Inspection·February 29, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few check and make sure the device was within the resident's reach before they left the room. CNA M clipped the cord to the resident's bed sheet and said, she knows how to use it; she knows what it is. The resident placed the device in her right hand, squeezed it and said, call light. On 2/26/24 at 3:22 PM, the DON said staff were expected to check residents' call lights before they left the room. She recalled she had responded twice earlier the same day to resident #5 when she heard her call out for assistance. She was informed the resident's call light was on the floor, out of the resident's reach. She explained, she was not aware the call device had been left on the floor and said, I must've missed it. The Comprehensive Care Plan showed there were Focus items for altered cardiovascular status, chronic and acute pain, high-risk medication adverse effects, incontinence, end stage renal disease and dialysis complication risks, ADL self-care performance deficits related to weakness, poor balance, decreased endurance, decreased mobility (bilateral BKA) (below the knee amputation of both legs) with an intervention that read, Encourage the resident to use bell to call for assistance, high-risk for falls with an intervention that read, ensure call light is within use and encourage use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 2 of 21 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 02/29/2024 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide personal fund quarterly statements to 1 out of 1 resident reviewed for personal funds out of a total sample of 27 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] from the hospital. His diagnosis included unspecified convulsions, hemiplegia, and hemiparesis following cerebral infarction, depression, and anxiety disorder. The most recent annual Minimum Data Set (MDS) with an assessment reference date of 12/29/23 revealed resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated the resident was cognitively intact. On 2/26/24 at 11:05 AM, resident #44 stated the facility held funds on his behalf but he had not received information regarding the balance in his account. He said he had never received financial statements from the facility. He explained he wanted to order some take out food but was uncertain about the balance in his facility held account. On 2/28/24 at 1:15 PM, the Business Office Manager (BOM) conveyed she had worked in her position for 1 year. She stated residents could choose to have their personal funds managed by the facility and quarterly statements were provided to the residents who were alert and oriented, or to their Power of Attorney (POA) if applicable. The BOM acknowledged there was not a system in place to ensure resident's quarterly statements were sent out. She checked resident #44's account and remarked, He does have a personal fund account. I was not aware he had an account. She verified the resident had not received his personal fund quarterly statements because she was not aware he had an account. Review of the facility's Resident Personal Funds Policy noted if the resident chooses to deposit personal funds with the facility, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage and account for the personal funds of the resident deposited with the facility. The individual financial record must be available to the resident through quarterly statements and upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 3 of 21 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 02/29/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to clarify code status related to a Do Not Resuscitate Order (DNRO) for 1 of 2 residents reviewed for Advance Directives of a total sample of 27 residents, (#57) Findings: Review of resident #57's medical record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included chronic obstructive pulmonary disease. Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on [DATE] revealed resident #57 required a surrogate for decision making. The form showed resident #57 was alert, disoriented but could follow simple instructions. Section H. Advance Directives was answered YES for DNR (Do Not Resuscitate). The form instructed the transferring facility to attach any relevant documentation. Review of hospital documentation revealed physician notes dated 2/6, 2/12, 2/13, 2/14, and [DATE] indicated resident #57 was a DNR. Review of hospital physician's note dated [DATE] revealed an end of life discussion with two of resident #57's sons. The note included resident #57 had limited capacity but does not have capacity at the time for complex goals of care discussion. The note read, At the time they are in agreement with hospice. Do want DNR/DNI. (do not intubate). A section of the form listed, Advanced Directive & Healthcare Proxy Surrogate Information: DNR/DNI. Assigned healthcare proxy is [name of resident #57's son]. Review of the Admit/Readmit Screener form with effective date of [DATE] at 5:01 PM, revealed resident #57 was alert but not oriented to person, place, time, or situation. The form did not include information regarding advanced directives. The form revealed the facility's physician was notified of the admission at 6:37 PM and resident #57's son at 6:57 PM. Review of a Narrative Note dated [DATE], entered at 10:30 PM, included patient is status full code and family was notified of patient arrival, verbal consent obtained via phone by surrogate [name of resident #57's son] also spoke about asking for appetite stimulant for patient and all other concerns addressed. Review of a Progress Note dated [DATE] read, Around 11:40 pm during round this writer noticed patient