Inspection·August 6, 2023

F 0565 escort the resident outside. Level of Harm - Minimal harm or potential for actual harm On 8/1/23 at 3:50 p.m., the DON said if a resident wanted to go outside, they needed to be assessed to see if they are safe to be outside alone. If not, they need to make a request to go out and a staff member must take them because they can't be outside alone. Residents Affected - Few The DON confirmed Residents #2 and #56 had not been screened to identify if they were safe to go outside of the facility alone. On 8/2/23 at 8:50 a.m., in an interview with the DON, the Administrator and the Regional Nurse Consultant, the DON said she checked the Brief Interview for Mental Status (BIMS) score for Resident #2 and #56, and both residents have a high BIMS score and may go outside. The Administrator said, we would like for them to go in the supervised courtyard because it is supervised. We are concerned they may become affected by the heat, and we can provide fluids out there. The Administrator said she would speak to the residents today so they know they can go outside on the supervised patio area. The DON said, we are a secured facility, and the doors are always locked because we don't want the residents to wander off. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 2 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 staff interviews and record review the facility failed to ensure they had discussed formulating an advance directive which would include the right to accept or refuse medical or surgical treatment with the resident or their representative for 1 (Resident #86) of 3 residents reviewed for advance directives. The findings included: A review of the facility policy, The Residents' Rights Regarding Treatment and Advance Directives implemented 11/2020, and last reviewed/revised on 1/2022 stated it was the policy of the facility to support and facilitate a resident's right to request, refuse, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Under the Policy Explanation and Compliance Guidelines, number 5 stated the facility would identify or arrange for an appropriate representative for the resident to serve as the primary decision maker if the resident was assessed as unable to make relevant health care decisions. On 8/1/23 review of Resident #86's medical records revealed she was admitted to the facility on [DATE] and placed in the facility's secure memory care unit. The MDS (Minimum Data Set) admission assessment, (a standardized assessment tool that measures health status) dated 12/11/22, assessed Resident #86's cognitive score as 5 out of 15, with a score of 0 to 7 meaning the resident's cognition status was severely impaired. Resident #86's MDS quarterly assessment dated [DATE] noted a cognitive score of 7 and Resident #86's MDS quarterly assessment dated [DATE] noted a cognitive score of 00. On 6/9/23 Resident #86's primary care physician conducted an evaluation and determined Resident #86 lacked the capacity to give informed consent to make medical decisions. A Social Service Progress note dated 2/17/23 stated they were asked to start a guardianship for Resident #86. They had contacted a legal representative to see if they would be a guardian for Resident #86. A nursing progress note dated 5/11/23 stated they had called Resident #86's daughter and husband, but all the phone numbers were disconnected or had been blocked. The note stated the facility would be looking into a guardianship for Resident #86. On 8/2/23 at 9:36 a.m., the Social Service Director (SSD) said the nursing home currently does not have a full-time SSD, so the nursing home's sister facility are sending their SSD to the facility Monday through Friday to complete the required social service duties. The SSD confirmed after reviewing Resident #86 medical record, Resident #86 was admitted to the facility on [DATE] to the facility's memory care unit due to her severely impaired cognition. She confirmed the MDS assessments dated 12/11/22, 3/28/23, and 4/23/23 assessed Resident #86's cognition as severely impaired. The SSD said due to the facility staff being unable to contact Resident #86's family since Resident #86's admission, she had written a progress note on 2/17/23 stating she would try to arrange for a guardianship for Resident #86. She said she was unable to find any documentation in Resident #86's medical record, the facility had obtained a guardianship for Resident #86. She said she was unable to find documentation the facility had discussed with Resident #86 and/or a representative about Resident #86's health care decision related to formulating an advance directive. On 8/3/23 at 5:26 p.m., in an interview with MDS Coordinator, after she reviewed Resident #86's medical record, she confirmed Resident #86 was admitted to the facility's memory care unit on 12/7/22 due to her impaired cognition. She confirmed the MDS assessments dated 12/11/22, 3/28/23, and 4/23/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 3 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 assessed Resident #86's cognition as severely impaired. The MDS Coordinator said currently Resident #86 did not have a Power of Attorney (POA), Healthcare Surrogate or court appointed guardian to assist in making health care decisions for her. She further said she was unable to find documentation the facility had discussed with Resident #86 and/or a representative about Resident #86's health care decision related to formulating an advance directive. Residents Affected - Few On 8/4/23 at 9:51 a.m., the Administrator said the facility's policy stated if the resident was unable to make their own health care decisions and they were unable to get in touch with a resident representative, the facility was responsible to attempt to find a legal guardianship for that resident. The Administrator confirmed after reviewing Resident #86's medical record, the resident was admitted to the facility on [DATE]. She said due to Resident #86's cognitive impairment since her admission she was unable to make health care decisions for herself. The Administrator said there was no documentation the facility had discussed with Resident #86 and/or a representative about Resident #86's health care decisions related to formulating an advance directive as required per their Advance Directive policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 4 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/31/23 during the initial tour of the 300 and 400 hallways in the memory care unit, observation included multiple areas, on both hallway walls, were damaged, and repaired but the damaged walls which were repaired were not painted to match the rest of the walls. One of the handrails on the 400 hallway was missing the end cap. Two hallway electrical outlet cover plates in the 400 hallway and two of the electrical outlet cover plates in room [ROOM NUMBER] were warped causing the corners to protrude outward. Several ceiling tiles in rooms [ROOM NUMBERS] were observed to have had large brown stains. One ceiling tile in room [ROOM NUMBER] by the window was observed to have had a black fuzzy substance in the middle of the brown stain. The chair rail on the wall behind bed 318B was observed to be broken and missing sections. The baseboard across from 318B was observed to be damaged and coming off the wall. The bathroom bulbs in rooms [ROOM NUMBERS] were observed as not working. On 8/3/23 at 10:47 a.m., the Director of Plant Operations said the facility currently did not have a Maintenance Director since 7/5/23. He said he had been filling in as the facility's Maintenance Director since then until they were able to hire a new Maintenance Director for the facility. He said all staff were required when they observed and/or heard of any facility damage or equipment not working to place the information in their computer maintenance program called TELS as a work order (is a web-based software designed to help senior Living operators and maintenance tract and schedule maintenance anf fire safety task). He stated he reviewed the TELS system on a routine basis, completed all work orders in the TELS system, and marked them as completed in the TELS program when he had finished the repair and/or work order. On 8/4/23 at 3:00 p.m. after a tour of the 300 and 400 hallways, the Director of Plant Operations confirmed multiple damaged wall repairs in the 300 and 400 hallways which were not painted to match the walls as required. He confirmed the end cap on the handrail on the 400 hallway was missing, there were several brown stained ceiling tiles in rooms [ROOM NUMBERS], and 1 ceiling tile in room [ROOM NUMBER] which had a black fuzzy substance in the middle of the brown stain. He confirmed the light bulbs in the bathroom in 305 and 308 were not working. He confirmed 2 electrical outlets in the 400 hallway and two electrical outlets in room [ROOM NUMBER] were warped and protruding outward which could cause an injury to the residents on the memory care unit. He also confirmed the chair rail around 318B bed was broken and missing a section, and the baseboard across from 318B's bed was damaged and falling off the wall. The Director of Plant Operations, after reviewing the work orders in the TELS computer system, said the facility staff did not enter the rooms and hallway damages and damage/repairs observed during our tour of the memory care unit into the TELS system as work orders as required. He said since the facility staff did not enter the work orders into the TELS system, he was unaware of the repairs needing to be completed in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 5 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 On 7/31/23 at 10:00 a.m., the ceiling tiles in room [ROOM NUMBER] in the secured memory care unit had multiple brown stains. Level of Harm - Immediate jeopardy to resident health or safety Photographic evidence obtained. Residents Affected - Some On 7/31/23 at 10:25 a.m., room [ROOM NUMBER]'s floor had dirt, grime and food particles. The shared toilet was dirty with brown stains, the bathroom light was broken, and the dresser was broken with exposed wood. Photographic evidence obtained. On 7/31/23 at 10:45 a.m., room [ROOM NUMBER] had a broken bathroom light. The paint in the bathroom was chipped and the toilet was running continuously. Photographic evidence obtained. On 8/3/23 at 11:55 a.m., brown bugs were observed crawling in the shower room and in the clean utility room of the memory unit. On 8/3/23 at 12:20 p.m., CNA Staff FF, in the memory care unit said, I see a lot of roaches. The guy comes and sprays and it is not doing anything. I also see ants sometimes, but I see roaches every time I work. I have heard about the rats but not seen them. On 8/3/23 at 12:33 p.m., Housekeeping Manager Staff U said she would expect staff to report to her if they saw roaches or bugs. She said they have a book in the front of the facility where they write the concerns. The pest guy reviews the book and then treats the identified concerns. On 8/3/23 at 1:00 p.m., RN Staff KK said, Most of the time we see roaches at nurses' stations and residents' rooms, I haven't seen rats. I have heard people saying they have seen rats mostly in the big dining room. We have a binder at the nurses' station to document if we see anything. Review of the binder provided by RN Staff KK revealed: On 7/1/23 a roach in the back hall nursing cart. On 7/24/23 two rats in the soiled utility room, roaches in med carts, roaches on nurse's station counters and on floor. On 8/3/23 at 1:15 p.m., LPN Unit Manager Staff AA said, That is not the master binder. I would like to see the master binder which is kept in the front. She confirmed she was aware of rats in the soiled utility. She said, It was reported to me, and I believe maintenance. I don't know where it went from there. I don't meet with maintenance. We don't have a set person for this facility. Reviewed master binder, sightings were not documented in master binder. On 8/4/23 at 1:00 p.m., a follow up tour of the memory care unit to review concerns identified on 7/31/23 revealed: room [ROOM NUMBER] remained with the stained ceiling tiles. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 6 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some room [ROOM NUMBER] still had the light out in bathroom, the dresser remained with missing front piece exposing wood. room [ROOM NUMBER] remained with the bathroom light bulb out, chipped paint on the bathroom wall and the toilet continuously running. Based on observations, record review and staff interviews, the facility failed to implement processes to ensure the residents' right to a safe and clean environment in that they failed to ensure an environment free of disease-causing pests. On 12/19/22 the facility became aware of rodent infestation in the building, including the kitchen. The facility consistently failed to implement the recommendations from the contracted pest control company to trim back over hanging trees next to the building to prevent wildlife from getting easier access to the building. The facility failed to identify and repair all rodent entry points. The failure to provide a safe and sanitary environment free of disease causing pests created a likelihood of spread of diseases through direct or indirect contact with infected rodents which could result in serious illness, or death, resulting in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. Rodents can also damage building structures and start fires by gnawing electrical wiring. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F600, F812, F835, F867, F880 and F925. The facility's Standard Precautions Infection Control policy (copyright 2023. The compliance Store LLC) noted, Care of the Environment: Policies and procedures have been established for routine and targeted cleaning of environmental surfaces as indicated by the level of resident contract and degree of soiling. Personnel are trained in the use of the procedures . The facility's Infection Prevention and Control Program (copyright 2023. The compliance Store LLC), noted, . Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside of their scope to the appropriate department . Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . Review of the Center for Disease Control (CDC) and Prevention document titled, How to Control Wild (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 7 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Rodent Infestations, last reviewed on January 3, 2023, noted, Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it . Rodents, such as rats, mice . are known to carry many diseases. Diseases can spread to people directly and indirectly from rodents .'' The CDC document listed 17 Diseases that can be spread directly by rodents (depending on geographic region), including Hemorrhagic Fever with Renal Syndrome (The condition affects many organ systems of the body, damages the overall cardiovascular system, and reduces the body's ability to function on its own. Symptoms of this type often include bleeding and hemorrhaging. This can cause a severe life threatening disease), Monkeypox (Virus that affects rodents, and causes a painful rash, enlarged lymph nodes and fever in humans), and rat-bite fever (causes fever, vomiting, headache, muscle, and joint pain, and rash in humans). Certain diseases can spread from rodents to people through indirect contact. This can occur when people are bitten by ticks, mites, fleas, and mosquitos that have fed on infected rodents. Diseases can also spread to people from rodents through the consumption of an intermediate host (for example, beetles or cockroaches) . The CDC document lists 17 diseases spread indirectly by rodents (depending on geographic region), including Angiostrongylus (rat lungworm), a disease transmitted from rodents to humans through infected larvae that affects the brain and spinal cord in humans, and Powassan virus (transmitted by ticks, and causes brain infection in humans). The Center for Disease Control and Prevention recommendation to clean up rodent urine and droppings (last reviewed January 3, 2023) noted, Step 1: Put on rubber or plastic gloves. Step 2: Spray urine and droppings with bleach solution or an EPA-registered disinfectant until very wet. Let it soak for 5 minutes or according to instructions on the disinfectant label. Step 3: Use paper towels to wipe up the urine or droppings and cleaning product. Step 4: Throw the paper towels in a covered garbage can that is regularly emptied. Step 5: Mop or sponge the area with a disinfectant. o Clean all hard surfaces including floors, countertops, cabinets, and drawers. o Follow instructions below to clean and disinfect other types of surfaces. Step 6: Wash gloved hands with soap and water or a disinfectant before removing gloves. Step 7: Wash hands with soap and warm water after removing gloves or use a waterless alcohol-based hand rub when soap is not available, and hands are not visibly soiled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 8 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 8/2/23 at 12:20 p.m., Licensed Practical Nurse (LPN) Staff NN said she has never seen a rat but has heard them running in the ceiling, and residents have complained about hearing rats in the ceiling. On 8/2/23 4:45 p.m., the Senior Regional Director of Culinary Services stated, I was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. On 8/3/23 at 9:25 a.m., LPN Staff I said, The rats are so bad. They have roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you and go into the holes in the cabinets. On 8/3/23 at 9:25 a.m., observation of the South Unit soiled utility room with LPN Staff I revealed a hole in the baseboard of the wall, with a missing tile. Photographic evidence obtained. There was hole at the lower left bottom of the storage cabinet. Photographic evidence obtained. There was a hole in the baseboard where two cabinets met. Photographic evidence obtained. LPN Staff I said, I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. LPN Staff I said she doesn't go in the soiled utility room because of the rats. She stands at the door and throws soiled linen and garbage into the bins. On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D said, The rats and roaches are disgusting and everywhere in the building. I have seen them in residents' rooms, the utility rooms and nourishment rooms. They run in the ceiling, you hear scratching, and you can hear them run around up there. If it fell on me, I would be screaming. I know I have reported it to the management staff, but the rats are still here. It doesn't matter what time of day, you will see them, but they are worse at night. On 8/3/23 at 9:45 a.m., Resident #89 reported he saw a rodent in his room approximately three weeks ago, and Maintenance filled the hole in the bathroom. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said about two weeks ago staff informed him they saw a rat in Resident #89's bathroom. He observed a hole in the wall, which he plugged at that time. There was no documentation the resident's room was disinfected after the sighting of the rat. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 9 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company and the observation of rodent feces on the floor of the kitchen storage area with the Infection Preventionist, she said, I knew there were rats in the kitchen about six months ago when the former Administration was here, but I was told it was taken care of. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been employed with the company since September 2022, and had been the acting Maintenance Director at the facility since the beginning of July 2023. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023 which was completed sometimes in June 2023. He said he started hearing from some of the facility staff about seeing rats and hearing rats in the ceiling during the roof construction. He said the first time he heard of rats in the kitchen was two weeks ago when a kitchen staff told him they saw a rat in the kitchen. He looked at the area where the kitchen staff said they saw the rat, and noted there was a hole in the wall. He said he has not had any meetings with the administrative staff related to the rats in the facility. He said as of this time no one from administration has asked him what interventions he had put into place to address the staff seeing rats in the facility. He said he conducted an informal meeting with the housekeeping director to remind her staff to ensure they were not leaving food which the rats might be eating, and remind them to do proper cleaning and disinfection in general. It was an informal meeting; he doesn't have any documentation related to the meeting. On 8/3/2023 at 12:08 p.m., Certified Nursing Assistant (CNA) Staff A said she has worked at the facility for over 10 years, and she can smell the rats. On 8/3/23 at 12:10 p.m., Certified Nursing Assistant (CNA) Staff K said she has seen rats in the facility, usually at night on the South Unit. The CNA said the rats are really bad on the secured memory unit. She said, I have seen roaches and the rats over there. It is an infestation there. On 8/3/23 at 12:20 p.m., CNA Staff E said, The roaches and the rats here are terrible, it is a problem. I have seen them both here in the facility, they know about it. On 8/3/2023 at 12:25 p.m., Resident #29 said he had seen rats in the front and back of the building and heard them in the ceiling. On 8/3/23 at 12:33 p.m., the Housekeeping Manager stated, There are pest issues at facility, they called the pest guy weekly. On 8/3/23 at 1:00 p.m., RN Staff KK stated, I have heard people saying they have seen rats mostly in the big dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 10 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 Level of Harm - Immediate jeopardy to resident health or safety On 8/3/23 review of the pest control logbook located at the front desk of the facility noted the following dietary staff entries: 11/3/22 at 6:00 a.m., rat, location found: Kitchen. 11/13/22 at 6:00 a.m., rats, location found: Kitchen. Residents Affected - Some 11/23/22 at 6:30 p.m., rat, location found: Homestead dining room. 12/13/22 at 6:30 a.m., rat, location found: Kitchen. 2/16/23, (no time in the morning), rat, location found: Kitchen. 2/20/23 in the morning, rat, location found: Beverage station, department: Kitchen. 3/18/23 (no time indicated), rat, location found: Kitchen. 3/25/23 (no time indicated), rat, location found: North dining room. 4/6/23 at 6:15 a.m., rat, location found: Kitchen. 4/22/23 at 6:00 a.m., rat, location found: Kitchen. 4/25/23 at 6:15 a.m., 3 rats, location found: Kitchen. The North Unit Pest sighting log noted: 7/1/23 at 2:00 a.m., roach back hall nursing medication cart. An initial was placed next to the entry and dated 7/13/23. 7/24/23 at 1:30 a.m., Rats (2) in soiled utility. An initial was placed next to the entry and dated 7/28/23. 7/24/23 at 1:30 a.m., Roaches in med carts, on nurses station counters, on the floors. An initial was placed next to the entry and dated 7/28/23. The contracted Pest Control inspection report dated 7/28/23 noted, Checked all 3 logbooks and scanned them. Signed off on rodent issues after checking on them. Baited nurse main cart with roach gel for roach sightings. Lots more rodent activity this month. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to the rats. He told them to put the bread in the refrigerator. On 8/3/23 at 12:30 p.m., the Administrator said the rat problem had been identified prior to her arrival to the facility. She said she has been employed at the facility since May 19, 2023. She did not know how long it has gone on. She said she knows the pest control company comes out weekly as needed. She said the Maintenance Director is in charge of pest control and has direct oversight over the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 11 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 building. She said she could provide a copy of the contract signed on 7/20/2023 addressing the rat problem. Level of Harm - Immediate jeopardy to resident health or safety On 8/4/23 at 11:15 a.m., black smear marks, resembling rodent grease marks were observed along the baseboard of the South Unit soiled utility room. Dried yellow stains, and rodent feces were observed on the floor of the soiled utility room. Residents Affected - Some On 7/31/23 at 9:46 a.m., Resident #88's shared bathroom had dried feces on the toilet tank, around the toilet base, and splattered on the wall. Photographic evidence obtained. On 8/1/23 at 9:28 a.m., Resident #88's shared bathroom remained with dried feces on the toilet tank, the toilet base, and on the wall. A used adult incontinent brief was observed on the floor underneath the sink in the bathroom. Photographic evidence obtained. On 8/1/23 at 3:03 p.m., Resident #88's shared bathroom remained with dried feces on the toilet tank, the toilet base, and on the wall. On 8/1/23 at 3:10 p.m., the Housekeeping manager stated all rooms are cleaned daily. The housekeepers spray and wipe all surfaces, empty trash can, dust, sweep and mop the floor, but do not clean up body fluids such as feces, urine, or emesis. The expectation is to get someone from nursing, have them dispose of the body fluids and then housekeeping will clean and sanitize the area. On 7/31/23 at 10:08 a.m., a trail of foul smelling watery stool of approximately 20 feet was noted on the hallway floor of the memory care unit between rooms 405, and 410. Photographic evidence obtained. Multiple staff members and residents were observed walking in the hallway. On 7/31/23 at approximately 10:15 a.m., a staff member was observed wiping, and smearing the watery stool in a circular motion. Housekeeping was not observed sanitizing the area once the stool was wiped. On 8/1/23 at 9:38 a.m., Resident #73's room was observed with a large amount of live white crawling bugs on the bedside table. Video documentation obtained. LPN Staff MM verified the observation of the bugs and said she had seen them in other rooms as well. Resident #73 said, Just brush them off on the floor. On 8/3/23 at 11:50 a.m., multiple ant-like insects were observed crawling on Resident #2's bed, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 12 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0584 on the resident's wound dressings on both ankles. Level of Harm - Immediate jeopardy to resident health or safety Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. Residents Affected - Some The resident said she requested to have her bed sheets changed since then to get rid of the ants and no one has come all morning. On 8/3/23 at 12:00 p.m., LPN Staff I was notified of the observation of the crawling insects on the resident's bed and her request to have her sheets changed and the pest removed. LPN Staff I said she would let the Certified Nursing Assistant know. On 8/3/23 at 3:30 p.m., Resident #2 said she felt, terrible, just terrible when the nurse told her she had ants in her bed. She said the ants were crawling in her dressings. She said, no one wants bugs in their bed. I told the nurse I wanted an aide to change my bed, but no one has come yet. On 8/3/23 at 3:45 p.m., Housekeeper Staff BB was observed cleaning Resident #2's mattress. Staff BB said there were ants in the resident's open bags of chips and in the resident's bed. On 8/3/23 at 4:00 p.m., the Director of Nursing said she was informed of the ants in Resident #2's bed and on her legs. She said she thought the ants were attracted to the Medi honey (medical grade honey) used to treat the resident's wounds. She said they will be changing the resident's wound treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 13 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of the facility's policies and procedures and staff interviews, the facility failed to protect the residents' rights to be free from neglect in that they failed to adequately address ongoing presence of rats in the facility, including the kitchen. On 12/19/22 the facility became aware of the rodent infestation in the building, including the kitchen, and neglected to implement appropriate immediate actions to eradicate the rodent infestation. Certain diseases can spread from rodents to people from direct or indirect contact with infected rodents which could result in serious illness, or death. Rodents can also damage building structures and start fires by gnawing electrical wiring. The facility failed to consistently implement recommendations from the contracted pest control company, including trimming back over hanging trees next to the building to prevent wildlife easier access to the building. The facility failed to identify and repair all rodent entry points into the building. The facility failure to provide services to ensure a clean and safe environment, free from disease causing pests resulted in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F584, F812, F835, F867, F880 and F925. Facility policy titled Abuse, Neglect and Exploitation revised 11/29/22 noted it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit neglect. The facility policy defines neglect as, The failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy noted the facility will implement policies and procedures to prevent and prohibit all types of neglect and ensure the health and safety of each resident, addressing features of the physical environment that may make neglect more likely to occur. The facility's pest sighting logbooks located at the front desk included the following entries: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 14 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0600 11/3/22 at 6:00 a.m., rat, location found: Kitchen. Level of Harm - Immediate jeopardy to resident health or safety 11/13/22 at 6:00 a.m., rats, location found: Kitchen. Residents Affected - Some 12/13/22 at 6:30 a.m., rat, location found: Kitchen. 