Inspection·May 29, 2025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Resident #43 was readmitted to the facility on [DATE] from an acute care hospital with diagnoses that included acute and chronic respiratory failure; partial paralysis following stroke, affecting the left dominant side; type 2 diabetes mellitus, trouble swallowing, unspecified dementia, moderate protein calorie malnutrition, colostomy status and gastrostomy (feeding tube) status. A colostomy is a temporary, or permanent surgical opening in the abdomen to drain stool from the body, (retrieved on www.hopkinsmedicine.org on 6/11/25). Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 5/06/25 revealed resident # 43 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was cognitively intact, had no behaviors nor rejection of care, ate independently and only required set up or clean up assistance during meals. A review of resident #43's Physician's Orders included a regular diet with thin consistency, 90 milliliter (ml) of House 2.0 calorie twice daily for nutritional supplement to be given with med pass (nutritional supplement), 30 ml Prostat AWC (Advanced Wound Care supplement) daily with med pass to promote wound healing. The orders indicated her gastrostomy tube was used for medication administration only. On 5/27/25 at 1:12 PM, resident #43 was in bed with her lunch tray in front of her. The assigned Certified Nursing Assistant (CNA) exited the room and stated she was going to get a grilled cheese sandwich for the resident because the resident did not like the sweet sauce on her mashed potatoes. The CNA mentioned the resident would eat on her own. About an hour later, on 5/27/25 at 2:06 PM, resident #43 was sleeping in bed, one bite of the grilled cheese sandwich was eaten from the plate on her bedside table. On 5/28/25 at 12:34 PM, resident #43 was in the dining room asleep in her wheelchair. One of the CNAs in the dining room reported the resident did not eat her lunch and she was waiting for help to put the resident back to bed. Later, on 5/28/25 at 2:05 PM, resident #43 continued to sleep in her room. A review of CNA documentation of resident #43's percentage of meal eaten for lunch on 5/27/25 was 0-25% and on 5/28/25 for breakfast, lunch, and dinner, it was 0-25%. A review of the medical record indicated the following weights for resident #43 since her re-admission to the facility on 4/29/25. On 4/30/25 resident #43 weighed 133 lbs. On 5/01/25 resident #43 weighed 133 lbs. and on 5/02/25 she weighed 132 lbs. There was no record of weights documented after 5/02/25 through 5/28/25. In a telephone interview on 5/28/25 at 6:03 PM, the Registered Dietician (RD) explained, resident #43 had multiple readmissions and came back to the facility on 4/29/25. On return from the hospital, resident #43 was placed on med pass supplements twice a day and another supplement, Prostat. The RD explained resident #43 was looked at as a new admission and was weighed every day for the first few days, then weekly for four weeks in order to more accurately assess her nutrition needs. She confirmed she was made aware the weekly weights were not performed and the last weight recorded was on 5/02/25 with no weight recorded thereafter. The RD explained the facility was aware she had asked for newly admitted residents to be weighed weekly since 5/09/25 and had spoken to the team during their last weekly meeting on 5/22/25. She said that the team was aware she was unable to complete her assessments without the weekly weights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 2 of 15 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 05/29/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/29/25 at 1:12 PM, CNA C and CNA D said their Activities of Daily Living (ADL) tasks in their electronic documentation would indicate which residents needed to be weighed or the nurse would let them know. They explained the restorative CNAs were usually responsible for weighing residents, however they could perform the task as long as they knew it needed to be done. On 5/29/25 at 1:25 PM, Registered Nurse (RN) B explained she followed the physician's orders if there was a weight that needed to be completed. On 5/29/25 at 10:39 AM, the Director of Nursing (DON) and RN A said that restorative CNAs performed the weekly weights but they would not have know which residents needed to be weighed. They acknowledged there was a communication problem within their process for staff to know who should be weighed. The DON confirmed she was told by the RD about the missing weekly weights and acknowledged the facility did not follow the process. The DON stated it was her responsibility to follow through on the issue of the weights, and said they, dropped the ball on this one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 3 of 15 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 05/29/2025 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interviews, the facility failed to post a complete Nurse Staffing report in a place readily accessible to residents, staff, and visitors. Residents Affected - Many Findings: On 5/27/25 at 2:30 PM, the Nurse Staffing sheet was posted on the wall in the hall leading from the lobby to the resident rooms. It was about six feet from the floor and out of view of the residents. Review of the posting revealed it did not include the facility census as required. On 5/28/25 at 2:00 PM, a facility visitor stated she was not aware of the facility staff posting on the wall. The visitor looked at it and acknowledged she could not read it because the typing was too small. On 5/29/25 at 12:14 PM, the Staffing Coordinator stated she was responsible