trying to get down the bed in presence of night Nurse making round as well. we assisted patient back to bed and fixed her blankets, no SOB [shortness of breath] noted at this time, patient was breathing normally. in about 4 minutes after this writer was giving report to night shift, CNA [Certified Nursing Assistant] assigned to patient called for assistance. when entering the room, patient face was still and pale, unresponsive, no breathing noted , no carotid pulse felt. this writer called code blue and initiated CPR [cardiopulmonary resuscitation] right away, while the other nurse called 911. Another Progress Note dated [DATE] read, [name of hospital] charge nurse called facility at 1 AM to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 4 of 21 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 02/29/2024 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 0578 notify that patient was pronounced dead exactly at 0042 (12:42 AM). Level of Harm - Minimal harm or potential for actual harm Review of facility's physician orders for resident #57 showed a code status full code order was entered on [DATE] at 5:04 AM, to be effective on [DATE] at 5:02 PM. Residents Affected - Few On [DATE] at 12:54 PM, during a telephone interview, resident #57' son stated he signed his mother's DNR in [DATE] at the hospital. He explained on [DATE], he received a call from the facility informing him his mother was admitted and a few hours later he received a second call letting him know she stopped breathing and was sent to the hospital. He stated the facility did not ask about Advanced Directives during the initial call. He recalled his mother told him, If I die, I want to die and that's it, not tube or nothing. He stated he agreed with following her wishes. On [DATE] at 1:25 PM, the admission Director explained she received referrals from hospitals electronically and accepted them tentatively pending review of documents and bed availability. She stated if there was something unfamiliar to her she asked the Director of Nursing (DON) because she was not a nurse. She reviewed the forms they requested from the hospital once they accepted the referral, and the DNRO was not one of them. She stated any other form came on admission and was reviewed by the nurse receiving the new resident. She shared she used a checklist to review the documents she needed against what was received from the hospital. She provided a copy of the documents to the nurses in the unit and emailed a copy to the Administrator, the DON, Medical Records, Social Services Director, Activities, Nursing Supervisor, Minimum Data Set Coordinator, and the Scheduler. She stated she received the referral for resident #57 on [DATE] at 11:40 AM. She recalled she received a call from the hospital Case Manager explaining the details of this case. She indicated she reviewed the referral paperwork, accepted the resident, and requested the forms needed. She explained before resident #57 was discharged from the hospital on [DATE], her son came to the facility and she showed him around including her room. She stated Advanced Directives was not discussed during their conversation. She stated after he left, she received a text from resident #57's son on [DATE] at 5:34 PM asking if his mom had arrived to the facility. On [DATE] at 3:07 PM, Licensed Practical Nurse (LPN) G explained upon resident #57's arrival to the facility, he reviewed the documents sent by the hospital and reviewed the AHCA 3008 form, face sheet, medication list, and discharge instructions. He indicated he called the physician to inform him the resident was in the facility. He stated he obtained vital signs and documents required on admission per facility protocol. He stated when the AHCA 3008 form showed the resident was DNR and the appropriate form was not included in the hospital paperwork, he followed up right away by calling the hospital and family. He stated he could ask the family to bring a copy if they had it and he would usually document the form was missing and the steps he took in the medical record. He recalled when he reviewed the AHCA 3008 form he noted resident #57 was a DNR in the hospital, but the DNRO form was not included. LPN G stated he contacted the hospital and spoke with the nurse who gave him the report and asked for the DNR form. He indicated he was told they did not have one. He said he contacted resident #57's family to clarify status and her son told him he was going to be in the facility the next day. LPN G did not answer when asked if he told the son the DNR form was not received from the hospital. He stated if a resident or family member wished DNR, he and another nurse could obtain a verbal consent and order from the physician. On [DATE] at 5:50 AM, LPN H stated she did not usually ask for code status during shift change report. She recalled resident #57's coded on [DATE] and they provided cardiopulmonary resuscitation (CPR). She stated she did not see the AHCA 3008 form and did not know it was marked DNR. She said, I think he (LPN G) was saying some paper did not come in the packet from the hospital. She explained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 5 of 21 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 02/29/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without the DNRO residents were treated as full code. She stated after the resident was taken to the hospital, she informed the DON. She stated there were no subsequent questions about this event after that day. On [DATE] at 10:44 AM, during a telephone interview, the former DON stated she worked in the facility from [DATE] until a week ago. She recalled resident #57 was admitted on a Friday evening and she received a phone call at approximately