11/23/22 at 6:30 p.m., rat, location found: Homestead dining room. 2/16/23, (no time in the morning), rat, location found: Kitchen. 2/20/23 in the morning, rat, location found: Beverage station, department: Kitchen. 3/18/23 (no time indicated), rat, location found: Kitchen. 3/25/23 (no time indicated), rat, location found: North dining room. 4/6/23 at 6:15 a.m., rat, location found: Kitchen. 4/22/23 at 6:00 a.m., rat, location found: Kitchen. 4/25/23 at 6:15 a.m., 3 rats, location found: Kitchen. The North Unit Pest sighting log noted: 7/1/23 at 2:00 a.m., roach back hall nursing medication cart. An initial was placed next to the entry and dated 7/13/23. 7/11/23, evening, rat, location found: room [ROOM NUMBER]. 7/24/23 at 1:30 a.m., Rats (2) in soiled utility. An initial was placed next to the entry and dated 7/28/23. 7/24/23 at 1:30 a.m., Roaches in med carts, on nurses station counters, on the floors. An initial was placed next to the entry and dated 7/28/23. Review of the contracted Pest Control company reports from 11/2022 through 7/28/23 revealed: 12/19/22: The facility has been given a quote for all other exclusions. Inspected several large rodent snap traps, previously placed in the Family Room and Kitchen areas. Four rodents were captured and removed. All traps were baited and reset, to monitor activity until mass trapping service and exclusion service are approved. 3/10/23: Couldn't find 3rd logbook at the 2nd nurse station. Inspected outside perimeter. Noticed multiple spots for wildlife to get in . 3/24/23: Overhanging trees next to building needs to be trimmed back for preventing ants and wildlife to getting easier access to building . 3/28/23: Caught a rat on glueboard [sic] underneath kitchen equipment. Replaced with 2 more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 15 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some glueboards. Dining room has roof rat activity. Set out 2 large glueboards in drawer. And 4 large glueboards on floor by cabinets. Inspected rest of dining room . 4/25/23: Inspected kitchen area, last nite [sic] 3 roof rats were caught and disposed of. Will be back this Friday with a follow-up to check on kitchen . 4/28/23: There is a lot of rodent activity feeding off bait. Spoke with head chef in the kitchen and we caught 2 more roof rats in kitchen on our large glueboards. Set out 8 more large glueboards in kitchen . 5/12/23: There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/2/23: There is moderate amount of rodent activity at this time. Spoke with front desk before leaving. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/8/23: The roof is repaired. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/15/23: Arrived on property and spoke with front desk. Spoke with kitchen staff. They had caught a large rat last nite [sic] . There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 6/29/23: Texting mrs.[sic] (name) info. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building . 7/28/23: Arrived on the property and spoke with acting director . Rodent activity in building. They know exclusion is being done . Signed off on rodent issues after checking on them . On 8/3/23 at 3:01 p.m., observation of the outside of the building revealed multiple overhanging branches over building that need to be trimmed back for preventing ants and wildlife easier access to building as per the multiple recommendations of the contracted pest control company. Photographic evidence obtained. On 8/3/23 at 3:10 p.m., the Administrator said since she has been employed at the facility in May 2023, the overhanging branches had not been trimmed. The Administrator provided a receipt dated 1/2/23 from an outside tree service company listing a different address from the facility that read, Canary palm + (plus) 1 Palm. She said the receipt was from an outside company for tree trimming at the facility. On 8/10/23 at 11:57 a.m., in a telephone interview, a representative from the outside tree service company said on 1/2/23 the company did not provide any tree trimming services at the facility. The address listed on the receipt was private residence. As of the exit date of 8/6/23, the facility failed to provide documentation the overhanging (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 16 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0600 Level of Harm - Immediate jeopardy to resident health or safety branches over building were trimmed back for preventing ants and wildlife easier access to building as per the multiple recommendations of the contracted pest control company on 3/24/23, 5/12/23, 6/2/23, 6/8/23, 6/15/23, and 6/29/23. On 8/3/23, the facility provided copies of email exchanges between the facility and the pest control company. Residents Affected - Some On 4/18/23 the pest control company noted, The best option to rid the facility of this rodent issue is a multi-step process. First we will need to seal up any holes, openings, entry points, and areas where rodents access into the building. I found several openings such as roof returns, plumbing stacks, AC (air conditioning) chases, opening around wires, and around conduits entering into building. The next step is a full trapping program for 1 month. We will do a 3 day trapping where we place traps in drop down ceiling but not set the traps. This will get the rodents from being trap shy and allow for the best capture rate . I know this facility is undergoing roof repairs, but my recommendation is for us to start this exclusion right after the roofers have completed their service . On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been employed with the company since September 2022, and has been the acting Maintenance Director at the facility since the beginning of July 2023. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023. The roof repair was completed several months later, sometime in June 2023. He said he started hearing from some of the facility staff about seeing rats and hearing rats in the ceiling during the roof construction. He said started emailing the pest control company in April 2023 about the rats in the facility, who gave him some recommendations about what they can do about stopping the rats from entering the facility. He said the pest control company told him the rats could not be fully removed from the facility until the new roof was completed and all entry points were sealed. The Regional Plant Operation Director said he got over a hundred rodent entry points sealed sometime in June 2023, and the pest control company signed an eradication agreement to remove all the rats in the facility on 7/20/23. The Regional Plant Operation Director toured the exterior of the facility and showed some possible rodent entry points he closed or covered to prevent the rats from entering the facility. He said the pest control company provides him with their findings for each visit, and he was aware of all the pest control recommendations the facility needed to implement to address the rats in the facility. He said he had not had an opportunity to trim back the trees overhanging branches the rats could use to get on the roof and enter the facility. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said, The rats are so bad. They have roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 17 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0600 and go into the holes in the cabinets. Level of Harm - Immediate jeopardy to resident health or safety On 8/3/23 at 9:25 a.m., observation of the South Unit soiled utility room with LPN Staff I revealed a hole in the baseboard of the wall, with a missing tile. Photographic evidence obtained. Residents Affected - Some There was hole at the lower left bottom of the storage cabinet. Photographic evidence obtained. There was a hole in the baseboard where two cabinets met. Photographic evidence obtained. LPN Staff I said, I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. On 8/4/23 at 11:15 a.m., black smear marks, resembling rodent grease marks, were observed along the baseboard of the South Unit soiled utility room. Dried yellow stains, and rodent feces were observed on the floor of the soiled utility room. On 8/3/23 at 9:45 a.m., Resident #89 reported he saw a rodent in his room approximately three weeks ago, and Maintenance filled the hole in the bathroom. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said about two weeks ago staff informed him they saw a rat in Resident #89's bathroom. He observed a hole in the wall, which he plugged at that time. On 8/3/23 at 10:04 a.m., during a follow up tour of the kitchen with the Director of Food and Nutrition Services and the Regional Hospitality director, rodent feces were noted on the floor beneath the canned goods cart and bread cart. The kitchen door leading to the outside had a visible gap at the bottom with outside daylight shining through the gap. The Director of Food and Nutrition Services and Regional Hospitality Director verified the observation of the rodent feces and stated they had swept there the day before. The Director of Food and Nutrition Services said a mouse ran across her foot last week in her office located in the kitchen. She said she noted the rodents chewed the tartar sauce packets. She cleaned them off and wiped the area with bleach. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company, and the observation of rodent feces on the floor of the kitchen storage area with the Infection Preventionist, she said, I knew there were rats in the kitchen about six months ago when the former Administration was here, but I was told it was taken care of. She verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 18 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0600 she was not aware of any plan to address the rodent infestation at the facility. Level of Harm - Immediate jeopardy to resident health or safety On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said the first time he heard of rats in the kitchen was two weeks ago when a kitchen staff told him they saw a rat in the kitchen. He looked at the area where the kitchen staff said they saw the rat, and noted there was a hole in the wall. Residents Affected - Some He has not had any meetings with the administrative staff related to the reporting of rats in the facility. He said as of this time no one from administration has asked him what interventions he had put into place to address the staff seeing rats in the facility. On 8/3/23 at 12:10 p.m., Certified Nursing Assistant (CNA) Staff K, she said she has seen rats in the facility, usually at night on the South Unit. The CNA said the rats are really bad on the secured memory unit. She said, I have seen roaches and the rats over there. It is an infestation there. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to rats. He told them to put the bread in the refrigerator. On 8/3/23 at 3:18 p.m., a follow up tour of the kitchen with the Senior Regional Director of Culinary Services revealed rodent feces on the floor throughout the kitchen food storage area. Photographic evidence obtained. Rodent feces were noted on canned good items, and metal shelving racks storing canned food. Photographic evidence obtained. Single service packages of mayonnaise stored in a basket in the kitchen were observed with visible rodent bite marks. Photographic evidence obtained. Multiple loaves of packaged bread were observed stored on shelves in the dry storage area where the rodent feces were observed on the floor. Photographic evidence obtained. The Senior Regional Director of Culinary Services verified the rodent feces throughout the kitchen storage area floor and metal shelves used to store food. He verified the bread, packets of mayonnaise and other food items were not stored in rodent proof containers as per the pest company recommendation. He stated there was no policy in place for additional cleaning precautions once rodent feces have been visualized. He stated, We have been cleaning and sanitizing being sure to change out the water, and rags to prevent cross-contamination. In regard to canned goods, we are especially sure to sanitize the can where it will connect with the opener. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 19 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0600 Level of Harm - Immediate jeopardy to resident health or safety On 8/4/23 at 6:20 p.m., the technician from the contracted pest control company said rats were entering the building through the air conditioning pipes. On July 25, 2023, he closed that hole. He said he usually gets three rats every two days. On 8/3/23 at 11:50 a.m., multiple ant-like crawling insects were observed crawling on Resident #2's bed, and on the wound dressings on both ankles. Residents Affected - Some Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. The resident said she requested to have her bed sheets changed since then to get rid of the ants and no one has come all morning. On 8/3/23 at 12:00 p.m., LPN Staff I was notified of the observation of the crawling insects observed on the resident's bed and her request to have her sheets changed and the pest removed. LPN Staff I said she would let the Certified Nursing Assistant know. On 8/3/23 at 3:30 p.m., Resident #2 said she felt terrible, just terrible when the nurse told her she had ants in her bed. She said the ants were crawling in her dressings. She said, no one wants bugs in their bed. I told the nurse I wanted an aide to change my bed, but no one had come yet. On 8/3/23 at 3:45 p.m., three hours and forty five minutes after LPN Staff I was notified of the ants in the resident's bed, Housekeeper staff BB was observed cleaning Resident #2's mattress. Staff BB said there were ants in the resident's open bags of chips and in the resident's bed. On 8/3/23 at 4:55 p.m., the Administrator said the trees have not been trimmed since she's been employed at the facility on 5/19/23 for preventing ants and wildlife easier access to building . She said the facility did not have a PIP (Performance Improvement Plan) in place to address the pest control, including the rat infestation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 20 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy, record review and staff interview the facility failed to provide the necessary care and services to maintain personal hygiene and nutrition for 4 (Resident #2, #52, #55 and #65)) of 4 residents reviewed for activities of daily living (ADL). Residents Affected - Few The findings included: The facility policy Activities of Daily Living documented, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in Activities of Daily Living (ADL's) do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #2 had an admission date of 7/13/23 with diagnoses including Multiple Sclerosis, muscle weakness, and Bipolar disorder. The Significant Change Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 4/10/23 documented Resident #2 required extensive assist of 1 for toileting and