for creating the staffing document that was posted in the lobby. She looked at the posting where it hung on the wall and acknowledged it could not be seen by anyone sitting in a wheelchair. She said there was another one posted outside her office door. When she looked at it, she agreed the words were too small for anyone in a wheelchair to read. The Staffing Coordinator acknowledged the census was not on either of the postings. She stated she was not aware the census was required on the posting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 4 of 15 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 05/29/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to ensure qualified staff had the appropriate competencies and skill sets to carry out management and oversight of the food and nutrition services as demonstrated by numerous irregularities including labeling/dating food, training to staff on food safety and preparation, and logs for the dish machine, which had the potential to affect all 53 of 53 residents residing and eating at the facility. Findings: On 5/27/25 at 9:38 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), multiple food items in the walk-in refrigerator, freezer and dry storage room had unlabeled, undated, expired, and improperly stored food items. The CDM did not provide required oversight of staff to monitor or address issues including food items left unlabeled, and undated or expired foods. The CDM did not provide to staff readily available policies and procedures for food labeling, storage and the expiration date policy. Instead, staff were directed to discard prepared foods after three days and was not aware of the actual policies of the facility. On 5/27/25 as the initial kitchen tour continued with the CDM, the dishwashing machine was observed at approximately 9:50 AM. The dishwashing machine's water temperatures were found to be lower than the required and the concentration of the chemical sanitizer was found to be higher than the appropriate level. The dishwashing machine's temperature log, for the previous months, revealed the dish machine temperatures to be out of the required range and entries for the dinner meals to be missing. The temperature log for the current month could not be located. The CDM did not provide the appropriate oversight to identify the concerns, nor to monitor or address the issues as required. Interview of a kitchen staff on 5/28/25 at 11:40 AM, revealed the cook never received instruction on how to take the dish machine temperatures at dinner meals. Other dietary staff and management were unsure which thermostat to use to record the dish machine temperatures and instructed staff to use one that recorded the temperature below the required minimum temperature. When provided with months of dish machine temperature logs which indicated the temperature did not meet regulatory requirements, management had not provided the oversight to address the inadequate temperatures and missing entries in the logs. The CDM also did not provide the oversight of the chemical sanitizer for the dish machine, review of the temperature logs contained documentation the chlorine disinfectant was at a level too concentrated to be safe for residents, instead she relied on the chemical supply company to notify her, saying she was never told any of it was an issue. Interview with staff and records revealed new staff received training online regarding food safety but documentation of direct staff education at the facility was minimal. A review of the staff training provided by the CDM revealed an in-service was completed on 7/04/24 reminding staff to fill out temperature logs. Over the next 10 months, only three additional in-services were provided, in April 2025 on the topics of slips and fall prevention, tray presentation and accuracy, and prevention of knife cuts. There were no additional in-services to address food safety, or storage for kitchen staff during that time. On 5/29/25 at 2:41 PM, the CDM stated it was the cook's responsibility to check food items for expiration and discard them which could be completed anytime during their shift, but she did not say what type of oversight she gave to kitchen staff beyond occasional verbal reminders. The CDM explained the facility's Administrator regularly asked her if staff completed the temperature logs, checked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 5 of 15 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 05/29/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete the milk carton dates, or had adequate supply of dish machine chemicals, but didn't inquire if she actually reviewed them regularly. The CDM was unable to say why the facility could not provide documentation of the dish machine temperature log for the month of May, or why she did not recognize or act on dish machine temperatures that were too low or missing entries in previous months' logs. The Dietary Manager had a current food safety certification, an associate's degree in management related to food service, and approximately 30 years' food service management experience according to her resume. She was directly employed by and provided oversight by a food service management contract company, yet numerous irregularities were noted which did not meet the Food and Drug Administration Food Code nor standards of practice for the industry. Event ID: Facility ID: 105379 If continuation sheet Page 6 of 15 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 05/29/2025 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 - Many 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 label and date stored food in accordance with professional