midnight, from LPN H informing her resident #57 had coded and they performed CPR. She remembered asking the nurse if resident #57 was a full code, and the response was yes. She stated she did not take a good look at the documentation from the hospital. She indicated she left the facility around 4:30 PM on Friday [DATE] therefore, she did not have an opportunity to review the admission paperwork that was emailed to her. She said she did not receive a call from LPN G when the resident was admitted to inform her the AHCA 3008 showed resident #57 was a DNR and the form was not included in the packet from the hospital. She mentioned at some point during the conversation after resident #57 coded, LPN G mentioned something about the DNR form and she was under the assumption her family had mentioned DNR in the past. She stated she had not had the opportunity to look at the packet when she returned to work on Monday [DATE]. She said she reviewed the CPR documentation and progress notes in resident #57's medical record but did not look at the AHCA 3008 form. She stated the nurse should have clarified the code status with the family when obtaining consent to treat. She indicated if the family wanted DNR for resident #57, LPN G with another nurse could have witnessed the call and obtain a physician's order. She stated she could not give a good answer as to why she did not look at the hospital documents, but she knew the resident had been discharged . She indicated her focus that Monday were the residents in the center, the ones admitted , and she took LPN G's word resident #57 was a full code. She recalled she was busy orienting with the new DON and LPN G was a very good nurse, so she had no reason to doubt him. On [DATE] at 2:35 PM, the DON and Administrator explained the admission process to the facility. The DON indicated the AHCA 3008 form showed who the decision maker was and specified Advanced Directives. The Administrator stated he recalled being informed on Monday [DATE] that resident #57 became unresponsive and emergency services was called. The DON stated she started working on [DATE] and there was a folder with an investigation for the event related to resident #57. The documents provided by the DON included a Code Blue Response Worksheet dated [DATE]. She indicated she had the folder, but she was unaware of any issues, therefore no investigation was initiated. The Administrator acknowledged that an investigation had not been done. Review of the policy and procedures titled admission of a Resident revised on [DATE] read, The admission process is intended to obtain all the information possible about the resident . The policy did not include information about obtaining Advance Directives. Review of the policy and procedures titled Advanced Directives Code Status issued on 1/2024 read, 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 6 of 21 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 02/29/2024 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 Advance Beneficiary Notification of Non-Coverage to 2 out of 3 residents reviewed for skilled nursing facility beneficiary notices out of a total of 27 sampled residents, (#7 and #48). Residents Affected - Few Findings: 1. Resident #7 was admitted to the facility on [DATE] from the hospital. Her diagnosis included chronic obstructive pulmonary disease, type II diabetes, dementia, depression, and anxiety disorder. Review of resident #7's Census Line revealed the resident's Medicare Part A skilled nursing care began on 12/4/23 with the last covered day of Part A service on 1/22/24. She remained in the Long-Term Care facility with Medicaid Pending as her primary payer source effective 1/23/24. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification revealed resident #7 received a Notice of Medicare Non-Coverage (NOMNC) at the end of her Medicare Part A service but did not receive a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). 2. Resident #48 was admitted to the facility on [DATE] from the hospital. His diagnosis included wedge compression fracture of the second lumbar vertebra, osteoporosis with current pathological fracture, transient ischemic attack, muscle weakness, and major depressive disorder. Review of resident #48's Census Line revealed the resident's Medicare Part A skilled nursing care began on 1/1/24 with the last covered day of Part A service on 1/7/24. He remained in the Long-Term Care facility with Medicaid Pending as his primary payer source effective 1/8/24 and patient liability as secondary payer. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed resident #48 received a Notice of Medicare Non-Coverage (NOMNC) at the end of his Medicare Part A service but did not receive a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). On 2/29/24 at 12:12 PM, the Business Office Manager (BOM) stated resident #7 and resident #48 had skilled benefit days remaining. She explained the residents were discharged from Medicare Part A services by the facility when benefit days were not exhausted, and they continued living in the facility's Long-Term care. The BOM confirmed residents #7 and #48 were not notified through an Advance Beneficiary Notice (ABN) that their Part A services were ending. She acknowledged she was not familiar with ABNs, indicating she had neither heard of them nor received training on their usage since assuming the BOM position about a year ago. She stated the sole beneficiary notification that she had provided to residents was the Notice of Medicare Non- Coverage (NOMNC). The facility's Resident Rights Policy read, The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct during his or her stay in the facility. It also read, The resident has the right to be informed of information regarding Medicare and Medicaid eligibility and coverage. The facility's Advance Beneficiary Notices Policy read, It is the policy of this facility to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 7 of 21 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 02/29/2024 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 0582 Level of Harm - Minimal harm or potential for actual harm provide timely notices regarding Medicare eligibility and coverage . For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055 .The Business Office Manager, or designee, is responsible for issuing notices. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 8 of 21 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 02/29/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders to prevent gastrostomy tube feeding complications and adequate hydration for 1 of 1 resident reviewed for gastric tube feeding out of a total sample of 27 residents, (#212). Findings: Review of the medical record revealed resident #212 was admitted to the facility on [DATE] from the hospital. Her diagnosis included hemiplegia and hemiparesis following cerebral infarction, dementia, obesity, dysphagia, gastrostomy status, unspecified protein-calorie malnutrition, and persistent mood disorders. Resident #212's Minimum Data Set (MDS) admission assessment with an assessment reference date of 2/18/24 revealed the resident scored 09 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she had moderately impaired cognition. The assessment also noted the resident had a feeding tube on admission that provided 51 percent or more of her total caloric intake and 501 cubic centimeters (cc) or more of her fluid intake per day. Review of resident #212's medical record revealed a care plan was initiated on 2/16/23 that indicated the resident required an enteral feeding tube to meet nutrition and hydration needs related to her disease process. A care plan initiated on 2/27/24 noted the resident required tube feeding for dysphagia and was at risk for dehydration and complications related to tube feeding. The care plan interventions included to provide tube feeding and water as ordered. Resident #212's Order Summary Report and the Medication Administration Record (MAR) revealed the continuous auto flush order of 100 milliliters (ml) of water every four hours through the percutaneous endoscopic gastrostomy (PEG) tube was discontinued on 2/16/24. A new physician order was initiated on 2/17/24, specifying that 42 ml of water per hour should be received by the resident for 20 hours, with the auto flush on at 2 PM and off at 10 AM. On 2/26/2024 at 2:38 PM, resident #212 was observed with Jevity 1.5 calorie tube feed formula infusing via pump at 50 ml an hour with 100 ml water auto flush set at every 6 hours. On 2/26/2024 at 2:40 PM, Registered Nurse (RN) A reviewed resident #212's enteral feeding order and stated the current order specified the resident was to receive auto water flushes set at 42 ml per hour for 20 hours. The nurse confirmed the resident's gastrostomy tube water flush currently infused at 100 ml every 6 hours, which did not match the physician's order. RN A acknowledged she initiated the tube feed at 2 PM and the water flush setting was incorrect. She stated the water flush should be set at 42 ml per hour for 20 hours. ON 2/26/24 at 3:30 PM, the Registered Dietician (RD) confirmed the resident's water flush order had changed from 100 ml every 4 hours to 42 ml every hour on 2/17/24. On 2/29/24 at 3:10 PM, the Director of Nursing (DON) stated RN A notified her the tube feed water flush was infused at the wrong rate. Instead of infusing at 42 ml an hour, it was set at 100 ml every 6 hours. When the error was brought to the DON's attention, she confirmed an incident report was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 9 of 21 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 02/29/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few initiated on 2/26/24, which indicated the enteral feeding pump did not match the water flush order. The DON acknowledged it was important the resident received water flushes as prescribed to prevent adverse outcomes such as dehydration, renal failure, or even death. Review of the facility's Tube Feeding Validation Checklist for RN A noted observation included flush feeding tube with prescribed amount of fluid. RN A signed and dated the in-service on 1/24/24. The facility's Care and Treatment of Feeding Tubes Policy read, It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 10 of 21 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 02/29/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nurses monitored complication risks for 1 of 1 resident reviewed for Dialysis, of a total sample of 27 residents, (#5). Residents Affected - Some Finding: Review of the medical record revealed resident #5, an [AGE] year old female was admitted to the facility on [DATE]. Her diagnoses included end stage renal (kidney) disease, dependence on renal dialysis, chronic respiratory failure, hypoxemia (low blood oxygen), congestive heart failure (heart pumping dysfunction), cardiomyopathy (heart muscle disease), Chronic Obstructive Respiratory Disease (COPD), anemia, type 2 diabetes mellitus, malnutrition, major depressive disorder, and acquired absence of both legs above the knee. After re-hospitalization, on 2/18/24 she was readmitted back to the facility with additional diagnoses that included pleural effusion (fluid in the lung space) and acute cystitis (bladder inflammation). The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) 11/19/23 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The assessment showed there were no rejections of