical Nurses (LPNs) received the required training by the Florida Board of Nursing to perform intravenous (IV) therapy for 1 of 2 LPNs, LPN A, reviewed for IV education and for 1 of 2 sampled residents reviewed with IV midlines in a total sample of 27 residents (#22). Findings: On 4/16/23 at 1:20 PM, resident #22 was seen from the hallway in bed lying on a low air loss mattress with an intravenous (IV) pump positioned by his bed. A contact isolation precaution sign was posted on his door next to a bin of personal protective equipment (PPE) that hung over the top of the door. Review of resident #22's physician orders and April 2023 Medication Administration Record (MAR) noted he had an order for IV antibiotic, Merrem 1 gram to be given three times a day for 7 days for a pressure ulcer infection, from 4/11/23-4/17/23 to be given at 6 AM, 2 PM, and 9 PM each day. On 4/17/23 at 2:15 PM, LPN A/Unit Coordinator was observed outside resident #22's room. She donned PPE bin and carried three 10 milliliter (ml) barreled syringes of normal saline (NS) and a luer lock cap in her hands. LPN A explained she was going into the room to attempt to clear resident #22's midline IV that was reportedly clogged. She said she would try to flush the line and the cap may need to be changed. LPN A's personnel and training files were requested and reviewed. They revealed she was hired on 11/3/2020. There was not any documented evidence the LPN had received the required Florida Board of Nursing's IV therapy education for LPNs. She had a single-state LPN license that was issued on 1/11/2010 with an expiration date of 7/31/23. On 4/19/23 at 10:05 AM, LPN A/Unit Coordinator verbalized she was able to clear resident #22's midline IV on the afternoon prior by replacing the IV cap and flushing the line. She explained the resident's midline IV was a single lumen catheter and he was given his final IV antibiotic yesterday evening. She said she was a LPN for about 18 years. LPN A indicated she had worked at this facility for about two years and no one had ever told her about the state's IV education requirements for LPNs. She stated, I guess I should have read the professional nursing standards of care for Florida. On 4/19/23 at 12:41 PM, the Assistant Director of Nursing/Education Development Coordinator acknowledged LPN A had not received the required State of Florida IV training for LPNs. At 2:31 PM, the Director of Nursing verbalized they had missed it. Review of Florida Administrative Code for the Department of Health and Board of Nursing revealed that Chapter 64B9-12, Administration of Intravenous Therapy By Licensed Practical Nurses, included the following: Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IC Therapy . The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.02(2), F. A. C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite for four hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 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 105379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kissimmee Health and Rehabilitation Center 320 N Mitchell St Kissimmee, FL 34741 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 specified in subsection (4), of this rule. 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: 105379 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 105379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kissimmee Health and Rehabilitation Center 320 N Mitchell St Kissimmee, FL 34741 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide proof of consent, refusal, or medical contraindication for pneumococcal vaccine for 1 of 5 residents reviewed for immunizations, (#26). Residents Affected - Few Findings: Resident #26, an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, hypertension, peripheral vascular disease, and history of falls. Review of resident #26's medical record revealed no documentation of consents, refusal, or medical contraindication for pneumococcal vaccine. Interview with the Assistant Director of Nursing (ADON) on 4/19/23 at 1:56 PM, revealed she was unable to provide a record of documentation of consent/refusal/contraindication for administration of the pneumococcal vaccine for resident #26. The ADON acknowledged they could not find documentation to show if the resident had previously received the vaccination, refused it or if the vaccination was offered. The ADON said the admission nurse was responsible for obtaining consent from the resident or representative on admission and enter the order for vaccination in the electronic medical record. The ADON explained new admissions were reviewed in the morning meetings to ensure nothing was missed and resident #26, just slipped through the cracks. Review of the facility's Policy and Procedure for Pneumococcal Vaccine revised 1/31/22 read, It is our policy to offer our residents, staff, and volunteer workers immunization .Each resident will be assessed for pneumococcal immunization upon admission .Each resident will be offered a pneumococcal immunization .A pneumococcal vaccination is recommended for all adults 65 years' and older FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 5 of 5