standards for food safety, failed to ensure the dish machine was operated at proper temperatures and sanitizer was dispensed at proper concentrations, and failed to ensure nutritional supplements and residents' food brought in from family were dated and discarded when expired to prevent foodborne illness. These deficiencies had the potential to affect all the 53 residents residing and eating at the facility. Findings: 1. On 5/27/25 at 9:38 AM, during the initial kitchen tour with the Certified Dietary Manager, (CDM) multiple food items in the walk-in refrigerator were dated with a 30-day span between when they were received/opened and when they were to be discarded. For example, a large, clear bin of diced tomatoes were dated 5/25-6/25, approximately 25 cucumbers which had small, soft, dent spots in them which indicted spoilage, were dated 5/19-6/19, a plastic container of blueberries, which the CDM stated were previously frozen, were smashed and leaking juices, dated 5/16-6/16, a container of lemons were dated 5/9-6/9, a plastic container of leftover mushrooms were dated, 5/24-6/24, and a plastic container of leftover crushed pineapple were dated 5/16-6/16. The Dietary Manager stated one of the cooks had mistakenly dated these items as good for one month. She added, the previously canned pineapples and mushrooms could, usually be kept about five to seven days. The CDM explained cooks were responsible for discarding outdated items, but could not explain how items dated for use for a month, beginning from 5/09/25 and 5/16/25, had not been identified as expired and discarded. The items were still available for use by kitchen staff today, 5/27/25. During the tour, several previously opened food items were found undated, for example, a package of shredded cabbage, resealed with plastic wrap, a plastic container of ham base and a container of garlic in water, a cube of butter, and an aerosol canister of whipped cream were all undated. A vacuum-sealed package which held a large piece of raw pork was found without a date on it. The CDM stated the food items should have been dated when opened and the raw meat should have been dated when it was originally refrigerated. There was an opened container of chocolate frosting dated 8/08 without a date as to when it should be discarded. The CDM stated this frosting was fudge and therefore could be kept a 'long time. Two stacks of American cheese slices were opened and rewrapped: one with approximately 25 slices, the other 40 slices with an illegible date written in pen directly on top of the plastic wrap instead of on a sticker. TheCDM stated leftover cheese could usually be kept about a week' and indicated she could provide a more exact length of time food items could be kept by referring to the online policy. She acknowledged she did not have any of this information posted for staff to reference within the department. The CDM stated many of the staff had been here for a long time and were aware of how long food could be stored, in conflict to what was found during the tour of the refrigerator. In the walk-in freezer, a plastic bag of premade hamburgers was left opened to the air. The CDM noted the burgers had white spots and white areas on them, which were evidence of freezer burn after being exposed to the air. In the dry storage room, two unopened tubs of chocolate frosting had two dates on them, 4/10 and 10/10. The CDM stated she was not sure if the dates indicated when they were received, opened, or when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 7 of 15 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 05/29/2025 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 they expired. She speculated the items were received on 4/10 and expired on 10/10. Level of Harm - Minimal harm or potential for actual harm On 5/28/25 at 11:28 PM, AM [NAME] H stated leftovers, including canned pineapple and mushrooms, could be kept for three days, diced tomatoes for one week, and butter for one month. Residents Affected - Many On 5/28/25 at 11:40 AM, PM [NAME] I stated he cooked at the facility for the past two months but worked in the food service business for over 50 years. He said a person could tell how long food could be kept using their eyes and sense of smell. [NAME] I explained, in general, perishable food could be kept for three days, chopped tomatoes could be kept for one week, and canned mushrooms and pineapple could be kept for five to seven days. He stated American cheese could be kept for about two weeks after it was opened, but should always be checked for mold first. The PM [NAME] acknowledged he received three days of training when he started at the facility by one of the cooks, but had not received any other training from the CDM including what the facility's food storage policies were. On 5/28/25, the CDM provided a part of the facility's written food labeling and dating policy. She stated she was surprised that their policy indicated prepared foods could be kept for seven days as she had thought it was three days. In addition, some items used at this facility were not listed on this policy. She explained her Regional Manager forwarded an email which indicated opened products with a longer shelf life should be discarded according the manufacture's expiration date on the container and if there were not one, it should be discarded after 30 days. The CDM reached out to food supplier and confirmed some of the information provided by the Regional Manager did not align with the food supplier's guidelines. For example, the food supply company stated their soup bases were good for six months if unopened, but after opened, should be thrown away after two weeks. The food supply company also informed her the Chocolate Frosting could be stored for 18 months if unopened but after opening, should be discarded after four weeks. This meant the opened frosting dated 8/08, should have been discarded 9/8/24, over eight months ago. The facility's policy entitled Food Storage: Cold, dated October 2019, indicated all food items would be stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code and would be labeled and dated in a manner to prevent cross contamination. The policy entitled Food Storage: Dry Goods with the same date indicated foods would be stored according to the FDA Food Code and would be date marked as appropriate. 