evaluation or care. The assessment noted the resident required maximum assistance and was dependent on staff for mobility and to complete Activities of Daily Living (ADLs). She had gained 5% or more unplanned weight in the last month or 10% or more in the previous month, and she received hemodialysis while a resident during the look back period. The Care Plan showed there were Focus items for altered cardiovascular status, chronic and acute pain, high-risk medication adverse effects, high-risk for falls, incontinence, ADL self-care performance deficits, end stage renal disease and dialysis complication risks with interventions that nurses monitored and assessed vital signs, port access, and weights after treatments. The Order Summary Report showed active physician orders for Consistent Carbohydrate Diet/Renal Diet puree texture with a 1000 milliliters (ml) daily fluid restriction. On 2/26/24 at 10:30 AM, resident #5 was observed in her room lying in bed. On 2/27/24 at 9:53 AM, Registered Nurse (RN) C stated the resident was out of the facility for dialysis treatment. On 2/27/24 at 3:39 PM, RN A said nurses were expected to complete a handwritten dialysis communication form every time a resident went out for dialysis treatment. She stated, all completed forms were kept at the nurses station in a binder under a tab with the resident's name. The nurse explained the forms were important to track the resident's condition and monitor for changes and complications so they could notify the physician if needed. On 2/27/24 at 3:50 PM, a review of the Dialysis Book kept at the nurse's station revealed it contained a total of six Dialysis Transfer Forms for resident #5 that dated back to April 29, 2023. The form noted three sections for nurses to complete before, at, and after dialysis treatments. The middle section was to be completed by the dialysis center, and a bottom section for facility nurses that read, Completion upon return to Center following dialysis appointment. All six of the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 11 of 21 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 02/29/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some forms were missing entries from the dialysis center and facility nurses upon the resident's return. RN A checked the binder and acknowledged there were only six forms for the resident, and all six were incomplete. She said she had not yet completed the current days form. Review of the Weights and Vitals Summary Report revealed from August 2023 to February 2024, resident #5 was not weighed after dialysis treatments 78 out of 92 times. The report did not include vital signs entries. In an interview on 2/29/2024 at 2:48 PM, the Director of Nursing (DON) said nurses were expected to follow physician's orders for dialysis treatments, monitor for complications, and notify the doctor if there were concerns. She stated weights were expected to be done upon the resident's return to the facility from dialysis. She explained, she had been working at the facility for less than a week and said the previous DON was, working with dialysis for the check site bleeding. Review of the Dialysis Book revealed it contained instructions for nurses that read, 1) Verify that the middle portion of the original form has been completed by the nurse at the dialysis center. If incomplete, immediately contact the dialysis center. You may need to fax the form to them for completion. 2) Complete the bottom portion of the dialysis transfer form and file under resident's tab in dialysis book. Review of the facility's undated standards and guidelines titled Care Planning Special Needs - Dialysis read, . 3. Interventions will include, but not limited to: a. Documentation and monitoring of complications b. Pre- and post- weights c. Assessing, observing, and documenting care of access sites, as applicable . f. Vital signs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 12 of 21 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 02/29/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist's recommendations were acted upon in a timely manner for 3 of 5 residents reviewed for unnecessary medications of a total sample of 27 residents, (#1, #28, #45). Findings: 1. Resident #1, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included multiple sclerosis, diabetes type 2, schizophrenia, bipolar disorder, pseudobulbar effect, major depressive disorder, and generalized anxiety. Review of the resident's Pharmacist recommendations revealed the following: on 8/16/23 the resident had an order for Austedo IR 18 milligram (mg) daily. The recommendation was for the physician to consider changing the medication to twice daily. The rationale documented for the recommendation was, Per manufacturer, doses greater than or equal to 12 mg/day should be administered in two divided doses. The prescriber's response dated 9/01/23 indicated the prescriber agreed with the recommendation, and documentation read, Give Austedo 12 mg BID (twice daily) Austedo tablets are prescription medicines that are used to treat .movements in the face, tongue, or other body parts that cannot be controlled. (retrieved from austedo.com on 3/11/2024) Review of the resident's physician orders showed an order dated 9/08/23 for Austedo 6 mg, and directive was to give 12 mg BID. This order was entered in the resident's clinical record seven (7) days after the prescriber's response to the Pharmacist's recommendation. The Pharmacist's recommendation on 1/05/24 indicated the resident had order for Aripiprazole 7 mg daily since 1/2023, and a GDR/decreasing (Gradual Dose Reduction) to Aripiprazole 5 mg daily was recommended. The prescriber agreed with the recommendation on 2/03/24. Review of the resident's physician orders revealed an entry dated 2/09/24 for Aripiprazole 5 mg daily. The order was entered six (6) days after the prescriber's response, and approximately one month since the Pharmacist's recommendation was made. 2. Resident #28, a 75- year-old male was admitted to the facility on [DATE], with diagnoses which included cerebral infarction, diabetes type 2, chronic obstructive pulmonary disease, dementia, mood disturbance, chronic diastolic (congestive) heart failure, major depressive disorder, and hyperlipidemia. The Pharmacist recommendation dated 5/12/23 revealed the resident had physician's order for Novolin Regular sliding scale insulin, and the recommendation was to consider discontinuing the sliding scale insulin. The rationale documented was, sliding scale insulin typically results in increased resident discomfort due to blood glucose monitoring and directs that a basal- bolus strategy more closely mimics a normal physiologic response for more effective glucose control. The physician/prescriber disagreed with the recommendation on 8/03/23 and added the insulin Glargine 15 Units at bedtime. Review of the resident's physician orders revealed the insulin Glargine was not addressed until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 13 of 21 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 02/29/2024 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 0756 8/18/23, 15 days after the physician's order. Level of Harm - Minimal harm or potential for actual harm On 2/29/24 at 2:30 PM, the Director of Nursing (DON) explained the process for the Pharmacist recommendations included, the Consultant pharmacist sends the report/recommendations to the DON via email. The DON then distributed the recommendations to the physicians, who would agree, or disagree with the recommendation, which would be signed and dated, and returned to the DON. She stated the expectation was that physicians would respond to the recommendations as soon as possible, and they would be acted upon before the next pharmacy review. The DON said, if the physician/prescriber agreed with the recommendations, the order should be entered into the facility's electronic system on the day the physician responded to the recommendations. Resident #1's pharmacy recommendations dated 8/16/23, and 1/05/24 were reviewed with the DON. She acknowledged that response to the recommendations was not timely. Resident #28's pharmacy recommendation dated 5/12/23 was reviewed with the DON. She acknowledged the physician's response was dated 8/03/23, and the order for the insulin Glargine was not entered into the resident's clinical records until 8/18/23. The DON acknowledged that response to the pharmacist's recommendation was not timely, and stated it was not acceptable, and should have been acted upon in a timely manner. Residents Affected - Few 3. Resident #45 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, dementia, type 2 diabetes, and depression. Findings: Review of the monthly Medication Regimen Review revealed that a pharmacy recommendation was made on 11/08/23 to taper or discontinue Prednisone if appropriate. The physician agreed with the recommendation and signed the recommendation to discontinue Prednisone on 11/15/23. The medication was not discontinued until one month later, on 12/15/23. A pharmacy recommendation dated 12/12/23 noted to add a diagnosis for Methotrexate. The recommendation was not signed by the practitioner until 2/01/24. A pharmacy recommendation was made on 12/12/23 for Humalog insulin sliding scale to have a 14 day stop date. The practitioner agreed and signed the recommendation on 2/01/24. On 2/29/24 at 2:30 PM, the DON stated she just started to work in this facility on 2/19/24. She stated her process would be, when she receives the monthly recommendations via email from the pharmacy, she would review the recommendations first and if the recommendation requires a medication change, she would call the physician with the recommendation and place the order in the computer. All other recommendations would be placed in the physician's book and she would request that the physician complete the recommendation and return it to her. The DON said, My expectation is to have the recommendation back as soon as possible and before the next monthly recommendation. She stated the order should be put in the facilities computer system the day that it is received. The DON reviewed the above recommendations for resident #45, and acknowledged none of the three orders were acted upon timely, which is unacceptable and they should have been completed the month they were received. The facility's policy Consultant Pharmacist Reports Documentation and Communication of Consultant Pharmacist Recommendations dated May 2022 read, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding resident's medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion . The timing of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 14 of 21 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 02/29/2024 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 0756 these recommendations should enable a response prior to the next medication regimen review. 