2. On 5/27/25 during the initial kitchen tour with the CDM, in the dish room there were two thermometers attached to the dish machine; one was a digital electronic thermometer and the other was an analog dial. The thermometer which had an electronic screen indicated the temperature was set at 160 degrees Fahrenheit (F) and the probe currently read 153 degrees F. The CDM stated she really did not know how the electronic temperature gauge worked and preferred to run a separate waterproof thermometer through the dish machine to get her temperature reading. The CDM ran a waterproof thermometer through the dish machine which read 111 degrees F, nine degrees below the required minimum temperature of 120 degrees F for a low temperature dish machine. The CDM then tested the concentration of the chemical sanitizer, which indicated approximately 200 parts per million (ppm). She said the chemical test strips were from a company which had provided their dish machine chemicals and service from over a year ago so she asked to use a different chemical test strip which had been received from the current chemical supply and dish machine maintenance company. The newer strips showed the same result of 200 ppm. The CDM stated the newer company periodically checked the machine and had never informed them there was a problem with the temperatures or concentration of the sanitizer that she knew of. The CDM could not provide the dish machine temperature logs from the month of May, and could not located them anywhere. The temperature logs for April indicated the dish machine temperatures ranged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 8 of 15 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 05/29/2025 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 - Many from 110-115 degrees F, which did not meet the minimum temperature required of 120 F. Review of the April 2025 log revealed temperatures were only recorded for the breakfast and lunch meal service and no dish machine temperatures were recorded for the dinner meals. The CDM initially could not explain why the recorded temperatures were low but explained she thought the reason staff had not recorded the temperatures for the dinner dishes was because the form only had two spots for temperatures to be recorded each day, so staff only recorded breakfast and lunch. The dish machine temperature logs included the chemical sanitizer was at 200 ppm even though the bottom of the form indicated the level of chemical sanitizer should be between 50-100 ppm. The CDM conveyed she thought levels of 200-400 ppm were acceptable, because she recalled that was what they were at previous facilities she worked at. The Maintenance Director arrived and explained the electronic temperature gauge was set to 160 degrees F and the probe indicated that actual water temperature. He stated he took care of the electricity and hot water going to the machine, but the calibrations were done by the company that provided the chemicals. During the kitchen revisit on 5/28/25 at 11:05 AM, the CDM explained dish machine temperatures recorded by the staff were low was because the staff were using the round analog thermometer to obtain the temperatures, which she acknowledged she had instructed them to use because whenever she looked at the electronic thermometer, the screen was blank. She added, when she started working at the facility a year ago, the main dish washing staff told her the electronic thermometer didn't work. In addition, she stated the current chemical company made a visit yesterday and told her the sanitizer strips she used were meant only for the pot sink and that was why it tested at 200 ppm. The representative asked her why she didn't use the correct strips and she told him they used the only ones he had provided. He then gave her the correct package of test strips and stated he would order the correct ones for her. She stated she didn't worry about the wash temperature being lower than the required 120 degrees F on the logs because the dishes always looked clean and they were sanitized after, and the representative never told her things were not OK after he checked the machine during his visits. She added, her Regional Manager made monthly visits and checked the temperature logs, the dish machine temperatures using the analog dial thermometer, and the concentration of the chemical sanitizer, and she was never told any of it was an issue. On 5/28/25 at 11:40 AM, PM [NAME] I stated he was responsible for washing the dishes after dinner but he did not take the dish machine temperatures at dinner time. Later that day, at 4:05 PM, PM [NAME] I stated he had not been shown how to take the temperatures for the dish machine nor instructed it was his responsibility to do it at the nightly meal. He stated he would do so if someone showed him how it was to be done. On 5/28/25 at 3:45 PM, the CDM stated new staff got most of their training on the computer from the management company but she provided specific education to the staff as needed. In a telephone interveiw on 5/29/25 at 8:26 AM, the account manager for the chemical supply company stated he had this account for the past six to seven months and confirmed he came in yesterday to find the CDM used an old strip provided by a prior chemical supply company which might have been too old to record accurately. He stated the CDM used incorrect strips which had been provided for the three-compartment sink and were not for testing the dish machine. He acknowledged it was his responsibility to provide the correct strips for the account but stated the ones they used from the previous company were in a similar container and he had not looked close enough to see if they were correct or not. He added, when he came to service the account, he brought and used his own strips. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 9 of 15 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 05/29/2025 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 - Many If the sanitizer concentration was truly at 200 ppm, which was the concentration at which the facility was getting measurements for, one would not want to serve meals from the dishes because that amount that would not be safe for resident to eat from; it would be too much. He also stated he used the analog thermometer, not the one with a digital screen and his own laser thermometer. He added, he had 70-80 accounts and therefore was not positive but thought the water temperature at this account usually measured between 110-122 and if he saw the temperature at 110, he primed the water to try to increase its temperature. He stated if he was unable to get the water to the required 120 minimum, he would let the manager know this was a concern. He was unsure if he had brought a concern for the water temperature to the manager's attention, but added he always emailed his report to the manager, usually by the end of the day he visited. In a phone interview on 5/29/25 at 8:00 AM, the Regional Manager stated she goes biweekly to this account and did monthly audits. She stated she checked the temperature logs to ensure they were completed and for what the temperatures were on the logs, but does not check the actual water temperature of the dish machine herself. When asked if she noticed the temperatures recorded on the logs were consistently between 110-115 degrees, instead of the required minimum of 120 degrees, and the concentration of chemical sanitizer was consistently at 200 ppm, she stated she has 8 facilities and cannot remember what she saw at this facility a month ago. She stated if she saw that the temperatures were out of line with the requirements, she would have made the manager aware to connect with the maintenance manager and with the chemical supply company to get it corrected and stated she was not sure whether there was an error with the instructions on the form regarding the required sanitizer concentration because she thought it should be 200 ppm. On 5/29/25 at 11:59 AM, the Regional manager stated she reviewed the dish machine temperature logs and confirmed the April log only recorded the temperatures for breakfast and lunch meals. She confirmed the temperatures recorded were not at the minimum required temperatures and the sanitizer concentration was too high for the requirements. She stated she had not noticed those items when she had checked the logs during her prior visits. She stated she was not worried about the data being out of range because the monthly reports from the company that provided the chemicals indicated there was not an issue with dish machine temperatures or sanitizer concentration. She acknowledged that a check once per month was not adequate and that temperatures needed to be taken and recorded for each meal to ensure any issue with sanitation did not arise in-between the chemical company's visits. Review of the chemical company's monthly reports revealed from 5/15/24 through 7/12/24, no visit or report was provided. On the report dated 7/12/24, no dish machine temperature nor sanitizer concentration measurements were provided. On the report dated 8/02/24, the wash and final rinse temperatures were both reported at 115 degrees F and on the report dated 10/21/24, the wash temperature of 110 F and the final rinse temperature of 114 F, which did not meet the minimum required 120 degrees F. On the report dated 11/11/24, no temperature was documented and no sanitizer concentration information was provided at all. On 5/29/25 at 5:00 PM, the Maintenance Director and dietary manager were informed of the findings from the reports from the chemical supply company and the maintenance director stated using a laser to take the temperature of the water was much less accurate than what he used as he sticks a thermometer directly into the water and makes sure it matches the electronic thermometer. He stated going forward he would ensure they all used the most accurate way and would remove the analog thermometer to decrease confusion for staff on which thermometer should be used. On 5/29/25 at 3:05 PM, the facility Administrator, stated he provided oversight to the dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 10 of 15 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 05/29/2025 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 department by reminding them of things they were supposed to be doing. For example, he went into the kitchen almost daily and reminded them to make sure they were completing the temperature logs and were dating foods, but he stated he does not check the logs nor the dated foods to ensure they were done accurately. He stated audits were completed in the kitchen by the dietary management