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 15 of 21 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 02/29/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 clarify an order for Voltaren gel 1%, that did not have directions for required amount of medication to be used for 2 of 5 residents reviewed for unnecessary medications of a total sample of 27 residents, (#23, #213). Residents Affected - Few Findings: 1. Resident #23 was admitted to the facility on [DATE] with diagnoses to include myocardial infarction, depression, anxiety, chronic pain, and chronic kidney disease. Review of the resident's physician orders dated 2/12/24, revealed orders for Voltaren external gel 1%, apply to bilateral knees topically two times a day for pain. On 2/14/24 an order for Voltaren external gel 1%, apply to bilateral feet typically every 8 hours as needed for pain (with no stop date) and an order on 2/15/24, for Voltaren external gel 1% (topical) apply to bilateral feet topically two times a day for pain for 7 days. The orders had no direction for the amount of gel to apply. 2. Resident #213 was admitted to the facility on [DATE] with diagnoses to include encephalopathy, dementia, type 2 diabetes, anxiety, and depression. Review of physician orders dated 2/27/24, read Voltaren external gel 1% apply to bilateral knees topically two times a day for pain. The order had no direction for the amount of gel to apply. On 2/29/24 at 2:48 PM, the Director of Nursing, (DON) stated If the physician did not write a complete order, my expectation is that the nurse will get a clarification order from the physician. The DON reviewed the order for Voltaren gel 1% for residents #23 and #213, and acknowledged the order required clarification because it had no direction as to the amount of the medication to be used. On 2/29/24 at 6:41 PM, Registered Nurse I stated, when she used Voltaren gel she would get the order from the physician and apply the gel topically. She stated she did not know the medication required direction for the amount of gel to use and did not know the medication had to be measured prior to applying it to the resident. Manufacturer's dosing recommendations included: Patients should use it 4 times a day, every day. Do not use on more than 2 body areas at the same time. After 21 days, patients should consult a physician before further use. The dosing card should always be used to measure a dose. For each upper body area (hand, wrist, or elbow) squeeze out 2.25 inches (2 grams) For each lower body area (foot, ankle, or knee) squeeze out 4.5 inches (4 grams). (retrieved from https://www.haleonhealthpartner.com/voltaren on 3/01/24). For Voltaren® 1% topical gel: Use the enclosed dosing card to measure the correct dose. The gel should be applied within the oblong area of the dosing card up to the 2 or 4 gram line (2 grams for each elbow, wrist, or hand, and 4 grams for each knee, ankle, or foot). (retrieved from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 16 of 21 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 02/29/2024 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 0757 www.mayoclinic.org on 3/01/24). 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 17 of 21 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 02/29/2024 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 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 observation, interview and record review, the facility failed to ensure food was stored in a safe and sanitary manner in the kitchen's walk in refrigerator and 1 of 1 nourishment room and failed to ensure 2 of 3 employees observed followed appropriate hygienic practices in food preparation areas. Findings: 1. An initial visit to the kitchen on 2/26/24 at 9:06 AM revealed a tray of refried beans and a tray of ravioli with tomato sauce in the walk-in refrigerator were covered with a plastic wrap but were not labeled or dated. The Certified Dietary Manager (CDM) stated they had to be from the weekend and acknowledged all leftovers in the refrigerator had to be properly labeled and dated. 2. On 2/29/24 at 5:56 PM, observation of a refrigerator located in the nourishment room with Certified Nursing Assistant (CNA) D revealed two Styrofoam cups with leftover shakes. One cup had a room number and 2/26 written and the other cup had 2/29 written but did not have a resident's name and room number. CNA D discarded both cups and stated they should not use food in the refrigerator after a couple of days and residents' leftovers had to be labeled with the appropriate name and room number. 3. On 2/29/24 at approximately 6:05 PM, [NAME] E was observed wearing large yellow hoop earrings and Dietary Aide F was eating from a Styrofoam cup while wrapping and labeling leftovers in the food preparation area. On 2/29/24 at 6:13 PM, [NAME] E stated she was not supposed to wear big hoop earrings when she worked. She explained the earrings could fall off in the food during preparation. On 2/29/24 at 6:15 PM, Dietary Aide F stated she was eating potato salad. She said they had already finished serving. She explained after serving food it is okay to do, not during working time when food is being served. Dietary Aide F then acknowledged she was not supposed to eat in the kitchen. On 2/29/24 at 6:17 PM, the CDM stated it was not acceptable for staff to eat while working, and staff were supposed to take a break to eat outside the kitchen. She indicated she did not notice [NAME] E wore long loop earrings today and acknowledged that was not acceptable attire for work. Review of the facility's policy Refrigerators and Freezers not dated read, This facility will ensure refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The policy included Use by dates were to be completed with expiration dates on all prepared food in refrigerators. Review of the policy Staff Attire dated October 2019 read, It is the center policy that all Dining Services employees wear approved attired for the performance of their duties. The policy included dangling jewelry was not permitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 18 of 21 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 02/29/2024 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 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. Based on interview, and record review, the facility failed to fully implement and monitor Performance Improvement Plans (PIPs) for identified resident care deficits. Residents Affected - Some Finding: In an interview on 2/29/24 at 2:48 PM, the Director of Nursing (DON) said nurses were expected to monitor residents who received dialysis for complications and notify the doctor if there were concerns. She explained, she had been working at the facility for less than a week and said the previous DON was, working with dialysis for the check site bleeding. On 2/29/24 at 3:20 PM, the DON stated she had a PIP related to dialysis residents with fluid restrictions. She provided documents she referred to as a PIP with logs titled Dialysis Audit Tool with handwritten entries dated from 1/19/2024 to 2/19/2024 and a blank form titled, Dialysis Communication Tool. She explained that the former DON had developed a new form and implemented the project two months prior. On 2/27/24 at 3:50 PM, a review of the Dialysis Book kept at the nurse's station revealed it contained blank and completed forms titled, Dialysis Transfer Form updated December 2017. RN A checked the binder and explained the forms were used to monitor and track conditions of residents on dialysis. The book did not contain the new form identified by the DON as new and included in the current PIP. On 2/29/24 at 6:07 PM, the Nursing Home Administrator (NHA) said the Quality Assurance Performance Improvement (QAPI) review was delayed because he had difficulty locating PIP records. In a joint interview with the NHA and DON on 2/29/24 at 6:14 PM, the NHA explained the QAPI committee met monthly to review, discuss, and identify root causes and develop plans for improvement. He said the committee used track and trending reports from its members and resident council to identify performance deviations, audit tool development, and any needs for ongoing PIP revisions. The DON said the dialysis PIP did not include evidence that indicated nurse education was provided as outlined in the actions. She reviewed the PIP documents and acknowledged the audit forms were incomplete with several missing entries. She could not explain why the Dialysis Book had not contained the new forms indicated in the PIP and stated, it was not successful; the interim DON told me it wasn't working, and I have to continue. The NHA said in October 2023, the committee identified concerns related to a high number of resident falls after meals. The NHA recalled that there was a PIP and audit tool created and forms were presented at the last two QAPI meetings however, he was unable to locate the records. He explained, the DON planned to bring the concern to their next QAPI meeting and said, we will start over next month. The NHA explained, monitoring and tracking of PIPs in QAPI and Quality Assessment and Assurance (QAA) programs was essential to facilitate improvement with facility identified concerns for the residents and stated, you know we bring it forward to QAPI to establish a root cause and try to improve on whatever needs improvement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 19 of 21 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 02/29/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Quality Assurance Performance Improvement (QAPI) Plan dated 1/18/24 read, .Guiding Principle #3: The outcome of QAPI in our organization is the quality of care and the quality of life of our residents. Guiding Principle #6: Our organization makes decisions based on data . Guiding Principle #7: Our organization sets goals for performance and measures progress toward those goals. The aim is safety and high quality with all clinical interventions . The committee shall maintain meeting agendas, minutes, attendance records, and QAPI program progress reports. A scorecard/dashboard(s) for individual performance improvement projects are used to communicate progress and outcomes of individual QAPI projects. The information is compared against the benchmark set by the QAA Committee and results are listed and graphed. The QAPI Lead or Coordinator is responsible for cataloging and maintaining these reports. Event ID: Facility ID: 105379 If continuation sheet Page 20 of 21 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 02/29/2024 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview, and record review, the facility failed to provide evidence of the Infection Preventionist's (IP) qualifications for 1 out of 1 staff reviewed for specialized training in infection prevention and control. Residents Affected - Some Findings: Review of the infection prevention and control module certificates provided by the Nursing Home Administrator and the Infection Preventionist (IP) indicated that only six modules were completed by the IP on September 25, 2021. There was no evidence presented to confirm completion of the Infection Prevention Training Course by the IP. On 2/29/24 at 4:17 PM, the Infection Preventionist (IP) stated she had been the IP at the facility for three years. She acknowledged she completed the CDC (Center for Disease Control) Infection Prevention and Control training course in 2021. The IP verified she was unable to provide proof of completion for the infection prevention training course and could only present evidence of having completed six modules on September 25, 2021. The facility's Infection Control Preventionist job description/job requirements read, Infection Control and Prevention Certification required. The facility's Infection Prevention and Control Program read, The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff . It also read, All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 21 of 21