company, and the dietitian was the one that does them. Residents Affected - Many A review of the Food Safety and Sanitation audits indicated the Dietary Regional Manager completed the audits monthly and the dietitian completes them every other month. The five audits provided were completed between January 28 and April 18th, 2025 with all providing an overall score between 97-100% satisfaction. The April 18th, 2025 audit completed by the regional manager, with an overall score of 98%, indicated foods that required time and temperature control for safety (TCS) were not held past their expiration date. It also stated a date marking was applied at the time of preparation to foods that require time/temperature control and were dated with a date by which the product must be consumed or discarded and the shelf life does not exceed the management company standards, including the day of preparation. The audit form also indicated chemical sanitizer solutions for dish machines were maintained at the proper concentration per their label instructions and if a violation was found, operation may need to cease until the imminent health hazard was resolved. It continued by indicating the dish machine was properly maintained and wash temperatures met the requirements. It added that dish machine logs were available and were properly completed. The dietary management company's policy entitled Ware washing, dated October 2019, indicated the Dining Services Director ensured the staff was knowledgeable for using proper ware washing techniques, dish machine water temperatures were maintained in accordance with the manufacturer recommendations, and that appropriate temperature and sanitizer concentration logs were completed as appropriate. 3. On 5/29/25 at 11:30 AM, on a tour of the nourishment room with the Unit Manager (UM), the refrigerator temperatures were recorded on the log twice per day and the freezer temperatures were not recorded at all. A package containing 11 hot dog buns were found in the refrigerator without a label as to whose it was and without a date. There were also seven containers of yogurt labeled with a resident's name; two were dated 5/04/25 without an expiration date and the other five had varying expiration dated between 4/21/25 and 5/15/25. There was a carton of whole milk for another resident which had been opened but was undated as to when it was opened or when it expired. Two opened, yet undated containers of the nutrition supplement MedPass were noted and the directions on the containers stated they were to be used within 3 days of opening. The UM stated it was the responsibility of the dietary department to record the refrigerator and freezer temperatures on the log and to check residents' food for expiration dates and discard them when expired. She added it was important to check expiration dates for residents to ensure they didn't get food poisoning from spoiled food. The UM acknowledged the nursing staff was responsible to label any food items, including when they opened the MedPass and discard it when expired. She added it was important do this so staff didn't serve spoiled items to the residents and get them sick. On 5/29/25 at 11:59 AM, the CDM stated she checked the expiration dates of resident's food items when she checked the nourishment refrigerator. She could not explain why expired and unlabeled foods had currently been found in the nourishment room refridgerator. The CDM explained possibly these items had been put in the refrigerator that morning. The Dietary Regional Manager who was present, stated the nursing department was responsible for checking resident food expiration dates and for logging daily temperatures of the nourishment refrigerator and freezer. The CDM stated she informed her staff to write the temperatures on the log if they had not been filled out by nursing when they brought snacks to the nourishment room, and could not explain why this had not been done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 11 of 15 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 05/29/2025 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 On 5/29/25 at 1:21 PM, the Director of Nursing (DON) and the Staff Development Coordinator stated the dietary department was responsible to take and record the daily nourishment refrigerator temperatures and to throw away resident's expired food items after three days of being in the refrigerator. They acknowledged, nursing was responsible to accept the food items from family members, ensure they were labeled with the resident name and date, and to date the MedPass nutrition supplement when it was opened. Residents Affected - Many The facility's policy entitled Use and Storage of Food brought in by Family and Visitors, dated 3/20/23, indicated prepared food items brought into the facility for a resident would be thrown away by facility staff if not consumed within three days. The policy did not stipulate which facility staff was responsible for this action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 12 of 15 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 05/29/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate documentation for medication administration for 1 of 7 residents reviewed for medication administration, of a total sample of 31 residents, (#10). Findings: Resident #10 was readmitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, emphysema, Alzheimer's disease, dementia, sensorineural hearing loss and dry eye syndrome. A review of the quarterly Minimum Data Set assessment with reference date 4/04/25 revealed resident #10 had moderately impaired cognition. The assessment revealed the resident had no behaviors, nor rejection of care during the lookback period. Review of physician's orders revealed resident #10 was scheduled to receive one drop of Refresh Liquigel Ophthalmic Gel 1% (Carboxymethylcellulose Sodium (Ophthalmic)) in both eyes, four times a day for dry eyes and one drop of Latanoprost Ophthalmic Solution 0.005% in both eyes at bedtime for glaucoma. On 5/28/25 at 9:36 AM, Registered Nurse (RN) E prepared to administer resident #10 his morning medications. RN E prepared the oral medications, then began to look for the resident's prescribed eyedrops. First she took out the Latanoprost eye drops but realized it was not the one to be administered at that time. RN E searched the medication cart and determined the Refresh Liquigel was not available. She stated she would reorder the medication from the pharmacy and notify the doctor. Review of the Medication Administration Record (MAR) Audit report on 5/28/25 revealed documentation completed by RN E at 9:45 AM, the Refresh Liquigel Gel 1% was administered for the 9:00 AM dose at 9:26 AM. The audit report showed the 1:00 PM dose was administered by RN F at 12:15 PM. A nurse's progress note documented at 9:46 AM, confirmed the physician was notified the eye drops were not available at that time. On 5/28/25 at 1:11 PM, RN G and RN F were together in the hallway at the medication cart. RN G said they received resident #10's Refresh Liquigel eye drops and retrieved it from the cart. The medication was in the package, unopened and still sealed. RN G began to label the box with the resident's name. RN F was asked if the resident had received the 1:00 PM dose and she stated she had not given it yet. RN F was then asked to verify on the MAR that the medication was marked as given and the initials of the nurse were in fact hers. RN F verified that the initials were hers and when she realized she had already marked the medication as given in the medical record, she stated oh .ok, I will give the medication now. The nurse could not say why she documented the medication was administered before the package was even opened, or given. On 5/28/25 at 1:27 PM, the Director of Nursing (DON) and RN E reviewed the documentation on MAR with regards to resident #10's Refresh Liquigel eyedrops. RN E's documentation on the MAR completed at 9:45 AM, revealed the 9:00 AM dose was marked as given, which was inaccurate. RN E explained she checked it off in error, however she said that she had given the afternoon dose. RN E retracted her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 13 of 15 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 05/29/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few statement, that she had given the afternoon dose of the medication when she realized the initials on the MAR were RN F's, not her own. On 5/28/25 at 1:40 PM, the DON confirmed the documentation on the MAR was inaccurate. She said that she would have RN E strike out the 9:00 AM dose and notify the physician. The DON presented the Medication Administration Audit report which revealed the 1:00 PM dose of Refresh Liquigel eyedrops were documented as administered by RN F at 12:15 PM, before the medication had even been taken out of the package and opened. On 5/28/25 at 1:55 PM, RN F conveyed nurses should not document until after a medication was given and acknowledged she should not have documented the 1:00 PM dose of Refresh Liquigel eyedrops were administered prior to her actually giving it. The facility's Policy and Procedure on Medication Administration revised October of 2023 indicated in the Policy Explanation and Compliance Guidelines number 17, Sign MAR after [medication is] administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 14 of 15 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 05/29/2025 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 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 ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan dated 1/18/24, revealed it was designed to be ongoing and comprehensive. The plan detailed the facility used a systematic approach to determine when in-depth analysis was needed to fully understand the problem, its causes and implications of change. The facility used a thorough and highly organized/structured approach to determine the root cause of identified problems. The plan indicated the facility would utilize a variety of tools to describe the current process used and identify any area of breakdown or weakness in the current process. The document described each Performance Improvement Project (PIP) subcommittee would provide the QAA committee with a summary report, analysis of activities, and recommendations. The facility had a deficiency cited at F812 during the previous recertification survey of 2/29/24 for food safety and sanitation. During the current survey, the facility was found to have repeated concerns with food safety and sanitation with dietary services. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation. On 5/29/25 at 4:58 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware of the repeat deficiency F812. The NHA explained the Dietary Regional Manager completed monthly audits, but he himself did not have access to those reports and was not aware of any issues within dietary services. The NHA acknowledged there was a breakdown and said the problem was his inability to access the reports. He acknowledged the facility should have access to reports completed by the Regional Manager in order to conduct performance activities to ensure improvements and measures were conducted and sustained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105379 If continuation sheet Page 15 of 15