dressing and was dependent on staff for bathing. The care plan identified Resident #2 can be resistive to care related to paranoid schizophrenia, Alzheimer's. The interventions instructed staff to provide cueing for safety and sequencing to maximize current level of function and allow the resident to make decisions about treatment regime, to provide sense of control and offer different days and times for bathing. On 8/1/23 at 2:10 p.m., Resident #2 said she had not received her scheduled showers since May 31, 2023, and had reported it to the Activity Director during Resident Council meetings. Review of the shower schedule revealed Resident #2 was scheduled for showers on the 3:00 p.m., to 11:00 p.m., shift on Tuesdays, Thursdays, and Saturdays. Review of the CNA (Certified Nursing Assistant) documentation for June 2023 showed Resident #2 received a scheduled shower on 6/1/23. The CNA documentation showed bed baths were provided on 6/6/23, 6/8/23, 6/20/23 and 6/24/23. There was no documentation of care provided on 6/3/23, 6/10/23, 6/13/23, 6/15/23, 6/17/23 and 6/22/23. The CNA documentation for July 2023 showed no documentation scheduled showers or bed bath were provided for Resident #2. The clinical record showed no documentation Resident #2 had refused her scheduled showers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 21 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the clinical record revealed Resident #52 had an admission date of 5/31/23 with diagnoses including Dementia, Human Immunodeficiency Virus and Major Depressive Disorder. The Significant Change Minimum MDS with an assessment reference date of 6/4/23 documented Resident #52 required extensive assist of one for personal hygiene and dressing and was dependent on staff for bathing. The MDS noted Resident #52's cognitive skills for daily decision making were moderately impaired. The care plan identified Resident #52 had an ADL self-care deficit and instructed staff to encourage her to participate and to assist her with ADL's as needed. Amount of assistance varies depending on how she is feeling. Review of the shower schedule showed Resident #52 was scheduled for showers on the 3:00 p.m., to 11:00 p.m., shift on Mondays, Wednesdays, and Fridays. On 7/31/23 at 1:31 p.m., Resident #52's hair was observed to be greasy, and uncombed. Resident #52 said she was unsure if she was receiving her scheduled showers. Review of the CNA documentation for June 2023 showed Resident #52 received a bed bath on 6/2/23, 6/5/23, 6/7/23, 6/9/23, 6/12/23, 6/16/23, 6/19/23, 6/21/23, 6/23/23, 6/26/23, 6/28/23 and 6/30/23. On 6/14/23 there was no documentation of care provided to the resident. The documentation showed Resident #52 did not receive scheduled showers for the month of June. Review of the CNA charting for July 2023 showed Resident #52 received a bed bath on 7/3/23, 7/5/23, 7/7/23, 7/12/23, 7/17/23, 7/19/23, 7/24/23, 7/28/23, 7/31/23. There was no documentation care was provided to the resident on 7/10/23, 7/14/23, 7/21/23 and 7/26/23. The documentation showed Resident #52 received no scheduled showers for the month of July. There was no documentation the resident refused her scheduled showers. On 8/2/23 at 11:10 a.m., CNA Staff J said, We have a shower sheet, and it goes by room numbers and that is what we go by. The schedule is in the shower book. We provide showers per the schedule and of course if needed and if the resident asks for one. If the resident refuses, we come back in an hour or so and ask again, if they still refuse, we let the nurse know. The nurse will try and talk them into it and if they can't it is documented the resident refused. On 8/2/23 at 12:48 p.m., the Director of Nursing (DON) said she was unaware there was an issue with residents not receiving scheduled showers. On 8/2/23 at 12:50 p.m., the Regional Nurse Consultant (RNC), said the CNAs document the showers in the electronic record. The RNC was informed the CNA documentation showed Resident #2 and #52 did not receive their scheduled showers. The RNC said Resident #2 had a care plan for refusal of showers and said the resident does not like to get out of bed, it is a whole process for her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 22 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/2/23 at 2:43 p.m., the RNC confirmed there was no documentation Residents #2 and #52 had refused their scheduled showers. The RNC said, We are aware of the concern and will work to tighten it up. On 8/2/23 at 8:20 a.m., while observing Licensed Practical Nurse (LPN) Staff H, administer medications to Resident #55, observation revealed Resident #55 did not have a breakfast tray at the bedside or in the room. Resident #55's roommate had a breakfast tray. LPN Staff H finished administering medications and said to Resident #55, They will be in to feed you soon. On 8/2/23 at 8:40 a.m., Certified Nursing Assistants were observed collecting breakfast trays for the assigned hall area. LPN Staff H said, I don't know if she [Resident #55] got any breakfast. LPN Staff H looked in the collected breakfast trays and said she could not find one for Resident #55. After reviewing Resident #55's paperwork she said Resident #55 came from the hospital the day before and it looked like the nurse from the evening and night shift did not send a diet order to the kitchen for Resident #55. She said the kitchen would not have known to send her a tray. LPN Staff H said Resident #55 required total assistance with feeding, was aphasic (inability speak) and could not communicate she had not eaten. LPN Staff H said, I hope this does not come back to fall on me. I will enter the order now and go get her a breakfast. On 8/2/23 at 8:50 a.m., the Director of Nursing (DON) said the evening nurse who readmitted the resident should have activated the medication and diet orders. The DON said she did not know why it was not done. On 8/2/23 at 9:10 a.m., CNA Staff L, assigned to Resident #55 for the shift said I didn't see her tray. I thought someone fed her. I was in room (Room #) feeding someone else. CNA Staff L confirmed she had not asked anyone else to assist Resident #55 with her meal and was unaware Resident #55 had not received anything to eat when she repositioned and settled her in bed a short while ago. CNA Staff L confirmed the resident did not communicate verbally and said, I can go get her something now. I did not know she had not eaten. Clinical records reviewed for Resident #55 including comprehensive care plan revised on 5/19/23 which documents Resident is at risk for decreased ability to perform ADLs including eating with interventions including resident required supervision of 1 staff to eat. Care plan also has focus stating the resident was at risk for malnutrition related to dementia, schizophrenia, hypothyroidism, hypertension, and history of significant weight loss with interventions to monitor po (by mouth) intake of meals/ fluids. Reviewed CNA documentation for meal intake for past 30 days. Resident #55 had been in the hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 23 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for six of the 30 days. Resident #55 had 72 opportunities for staff to document meal intake during the time period reviewed. No documentation of a meal being provided or eaten in the clinical records for 39 of the 72 meals. On 8/3/23 at 10:30 a.m., the DON said she expects staff assigned to each resident to make sure the resident has their meals. If they are unable to feed the resident themselves then they need to hand off to either another CNA or the assigned nurse. The DON said she was unaware so many of the meals had not been documented for Resident #55. The DON said she knew resident had her meals but could not guarantee it because of the lack of documentation and the resident's condition. She said, I have work to do with the staff. On 8/4/23 at 12:15 p.m., interviewed CNA, Staff GG, assigned to resident #65 about the resident's daily hygiene needs. The CNA said if the resident is not scheduled for a shower, she will get her up and dressed, wash her face, and brush her teeth to get her ready for the day. She said she had already done these things for the resident today. Observation of Resident #65's room, and bathroom with CNA Staff GG failed to reveal a toothbrush, or toothpaste. CNA Staff GG said, I usually keep them in the upper drawer. She opened the drawer of the resident's dresser, no toothbrush or toothpaste were present. CNA Staff GG said, I remember. She did not have a toothbrush, so I had her gargle today. CNA Staff GG verified it was not routine to have residents gargle instead of brushing their teeth. She said, We don't have toothbrushes a lot. Gargling cleans out their mouths too. On 8/4/23 at 12:30 p.m., Unit Manager LPN, Staff AA said gargling was not acceptable in place of brushing teeth. She said, We have been having issues with having the toothbrushes available. We are making tooth care kits for one time use now and they can be placed on the high shelf in the closet. On 8/4/23 at 12:50 p.m., the DON said they have been having issues with toothbrush supplies, so they were making oral kits today. The kits were to make sure the CNAs have toothbrushes and toothpaste available for the residents in their rooms. The DON confirmed it was unacceptable to have the resident gargle instead of brushing their teeth, and the CNAs were expected to help them brush their teeth and perform oral care. Records reviewed for Resident #65 including comprehensive care plan documented the resident has potential for dental or oral problem related to some missing teeth. Interventions included assist or complete mouth/oral care daily and PRN (as needed). Review of the CNA documentation for July 2023 showed no oral care provided for seven of 31 days in the month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 24 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and staff interview, the facility failed to ensure 7 (Residents #35, #40, #55, #67, #73, #194, #88) of 7 residents received medications in accordance with professional standards of practice by failing to order medications on a timely manner or failure to administer medications in accordance with the physician's orders. Residents Affected - Some The findings included: Review of facility policy titled, admission Orders, revised 5/2022 which states, A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and /or verbal orders for the residents' immediate care and needs. 1. The written and/or verbal orders should include at a minimum: (a) Dietary, (b) Medication orders if indicated; (c) Routine care orders. 2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. 3. The orders should provide information to maintain or improve the resident's functional abilities. Review of facility policy titled, Medication Administration, revised 5/3/2022 which states Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. Keep medication cart clean, organized and stocked with adequate supplies .11. Compare medication source with medication administration record (MAR) to verify resident name. form, dose, route and time. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician . 13. Remove medication from source, taking care not to touch medication with bare hand. Review of facility policy titled Controlled Substance Administration and Accountability, revised 7/19/22 which stated, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . 1.(j) The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify: i. Controlled substances that are destroyed are appropriately documented; and ii. Medications removed from either the automated dispensing system or medication cart/ cabinet have a documented physician order. Review of facility policy titled, Unavailable Medications, revised 2/9/2022 which states, If a resident misses a scheduled dose of a medication, staff shall follow procedures for medication errors, including physician/ family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. 1. On 8/2/23 at 8:04 a.m., observed Licensed Practical Nurse (LPN) Staff H administer scheduled medications to Resident #40. The physician's orders included Cyclobenzaprine HCl Tablet 10 milligrams (mg) one tablet by mouth three times a day related to chronic pain syndrome. LPN Staff H said the medication was not available to be given. There was none available in the medication cart and this medication was not included in the floor stock of prescription medications. On 8/2/23 at 8:15 a.m., LPN Staff H said, It does not happen that often, looks like someone did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 25 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 request the reorder. She said she would reorder the Cyclobenzaprine now. Level of Harm - Minimal harm or potential for actual harm 2. On 8/2/23 at 8:20 a.m., observed LPN Staff H, administering scheduled medications to Resident #55. Residents Affected - Some LPN Staff H said the resident returned to the facility the previous afternoon into the evening. She noted her medications had not been ordered so she was unable to administer the medications as ordered. Medications unable to be administered included Dexamethasone 6 mg tablet once a day for two days for COVID-19; Famotidine tablet 10 mg once a day for indigestion; Labetalol HCl 100 mg tablet, 1 tablet twice a day for hypertension (high blood pressure); Incruse Ellipta 62.5 mcg (micrograms)/ACT inhaler 1 puff once a day for Chronic Obstructive Pulmonary Disease (COPD); Depakene Solution 250 mg/ml (milliliter) 10 ml 2 times a day for mood disorder. LPN Staff H said, I don't know why they did not order them. I got two of the medications from the medication room supply. I will have the rest later today. On 8/2/23 at 8:45 a.m., the Director of Nursing (DON) was interviewed about Resident #55's orders not sent to the pharmacy after readmission the previous evening 8/1/23 around 6:00 p.m. The DON reviewed the records and said, I don't know why the nurse did not get the medications from the pharmacy. That should not have happened. 3. On 8/2/23 at 5:30 p.m., RN Staff M was observed conducting a narcotic count with the Director of Nursing RN, Staff M, said, Let me get the book. I can't leave it on the cart because the residents will take it. RN, Staff M said, Wait let me fill in the medications I have already given. RN Staff M documented on the declining inventory of the narcotic log for six residents, #67, #73, #70, # 35, #194 and #88 as follows: Resident #35, administered lorazepam tablet 1 mg 8/2/23 at 2000 (8:00 p.m.) Resident #194, administered lorazepam tablet 0.5 mg at 2000 (8:00 p.m.) Resident #88, administered alprazolam (used to treat anxiety) 0.25 mg at 2000 (8:00p.m.) Resident #67, administered tramadol (opioid analgesic) HCL tablet 50 mg on 8/2/23 at 1800 (6:00p.m.) Resident #73, administered oxycodone/acetaminophen 5-325 mg (opioid analgesic) tablet 8/2/23 at 1800 (6:00 p.m.) Resident #70, administered lorazepam (antianxiety) tablet 0.5 mg 8/2/23 at 1800 (6:00 p.m.) RN Staff M verified he documented he administered the Lorazepam to Residents #35, and #194, and the alprazolam to Resident #88 approximately three hours before scheduled time. RN Staff M said, I know that you should do one hour before and one hour after. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 26 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm RN, Staff M said, You need to understand that these residents get very confused and sundown [confusion occurring in late afternoon]. They will have behaviors, so they need their medications early. Review of the clinical record with the DON for Resident #35 revealed a physician's order dated 6/9/23 to discontinue the lorazepam 1 mg. Residents Affected - Some There was no documentation in the clinical record Resident #35 was experiencing anxiety, and the physician was contacted and had authorized the administration of the discontinued lorazepam to Resident #35. Review of the clinical record with the DON for Resident #194 revealed an active physician's order dated 7/12/23 to administer lorazepam 0.5 mg tablet twice a day for restlessness. The medication was scheduled to be administered every 12 hours, at 9:00 a.m., and 9:00 p.m. Staff M had administered the lorazepam to the resident four hours before the scheduled time. There was no documentation in the clinical record Resident #194 was experiencing any restlessness and the physician was contacted and authorized the administration of the lorazepam outside of the scheduled time. Review of the clinical record for Resident #88 with the DON revealed an active physician's order dated 7/1/23 for alprazolam once a day at bedtime for anxiety. The medication was scheduled to be administered every evening at 8:00 p.m. RN Staff M had administered the alprazolam to the resident three hours prior to the scheduled time. The clinical record lacked documentation of behavior to support the early administration. There was no documentation the physician was contacted and had authorized the early administration of the alprazolam. Review of the physician's orders with the DON for Resident #67 revealed to administer Tramadol HCl 50 mg twice a day for pain. The medication was scheduled to be administered every 12 hours at 9:00 a.m. and 9:00 p.m. RN Staff M had administered the Tramadol four hours prior to the scheduled time. There was no documentation in the clinical record, Resident #67 was experiencing any pain and the physician had authorized the administration of the Tramadol outside of the scheduled time. Review of the clinical record with the DON for Resident #73 revealed a physician's order for oxycodone/acetaminophen 5-325 mg which was discontinued on 7/3/23. Resident #73 did not have an active order for the oxycodone/acetaminophen 5/325 RN Staff M documented he administered on 8/2/23 at 6:00 p.m. There was no documentation in the clinical record Resident #73 was experiencing any pain and the physician had authorized the administration of the discontinued oxycodone/acetaminophen 5/325. On 8/2/23 at 6:30 p.m., the Administrator who is the risk manager, and the Regional Nurse Consultant said RN Staff M was suspended pending investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 27 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm On 8/3/23 at 10:07 a.m., the DON said she could not explain why the narcotics were kept in the medications carts several weeks after they were discontinued. She said the discontinued narcotics would be brought to the DON for destruction. The DON said, I cannot control everything. Best practice we know they should not have been in the cart. It is an expectation that when medication is discontinued you bring to the DON. Residents Affected - Some The DON verified she has been employed at the facility since April 2023 and she has not sought out discontinued narcotics but has waited for staff to bring them to her. The DON said, moving forward I will be going to those carts every day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 28 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview the facility failed to ensure a resident with lost glasses received the proper treatment to maintain vision and assist with arrangements to have the glasses replaced in a timely manner for 1 (Resident #88) of 1 resident reviewed for vision impairment. Residents Affected - Few The findings included: The Facility policy titled Hearing and Vision Services, revised 5/2022 stated the facility is to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Employees should refer any identified need for vision services to the social worker or social service designee. The social worker or designee will assist the resident by making appointments and arranging for transportation. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision. Assistive devices to maintain vision include glasses, contact lenses, and magnifying lens or other devices used by the resident. Resident #88 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Dementia, Anxiety, and a history of Transient Ischemic Attacks. Section B of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated the residents' vision was moderately impaired. The resident's cognition was moderately impaired with a Brief Interview of Mental Status (BIMS) score of 9. Resident #88's care plan initiated on 4/26/23 indicated Resident #88 has vision impairment related to: history of TIA'S (Transient Ischemic Attacks, sometimes known as mini strokes). Interventions included assist with activities of daily living, arrange meals in residents' visual field, resident requires task-focused lighting when reading, during activities, and approach resident from the front and face to face contact to promote communication. On 7/31/23 at 9:46 a.m., Resident #88 stated he had worn glasses since grade school, sometime around 3rd grade and they helped a lot. He stated he had not seen an eye doctor in a long time. On 8/01/23 at 9:37 a.m., Resident #88 was observed in bed. He stated he has not had his glasses for a while. On 8/1/23 at 7:56 p.m., Resident #88's daughter stated in a telephone interview Resident #88, had glasses and is horribly visually impaired without them. Somewhere between the transfer to the hospital and to the sister facility, the glasses have been lost. Resident #88's daughter stated she had talked to so many people at the facility about them but could not recall who specifically. On 8/2/23 at 2:14 p.m., the Administrator stated she showed the resident a piece of paper and he was able to read two words from it. The Administrator stated, I think the MDS assessment was inaccurate because he could read this. The Administrator agreed the resident should be evaluated by a vision professional. On 8/4/23 at 9:31 a.m., the Interim Social Service Director (SSD) stated Resident #88 has been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 29 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0685 scheduled for a vision appointment on September 5, 2023 and stated he should have been seen by now. The SSD agreed resident should not have had to wait so long to get his glasses replaced. 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: 105407 If continuation sheet Page 30 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, review of the clinical records and staff interviews, the facility failed to provide appropriate restorative services and physician ordered interventions for the management of contractures (fixed deformity of joints) for 1 (Resident #31) of 1 resident reviewed with positioning devices. The findings included: The facility policy Restorative Nursing Programs (revised 5/2022) documented, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The interdisciplinary team with the support and guidance form the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licenses nurse oversight. The training may include but is not limited to: Assisting residents in adjustment to their disabilities and use of any assistive devices. Review of the clinical record revealed Resident #31 had an admission date of 9/3/19 with diagnoses including dementia, muscle wasting and atrophy, anxiety, and chronic pain syndrome. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 5/11/23 documented Resident #31 was dependent on staff for bed mobility and had limitation in range of motion on both sides of the lower body. The MDS noted Resident #31's cognitive skills for daily decision making were severely impaired. Review of the physician orders revealed the following orders: 1. Apply soft heel boot to left foot and wear at all times when in bed. 2. Wear offloading boot to right foot at all times. 3. Recommend bilateral knee brace and abductor brace while in bed and sitting up in chair for 3- (to) 4 hours or as tolerated during am care and remove before lunch, skin check before and after donning brace and every shift. 4. Recommend bilateral knee brace for knee flexion contracture and hip abductor orthosis, therapy to work on wearing schedule. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 31 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/31/23 at 10:07 a.m., Resident #31 was in bed in a fetal position (legs bent and drawn up) and did not answer any questions. There was a pair of heel boots lying on the floor in the room. The resident was not able to straighten his legs due to knee contractures. The resident did not have any positioning devices on. Licensed Practical Nurse (LPN) Staff I said the resident was to have the boots on at all times and confirmed the heel boots were on the floor and not on the resident as ordered. During additional random observations on 7/31/23 at 3:00 p.m., 8/1/23 at 8:29 a.m., and 2:30 p.m., Resident #31 was in bed with no positioning devices or knee braces in use. The heel boots remained on the floor in the room. Review of the Certified Nursing Assistant (CNA) care [NAME] (instructions on care needs) revealed for staff to apply bilateral knee brace for knee flexion contracture and hip abductor orthosis. On 8/2/23 at 8:56 a.m., CNA Staff L said Resident #31 was to have the boots on when in bed, it was the only device she knew the resident used. The CNA said she had not seen splints for the residents legs or knees. The CNA said the resident was not able to straighten his legs and was non ambulatory. On 8/2/23 at 10:07 a.m., Licensed Practical Nurse (LPN) Staff H confirmed Resident #31 was to have heel boots on at all times and confirmed the boots had not been applied. LPN Staff H confirmed the resident had no positioning devices in place including the ordered knee braces. On 8/2/23 at 12:30 p.m., LPN Staff C, wound care nurse, said Resident #31 did not have splints for his knees. Staff C said the resident had heel boots and had no pressure wounds on the heels. On 8/4/23 at 8:30 a.m., the Registered Nurse Consultant (RNC) said the information for the application of splints was located in the restorative binder and the Restorative CNA applies the devices. 8/4/23 at 8:36 a.m., the Director of Nursing (DON) said she was aware Resident #31 did not have the physician ordered knee braces, orthosis and heel boots applied. The DON said the devices caused him pain and, we don't want to do anything to cause pain. The DON said Resident #31 refuses the devices due to pain but confirmed there was no documentation the resident had refused the positioning and pressure reduction devices. On 8/4/23 at 8:49 a.m., a review of the Restorative CNA book documented a Therapy Referral to Restorative Nursing Program or Functional Maintenance Program form dated 6/13/23 provided instructions for right and left knee abduction brace in bed or wheelchair for 3 to 4 hours as tolerated. There was no documentation in the Restorative book indicating the program was initiated or completed by the Restorative CNA. On 8/4/23 at 9:00 a.m., during an observation and interview, Resident #31 was in bed with no splints in place. Registered Nurse (RN) Staff D said she did not know anything regarding the use of braces or other positing device for Resident #31. The nurse said, The only thing I know is he has boots that are supposed to be on. On 8/4/23 at 9:09 a.m., the RNC said the documentation in the Restorative binder was for a therapy referral and the process was the Physical Therapist (PT) would review to see if it was appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 32 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0688 Level of Harm - Minimal harm or potential for actual harm for the resident. If it was, the therapist would initiate a program and provide education to the Restorative CNA. On 8/4/23 at 9:55 a.m., CNA Staff K said she did not know anything about leg/knee braces for Resident #31. Staff K said she had never seen them or put them on him. Residents Affected - Few On 8/4/23 at 10:05 a.m., the Restorative CNA Staff J said Resident #31 wears a soft inflatable heel boot and it is considered a splint, all foot boots are splints. Resident #31 will refuse and kick off the boots. I try and get him to keep them in place for 3-4 hours and I document if he refuses to wear them. I document in the CNA documentation. We have a weekly restorative meeting with the DON, the unit nurse and therapy to review the program. The bilateral knee splints the resident does not wear so we put the pillows between his knees. On 8/4/23 at 11:45 a.m., Restorative CNA Staff J said she documented in the CNA task section when Resident #31 refused to have the knee brace and orthosis applied. A review of the CNA task section of the documentation for August 2023, showed no documentation of the restorative program or documentation Resident #31 refused the knee brace. Restorative CNA Staff J said she was not able to locate her documentation of care in the CNA task list, because there was none. Restorative CNA Staff J confirmed she had no documentation the restorative program for the knee brace and abductor orthosis was initiated and had not applied the devices. On 8/4/23 at 12:46 p.m., the Rehab Director said, Once a resident comes off therapy and has a restorative program, the nurses are responsible to oversee that it is done. (Resident #31) has contractures of both knees and hands and is in a fetal position, he is not able to straighten his legs. The splints are bilateral knee abductor braces, and it is used to keep the contracture form getting worse, it will not get better. The pillow is to keep the knees separated and to prevent pressure ulcers. The splints and pillow are to be used when in the resident is in bed or wheelchair. On 8/4/23 at 12:33 p.m., the RNC confirmed there was no documentation the Restorative CNA completed the assigned tasks to apply the bilateral knee braces, the heel boots and abductor pillow for Resident #31. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 33 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and staff record review the facility failed to ensure 4 (Staff O, CC, DD, and FF) of 5 staff employee records had a performance review completed at least once every 12 months with in-service education based on the outcome of the performance reviews. Residents Affected - Some The findings included: Review of the Facility Assessment Tool last updated on 5/19/23, noted documentation in the Staff Training/Education and Competencies section the nurse aides are required to have in-service training throughout the year. In-service training must . address areas of weakness as determined in nurse aides' performance reviews as noted in the Facility Assessment Tool and the training may address the special needs of residents as determined by the facility staff. On 8/3/23 a review of Staff O's employee file, a CNA (Certified Nursing Assistant), revealed a date of hire of 6/11/14. Further review of Staff O's employee file failed to reveal documentation of an annual performance review for 2022 nor 2023. On 8/3/23 a review of Staff CC's employee file a CNA, revealed a date of hire of 11/21/12. Further review of Staff CC's employee file revealed the employee did not have an annual performance review completed for 2022 or 2023. On 8/3/23 a review of Staff DD's employee file a CNA, revealed a date of hire of 8/9/17. Further review of Staff DD's employee file revealed the employee did not have an annual performance review completed for 2022 or 2023. On 8/4/23 at 12:43 p.m., in an interview with Staff FF, a CNA, she said she was hired over 6 years ago. She said she did not remember the last time the facility completed her annual performance review, but she knew her annual performance review was not conducted in 2022 or 2023. On 8/4/23 at 1:25 p.m., in an interview with the Administrator, she said all CNA/nurse aides were required to have a performance review completed every 12 months which should address the CNA/nurse aides' areas of weakness as noted in the facility's Facility Assessment Tool. She said she was told by the Human Resource (HR) Director several months ago during an employee file audit, the HR Director noted several of the CNA/nurse aides annual performance reviews were not completed as required. The Administrator confirmed Staff O, CC, DD, and FF's annual performance reviews were not completed as of 8/4/23. On 8/4/23 at 2:01 p.m., in an interview with the HR Director, during an employee file audit, she informed the Administrator several of the staff required annual performance reviews were not completed. The HR Director confirmed Staff (O, CC, DD, EE, and FF)'s annual performance reviews were not completed for 2022 and 2023 as of this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 34 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, staff interviews, resident records review and facility policy review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals. The facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The findings included: Review of facility policy titled, Medication Administration, revised 5/3/2022 which states Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. Keep medication cart clean, organized and stocked with adequate supplies . 11. Compare medication source with medication administration record (MAR) to verify resident name. form, dose, route, and time. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician . 13. Remove medication from source, taking care not to touch medication with bare hand. Review of facility policy titled Controlled Substance Administration and Accountability, revised 7/19/22 which stated, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure . 1.(j) The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify i. Controlled substances that are destroyed are appropriately documented; and ii. Medications removed from either the automated dispensing system or medication cart/ cabinet have a documented physician order. Review of facility policy titled, Unavailable Medications, revised 2/9/2022 which states, If a resident misses a scheduled dose of a medication, staff shall follow procedures for medication errors, including physician/ family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. On 8/2/23 at 8:04 a.m., observed Licensed Practical Nurse (LPN), Staff H, administer scheduled medications to Resident #40. Resident was ordered to receive Cyclobenzaprine HCl Tablet 10 milligrams (mg) one tablet by mouth three times a day related to chronic pain syndrome. LPN Staff H said the medication was not available to be given. There was none available in the medication cart and this medication was not in the floor stock of prescription medications. On 8/2/23 at 8:15 a.m., LPN Staff H said, It does not happen that often, looks like someone did not request the reorder. She said she would reorder the Cyclobenzaprine now. On 8/2/23 at 8:20 a.m., observed LPN Staff H, attempting to administer scheduled medications to Resident #55. LPN Staff H said the resident returned to the facility the previous afternoon into evening. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 35 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some noted her medications had not been ordered so she was unable to administer the medications as ordered. Medications unable to be administered included Dexamethasone 6 mg tablet once a day for two days for COVID-19; Famotidine tablet 10 mg once a day for indigestion; Labetalol HCl 100 mg tablet, 1 tablet twice a day for hypertension (high blood pressure); Incruse Ellipta 62.5 mcg (micrograms)/ACT inhaler 1 puff once a day for Chronic Obstructive Pulmonary Disease (COPD); Depakene Solution 250 mg/ml (milliliter) 10 ml 2 times a day for mood disorder. LPN Staff H said, I don't know why they did not order them. I got two of the medications from the medication room supply. I will have the rest later today. On 8/2/23 at 8:45 a.m., the Director of Nursing (DON) was interviewed about Resident #55's orders not sent to the pharmacy after readmission the previous evening 8/1/23 around 600 p.m. The DON reviewed the records and said, I don't know why the nurse did not get the medications from pharmacy. That should not have happened. On 8/2/23 at 5:10 p.m., observation of the North Back Hall medication cart with Registered Nurse (RN) Staff M revealed a personal coffee cup stored in the center of the medication drawer. RN Staff M verified personal cups should not be stored in the medication cart and said, I had to go into a room, and we can't leave anything on the cart. RN Staff M said, I can't lie, and I don't want anyone else to get into trouble. It is mine. 11 full loose pills and many partial pill pieces were found in the bottom of the drawer among the medication cards. A white, half pill was observed loose in the controlled substance (narcotic) drawer. The half pill appeared to be Ativan (antianxiety). RN Staff M could not explain who was responsible for ensuring the cart did not have any loose pills. When asked if he checks the cart when working, RN Staff M replied, I don't know. On 8/2/23 at 5:30 p.m., The DON said, we just checked the carts the other day. I don't know why there are so many loose pills. It is a nurse's responsibility to ensure the carts are clean and the counts are correct. The DON said it was unacceptable for a nurse to store his coffee cup inside the medication drawer and that there should not be loose unaccounted for medications in the bottom of the drawer. On 8/2/23 at 5:30 p.m., RN Staff M was observed conducting a narcotic count with the Director of Nursing (due to the loose half pill in the narcotic drawer which appeared to be Ativan. The narcotic book was at nurses' station not with cart. RN, Staff M, said, Let me get the book. I can't leave it on the cart because the residents will take it. RN, Staff M said, Wait let me fill in the medications I have already given. RN Staff M documented on the declining inventory of the narcotic log for six residents, #67, #73, #70, # 35, #194 and #88 as follows: Resident #67, administered tramadol (opioid analgesic) HCL tablet 50 mg on 8/2/23 at 1800 (6:00p.m.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 36 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0755 Resident #73, administered oxycodone/acetaminophen 5-325 mg (opioid analgesic) tablet 8/2/23 at 1800 (6:00 p.m.) Level of Harm - Minimal harm or potential for actual harm Resident #70, administered lorazepam (antianxiety) tablet 0.5 mg 8/2/23 at 1800 (6:00 p.m.) Residents Affected - Some Resident #35, administered lorazepam tablet 1 mg 8/2/23 at 2000 (8:00 p.m.) Resident #194, administered lorazepam tablet 0.5 mg at 2000 (8:00 p.m.) Resident #88, administered alprazolam (used to treat anxiety) 0.25 mg at 2000 (8:00p.m.) RN Staff M verified he documented he administered the Lorazepam to Residents #35, and #194, and the alprazolam to Resident #88 approximately three hours before scheduled time. RN Staff M said, I know that you should do one hour before and 1 hour after. RN, Staff M said, You need to understand that these residents get very confused and sundown [confusion occurring in late afternoon]. They will have behaviors, so they need their medications early. Review of the physician's orders with the DON for Resident #67 revealed to administer Tramadol HCl 50 mg twice a day for pain. The medication was scheduled to be administered every 12 hours at 9:00 a.m. and 9:00 p.m. RN Staff M had administered the Tramadol four hours prior to the scheduled time. There was no documentation in the clinical record, Resident #67 was experiencing any pain and the physician had authorized the administration of the Tramadol outside of the scheduled time. Review of the clinical record with the DON for Resident #73 revealed a physician's order for oxycodone/acetaminophen 5-325 mg which was discontinued on 7/3/23. Resident #73 did not have an active order for the oxycodone/acetaminophen 5/325 RN Staff M documented he administered on 8/2/23 at 6:00 p.m. There was no documentation in the clinical record Resident #73 was experiencing any pain and the physician had authorized the administration of the discontinued oxycodone/acetaminophen 5/325. Review of the clinical record with the DON for Resident #35 revealed a physician's order dated 6/9/23 to discontinue the lorazepam 1 mg. There was no documentation in the clinical record Resident #35 was experiencing any anxiety, and the physician was contacted and had authorized the administration of the discontinued lorazepam to Resident #35. Review of the clinical record with the DON for Resident #194 revealed an active physician's order dated 7/12/23 to administer lorazepam 0.5 mg tablet twice a day for restlessness. The medication was scheduled to be administered every 12 hours, at 9:00 a.m., and 9:00 p.m. Staff M had administered the lorazepam to the resident four hours before the scheduled time. There was no documentation in the clinical record Resident #194 was experiencing any restlessness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 37 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and the physician was contacted and authorized the administration of the lorazepam outside of the scheduled time. Review of the clinical record for Resident #88 revealed an active physician's order dated 7/1/23 for alprazolam once a day at bedtime for anxiety. The medication was scheduled to be administered every evening at 8:00 p.m. RN Staff M had administered the alprazolam to the resident three hours prior to the scheduled time. The clinical record lacked documentation of behavior to support the early administration. There was no documentation the physician was contacted and had authorized the early administration of the alprazolam. On 8/2/23 at 6:30 p.m., the Administrator who is the risk manager, and the Regional Nurse Consultant said RN Staff M, was suspended pending investigation. They said they were not sure if the situation was drug diversion or medicating without orders and had contacted the police. The administrator said she did not know why the discontinued controlled substances were still in the medication carts. On 8/3/23 at 10:07 a.m., the DON said she could not explain why the narcotics were kept in the medications carts several weeks after they were discontinued. She said the discontinued narcotics would be brought to the DON for destruction. The DON said, I cannot control everything. Best practice we know they should not have been in the cart. It is an expectation that when medication is discontinued you bring to the DON. The DON verified she has been employed at the facility since April 2023 and she has not sought out discontinued narcotics but has waited for staff to bring them to her. The DON said, moving forward I will be going to those carts every day. The DON confirmed when she receives discontinued narcotics, she places them with the declining inventory log paper into the double locked cabinet in her office. The DON said she did not know what was currently in her cabinet and had no means of reconciling if what was in the cabinet matched medications which had been discontinued at facility. On 8/3/23 10:55 a.m., during a telephone interview the consultant pharmacist said he comes to the facility every four to six weeks, but it was not a scheduled visit. The pharmacist said it was the responsibility of the nursing team to collect and secure discontinued narcotics until he is at the facility for destruction. The pharmacist and the pharmacy technicians do not remove discontinued medications from the medication carts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 38 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, resident records review and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Two nurses and 25 opportunities were observed. Six medication errors were identified, resulting in a 24% medication error rate. Residents Affected - Some The findings included: Review of facility policy titled, Medication Administration, revised 5/3/2022 which states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 11. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. On 8/2/23 at 8:04 a.m., observed Licensed Practical Nurse (LPN), Staff H, administer seven different scheduled medications to Resident #40. The physician's orders included Cyclobenzaprine HCl Tablet 10 milligrams (mg) one tablet by mouth three times a day related to chronic pain syndrome. LPN Staff H did not administer the Cyclobenzaprine. She said the medication was not available, and she'll have to reorder it. On 8/2/23 at 8:20 a.m., LPN Staff H administering scheduled medications to Resident #55, including Aspiring 325 mg, one tablet; Citalopram Hydrobromide 20 mg, one tablet and Furosemide 20 mg, one tablet. Review of the clinical record revealed orders for Dexamethasone 6 mg tablet once a day for two days for COVID-19, Famotidine tablet 10 mg once a day for indigestion, Labetalol HCl 100 mg tablet, 1 tablet twice a day for hypertension (high blood pressure), Incruse Ellipta 62.5 mcg (micrograms)/ACT inhaler 1 puff once a day for Chronic Obstructive Pulmonary Disease (COPD), and Depakene Solution 250 mg/ml (milliliter) 10 ml 2 times a day for mood disorder. LPN Staff H said the resident returned to the facility the previous afternoon into evening. She said her medications had not been ordered so she was unable to administer all the ordered medications. On 8/3/23 at 10:07 a.m., the Director of Nursing said she would be working with the staff for improvement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 39 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, records review, and facility policy review, the facility failed to ensure medications left at the bedside were appropriately stored for 1 (Resident #73) of 1 resident observed with unsecured medications at the bedside and 1 (North Hall) of 2 medication carts observed. The findings included: Review of facility policy titled, Medication Storage, revised [DATE] noted, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels. Review of facility policy titled, Destruction of Unused Drugs, revised 5/2022 which stated, All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations . Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. On [DATE] at 09:27 a.m., Resident #73 was observed with an unsecured medication cup on the bedside table containing four red capsules and three small pills. Photographic Evidence Obtained Resident #73 stated he couldn't take all the pills at one time so the nurse left them with him. On [DATE] at 9:38 a.m., Licensed Practical Nurse (LPN) Staff MM, verified she left the medication at the bedside and stated she should not have left them in the room. On [DATE] at 5:10 p.m., observation of the North Back hall medication cart with Registered Nurse (RN) Staff M revealed 11 loose pills in the medication drawer and one ½ loose pill in the controlled substance drawer. On 8/2 at 5:30 p.m., the DON said, We just checked the carts the other day. I don't know why there are so many loose pills. It is a nurse's responsibility to ensure the carts are clean and the counts are correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 40 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0791 Provide or obtain dental services for each resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to ensure 2 (Resident #29 and Resident #88) of 2 residents reviewed experiencing mouth pain, received dental services to meet their needs. Residents Affected - Few The findings included: The facility policy for Dental Services Implemented 1/2022 and last revised 5/2022 stated, it is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease/dental radiographs as needed, dental cleaning, fillings, minor partial or full denture adjustments, smoothing broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. On 8/01/23 at 11:45 a.m., Resident #29, he said he has been a resident at the facility for 16 months. He said he had pain when he ate due to broken teeth. The resident opened his mouth. Multiple broken teeth were observed worn down to the down to the gum line on his lower jaw. He said the facility offered to send him to a dentist when he was admitted but no one has mentioned it since. He said he told them he would have to be put to sleep to have the work done because he was scared of going to the dentist. He said he was afraid of the pain and would be unable to have dental work if he was awake. He said he would love to get his teeth fixed or get dentures. Resident #29 was admitted to the facility on [DATE]. His BIMS (Brief Interview for Mental Status) was a 15 of 15 which indicated the resident was cognitively intact. The admission Record noted the primary payer to be Humana Medicaid. Resident # 29's Care Plan initiated on 4/27/2023 stated Resident #29 has 1 tooth, history of inflamed gums, but no complaints of anything new. The goal was for resident to be free of infection, pain, or bleeding in the oral cavity by review date. Interventions listed as initiated were coordinate arrangements for dental care, transportation as needed/as ordered . Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted . Monitor/document/report as needed any signs or symptoms of oral/dental problems needing attention: Pain, abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue inflamed, ulcers in mouth, lesions. There were no further interventions or documentation addressing Resident # 29 dental issues in the resident's care plan. Resident #29's oral evaluation completed on 4/20/2022 noted some missing teeth and, has very few teeth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 41 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0791 Level of Harm - Actual harm Residents Affected - Few The Minimum Data Set (MDS) for Oral/Dental Status dated 11/8/2022 and 7/24/2023 for Resident #29 reported no broken or loosely fitting full or partial denture and no mouth or facial pain, discomfort or difficulty with chewing. The Nutritional Risk Screen completed on 4/5/2023 for Resident #29 reported no chewing problems reported or observed. The diet upon admission to facility and the current diet ordered for Resident #29 was a Regular diet. On 8/2/2023 at 1:00 p.m., the Administrator and the Director of Nursing (DON) both said Resident #29 never wanted to see a dentist. They said it was offered but he refused. They denied having knowledge of the resident having pain when chewing. On 8/2/23 at 1:30 p.m., Resident #29 said he had no teeth to chew so there was pain every time he ate, he was just used to the pain. He said he would love to have teeth, but was so scared of the dentist. He denied saying he didn't want to go to the dentist, he just said he was afraid to go to the dentist. He said he had not seen a dentist since his admission to the facility. The DON provided an email from Medical Records dated 8/3/2023 stating that Resident #29 had refused dental services in the past. The email noted there was no documentation the resident had ever been seen by the dentist before. Record review revealed Resident #88 admitted on [DATE]. The admission Record information noted the payor source was Medicaid. The admission Minimum Data Set (MDS) assessment with a target date of 4/18/23 noted diagnoses of Alzheimers Dementia, and Anxiety. The Brief interview of Mental Status (BIMS) indicated Resident #88's cognition was moderately impaired with a score of 9. The MDS noted the resident had obvious or likely cavity or broken natural teeth. A physician order with an effective date of 6/22/23 noted Resident #88, may be seen and evaluated by dental. Resident #88's care plan with an effective date of 4/26/23 noted resident has a dental or oral problem related to chipped teeth to his upper ridge and edentulous (without teeth) to lower ridge. Interventions included to assist or complete mouth/oral care daily and as needed. On 8/2/23 at 1:48 p.m., Resident #88 stated his front teeth hurt. He stated, It's hard to chew and bite down, it hurts. Resident #88's upper front teeth were observed to be broken, and jagged. The resident stated he had not brushed his teeth. On 8/4/23 at 9:02 a.m., Resident #88 was observed eating breakfast, chewing on the side. He opened his mouth, and showed the DON his teeth. They were brown with debris along the gum line and between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 42 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0791 teeth. The DON verified his teeth looked bad and needed to see a dentist. The DON verified the resident did not have a toothbrush or toothpaste in his room, bathroom or drawers. Level of Harm - Actual harm On 8/4/23 at 9:24 a.m., Resident #88 stated his teeth were worse than they have ever been. Residents Affected - Few On 8/4/23 at 9:32 a.m., the interim Social Service Director (SSD) stated the dental provider was in the building on 6/27/23 but there was no record of Resident #88 receiving dental services since admission. The SSD stated she was not aware resident had mouth pain. Record review revealed no documentation of a referral to the dentist for Resident #88. On 8/4/23 at 12:27 p.m., the Regional Nurse stated, we would ask the resident if they would like to see the dentist, and we would do a consult. That is the way it should be. The dental evaluation should be completed by Social Services and documented in the progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 43 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and record review, the facility failed to ensure residents with chewing or swallowing problems were served diets in a form to meet their individualized needs as prescribed by their physician for 2 (Resident #58 and #61) of 9 residents reviewed. This failure could potentially cause inadequate nutritional intake or swallowing concerns. The findings included: The facility dietary guideline titled: Texture Progression stated Pureed: all foods must be presented in a form that is homogenous and cohesive in nature, e.g. foods should have a pudding or mousse like consistency. Most foods would be pureed and/or strained to ensure a smooth cohesive consistency without lumps. On 7/31/23 at 11:54 a.m., Certified Nursing Assistant (CNA) Staff Q was observed feeding Resident #58 a pureed diet. The blueberry muffin was not pureed into a homogenous smooth texture. The CNA stated, those look like blueberries, its chunky. Photographic evidence obtained On 8/1/23 at 12:23 p.m., Resident #61 and Resident #58 were observed eating lunch. Both Residents had orders for a pureed diet and received pureed mixed vegetable with multiple seed like substances. The texture was chunky not a smooth, even texture. Photographic evidence obtained. CNA staff F agreed the pureed vegetable was chunky, not smooth. On 8/1/23 at 12:32 p.m., The Senior Regional Director of Culinary Services observed the food and stated it was not what he would have expected to see for pureed. On 8/1/23 at approximately 1:30 p.m., the cook stated spinach was the vegetable on the menu and he stated spinach was difficult to puree so he used a combination of butter beans and lima beans. On 8/2/23 at 1:21 p.m., Speech Therapist Staff S stated typically puree should be a smooth consistency without texture. There should not be any chunks, it should be a smooth consistency. On 8/3/23 at 3:33 p.m., the Director of Food and Nutrition Services stated she was concerned about the texture of the pureed vegetable and verified the pureed blueberry muffin served to Resident #58 at lunch time on 7/31/23 was left over from breakfast and was not a smooth consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 44 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to mitigate rodent infestation in the foodservice establishment and failed to take effective measures to protect packaged food, clean equipment, single service, and single use items from contamination from rodents. On 12/19/22 the facility became aware of rodent infestation in the kitchen and failed to take effective immediate actions to eradicate rodent infestation, store and prepare food in a manner to prevent contamination from disease causing rodents. This failure created a serious threat to residents health and safety due to the spread of certain diseases from rodents to people from cross contamination of food and equipment from infected rodent urine, feces, and saliva which could result in serious illness or death and resulted in the determination of Immediate Jeopardy at a scope and severity of pattern (K) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86 with 85 residents consuming an oral diet. The findings included: Cross reference to F584, F600, F835, F867, F880 and F925. The facility's NEXTLEVEL policy Food Storage-Dry Goods (policy 18), with an effective date of 10/2019, stated it is the center policy to ensure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code . The Dining Services Director or designees ensures that the storage area . shall not be subject to contamination by condensation, leakage, rodents, or vermin. The Dining services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. Review of the Center for Disease Control (CDC) and Prevention document titled, How to Control Wild Rodent Infestations, last reviewed on January 3, 2023, noted, Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it . Rodents, such as rats, mice . are known to carry many diseases. Diseases can spread to people directly and indirectly from rodents .'' Rodents can transmit food pathogens, such as Salmonella, Escherichia coli, and Listeria monocytogenes. These pathogens can make nursing home residents seriously ill or die from foodborne illness, as they are a highly susceptible population. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 45 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. Level of Harm - Immediate jeopardy to resident health or safety Photographic evidence obtained. Residents Affected - Some On 8/2/23 4:45 p.m., The Senior Regional Director of Culinary Services stated he was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. Review of the contracted pest control company reports from 11/2022 through 7/28/23 revealed: On 12/19/23 the company had given the facility a quote for all other exclusions. The report noted, Inspected several large rodent snap traps, previously placed in the Family Room and Kitchen areas. Four rodents were captured and removed. All traps were baited and reset, to monitor activity until mass trapping service and exclusion service are approved. On 3/24/23, Inspected with head chef in main kitchen for rodent issues. Set up and baited 1 rat trap under kitchen equipment. Set up 4 large rat glueboards under other side of main kitchen equipment. Roof is still under construction. Overhanging trees next to building needs to be trimmed back for preventing ants and wildlife to getting easier access to building. On 3/28/23, Arrived on property and spoke with front desk and head chef. Caught a rat on glueboard underneath kitchen equipment. Replaced with 2 more glueboards. Dining room has roofrat [sic] activity. Set out 2 large glueboards in drawer. And 4 large glueboards on floor by cabinets. On 4/25/23, Inspected kitchen area, last nite [sic] 3 roof rats were caught and disposed of. Will be back this Friday with a follow-up check on kitchen. On 4/28/23, Arrived on property and spoke with manager and front desk. There is a lot of rodent activity feeding off bait. Spoke with head chef in kitchen and we caught 2 more roof rats in kitchen on our large glueboards. Set out 8 more glueboards in kitchen. On 6/2/23, Inspected, cleaned, and rebaited rodent stations 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, rodent station 4 is missing. There is moderate amount of rodent activity at this time. Spoke with front desk before leaving. On 6/15/23, Spoke with kitchen staff. They caught a large rat last night. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. On 6/29/23, Texting mrs.[sic] (name) info. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. On 7/13/23, Spoke with (Maintenance Director) about adding more rodents stations. On 7/28/23, Checked all 3 logbooks and scanned them. Signed off on rodent issues after checking on them. Lots more rodent activity this month. Spoke with [name] before leaving. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said, The rats are so bad. They have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 46 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety Residents Affected - Some roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you and go into the holes in the cabinets. I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D, said, The rats and roaches are disgusting and everywhere in the building. I have seen them in the resident rooms, in the utility rooms and nourishment rooms. They run in the ceiling, you hear scratching, and you can hear them run around up there. If it fell on me, I would be screaming. I know I have reported it to the management staff, but the rats are still here. It doesn't matter what time of day, you will see them, but they are worse at night. On 8/3/23 at 10:04 a.m., during a follow up tour of the kitchen, rodent feces were noted on the floor beneath the canned goods cart and bread cart. The Director of Food and Nutrition Services, and Regional Hospitality Director verified the observation of the rodent feces and stated they had swept there the day before. There was no documentation the facility followed the CDC guidelines to clean up rodent urine and droppings. Review of the CDC document titled Clean up rodent urine and droppings with a review date of January 3, 2023 noted, Step 1: Put on rubber or plastic gloves. Step 2: Spray urine and droppings with bleach solution or an EPA-registered disinfectant until very wet. Let it soak for 5 minutes or according to instructions on the disinfectant label. Step 3: Use paper towels to wipe up the urine or droppings and cleaning product. Step 4: Throw the paper towels in a covered garbage can that is regularly emptied. Step 5: Mop or sponge the area with a disinfectant. Clean all hard surfaces including floors, countertops, cabinets, and drawers. Step 6: Wash gloved hands with soap and water or a disinfectant before removing gloves. Step 7: Wash hands with soap and warm water after removing gloves or use a waterless alcohol-based hand rub when soap is not available, and hands are not visibly soiled. https://www.cdc.gov/healthypets/pets/wildlife/clean-up.html The Director of Food and Nutrition Services stated she had a mouse run across her foot last week. She said she noted the rodents chewed the tartar sauce packets. She cleaned them off and wiped the area with bleach. She said the rats were very fond of the tartar sauce. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 47 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company with the Infection Preventionist, and the observation of rodent feces on the floor of the kitchen storage area, she said, I knew there were rats in the kitchen about six months ago when the former Administration was here, but I was told it was taken care of. Residents Affected - Some On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been the acting Maintenance Director at the facility since the beginning of July 2023. He said the housekeeping nor kitchen director had informed him of seeing rodents/rats in the facility. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023 which was completed sometimes in June 2023. He said he started hearing from some of the facility staff about seeing rats and hearing rats in the ceiling during the roof construction. He said the first time he heard of rats in the kitchen was two weeks ago when a kitchen staff told him they saw a rat in the kitchen. He looked at the area where the kitchen staff said they saw the rat, and noted there was a hole in the wall. He knows of two rodent traps in the facility located in the memory care dining room. On 8/3/23 review of the pest control logbook located at the front desk of the facility noted the following dietary staff entries: 12/13/22 at 6:30 a.m., rat, location: Kitchen. 2/16/23, (no time in the morning), rat, location: Kitchen. 2/20/23 in the morning, rat, Kitchen, beverage station. 3/18/23 (no time indicated), rat, location: Kitchen. 3/25/23 (no time indicated), rat, location: North dining room. 4/6/23 at 6:15 a.m., rat in the kitchen. 4/22/23 at 6:00 a.m., Dietary Staff Z documented rat, location: Kitchen. 4/25/23 at 6:15 a.m., Dietary Staff Z documented 3 rats, location: Kitchen. On 8/1/23 at 11:07 a.m., Dietary Staff Z said if he saw rodent activity, he would put it in the log/sighting book. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to the rats. He told them to put the bread in the refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 48 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety Residents Affected - Some On 8/3/23 at 12:30 p.m., The Administrator said the rat problem had been identified prior to her arrival to the facility. She said she has been employed at the facility since May 19, 2023, and did not know how long the rodent problem has been going on. She said she knows pest control comes out weekly as needed. She said the Maintenance Director was in charge of pest control and had direct oversight over the building. She said the facility had a contract as of 7/20/23 with the pest control company to address the rat problem. On 8/3/23 at 1:00 p.m., Registered Nurse (RN) Staff KK stated I have heard people saying they have seen rats mostly in the big dining room, (The big dining room is located next to the kitchen). On 8/3/23 at 3:18 p.m., a follow up tour of the kitchen with the Senior Regional Director of Culinary Services revealed rodent feces on the floor throughout the kitchen food storage area. Photographic evidence obtained. Rodent feces were noted on canned good items, and metal shelving racks storing canned food. Photographic evidence obtained. Single service packages of mayonnaise stored in a basket in the kitchen were observed with visible rodent bite marks. Photographic evidence obtained. Multiple loaves of packaged bread were observed stored on shelves in the dry storage area where the rodent feces were observed on the floor. Photographic evidence obtained. The Senior Regional Director of Culinary Services verified the rodent feces throughout the kitchen storage area floor and metal shelves used to store food. He verified the bread; packets of mayonnaise and other food items were not stored in rodent proof containers. He stated there was no policy in place for additional cleaning precautions once rodent feces have been visualized. He stated, We have been cleaning and sanitizing being sure to change out the water, and rags to prevent cross-contamination. In regard to canned goods, we are especially sure to sanitize the can where it will connect with the opener. On 8/4/23 at 6:20 p.m., the technician from the contracted pest control company said rats were entering the building through the air conditioning pipes. On July 25, 2023, he closed that hole. He said he usually gets three rats every two days. The facility continued foodservice operations despite rodent infestation in the kitchen area. The facility failed to protect packaged foods, clean equipment and utensils and single-use items from being contaminated with rodent excrement and failed to discart rodent contaminated foods. On 8/4/23 at 2:00 p.m., the State Survey Agency mandated that the facility cease foodservice operations due to the rodent infestations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 49 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect in that the Administration failed to ensure a safe and sanitary environment free from disease causing pests. Residents Affected - Some On 12/19/22 the facility administration became aware of a rodent infestation. The facility Administration failed to take appropriate actions to eradicate the rodent infestation. Certain diseases can spread from rodents to people through direct or indirect contact with infected rodents which could result in serious illness, or death of residents. Rodents can also damage building structures and start fires by gnawing electrical wiring, the extent to which is not known at this time. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of ready to use packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The facility Administration failure to take immediate appropriate actions to address the ongoing rodent infestation resulted in the determination of Immediate Jeopardy at a scope and severity of pattern (K), starting on 12/19/22. On 8/4/23 at 7:27 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross Reference to F584, F600, F812, F867, F880, and F925. The Administrator's job description signed 2/24/2021 noted the duties and responsibilities included to verify that the building and grounds are maintained appropriately, and that equipment and work areas are clean, safe, and orderly, and any hazardous conditions are addressed. The Director of Nursing's job description signed on 3/24/23 noted, Summary: To manage the overall operations of the Nursing department in accordance with Company policies, standards of nursing practices and governmental regulations to maintain excellent care of all residents' needs. On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. On 8/2/23 at 12:20 p.m., Licensed Practical Nurse (LPN) Staff NN said she has heard rats running in the ceiling, and residents have complained about hearing rats in the ceiling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 50 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 8/3/23 at 9:25 a.m., LPN Staff I said the rat problem was bad. She said they were out any time of the day. She said there were holes in the soiled utility room where the rats came in. She said she's reported the rat problem to the management all the time, and the pest control company technician who said the management would not pay to have the rats removed. On 8/3/23 at 9:25 a.m., the soiled utility room of the South Unit was observed with holes in the baseboard and the bottom of the cabinets where LPN Staff I said the rats come in. On 8/3/23 at 9:35 a.m., Registered Nurse Staff D said rats were everywhere in the building. She has seen them in residents' rooms, utility rooms and nourishment rooms. She said she has reported it to the management but the rats were still here. On 8/3/23 at 9:45 a.m., Resident #89 said he saw a rodent in his room approximately three weeks ago. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director verified approximately two weeks ago there was a rat in Resident #89's room and he plugged a hole in the wall at that time. He said he has been the Maintenance Director at the facility since the beginning of July 2023. On 8/3/23 at 10:04 a.m., the Director of Food and Nutrition Services said the week before she was in her office located in the kitchen and a mouse ran across her foot. On 8/3/23 at 10:04 a.m., during a tour of the kitchen, rodent feces were noted on the floor beneath the canned goods cart and bread cart in the kitchen dry storage area. The Director of Food and Nutrition Services verified the rodent feces on the floor beneath the canned goods cart and bread cart. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said about six months ago there were rats in the kitchen, but the former administration said it was taken care of. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he became aware of seeing rats and hearing rats during the roof construction in March 2023. He said no one from administration has asked him about interventions in place to address the rats in the building. On 8/3/23 review of the pest control logbook located at the front desk of the facility noted on 11/3/22, 11/13/22, 11/23/22, 12/13/22, 2/16/23, 2/20/23, 3/18/23, 3/25/23, 4/6/23, 4/22/23, 4/25/23, and 7/24/23, rats were observed in the facility, kitchen, or dining room. On 8/3/23 at 12:30 p.m., the Administrator said the rat problem had been identified prior to her arrival at the facility on May 19, 2023. She did not know how long it had been going on. She said the Maintenance Director was in charge of pest control and had direct oversight over the building. The pest control company was responsible to check the pest control sighting log and address it. The Administrator said on 7/20/23 the facility signed a contract with the pest control company addressing the rat problem. The Administrator said she did not know the extent of the rat infestation until 7/31/23 and developed a performance improvement plan. She said they have just changed the process and the pest control log will be reviewed by Administrator or designee daily. On 8/3/23 at 4:55 p.m., the Administrator said the trees have not been trimmed since she's been employed at the facility on 5/19/23. She said the facility did not have a PIP (Performance Improvement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 51 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0835 Plan) in place to address the pest control, including the rat infestation. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 52 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review, review of the facility's policies and procedures, and staff interviews, the facility failed to show effective communication and coordination to develop and implement adequate corrective actions related to pest control and rodent infestation to ensure a safe and sanitary environment free from disease causing pests, which could lead to the spread of diseases from direct and indirect contact with infected rodents. On 12/19/22 the facility administration became aware of a rodent infestation. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of single service packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The facility's lack of an effective ongoing QAPI (Quality Assurance and Performance Improvement) process to protect residents' health and safety created a likelihood of serious illness or death for the residents from direct or indirect contact with infected rodents resulted in the determination of Immediate Jeopardy starting on 12/19/22. On 8/4/23 at 7:27 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross Reference to F584, F600, F812, F835, F880, and F925. The Quality Assessment and Assurance Committee Policy implemented 11/2020 and last revised 8/8/2022 stated This facility will maintain a Quality Assessment and Assurance (QAA) Committee to identify issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. The Administrator's job description signed on 2/24/21 noted the Administrator is Responsible for the QA (Quality Assurance) program. Review of the contracted pest control company's reports from 12/19/2022 through 7/28/23 noted multiple incidents of rodent sightings on the Memory Care Unit, the kitchen, and South Nursing Unit. Rodent stations, live traps and glue sticks have been placed in the kitchen and throughout the building. Roaches and ants were also identified throughout the building. Review of the pest control logbook located at the front desk of the facility revealed multiple entries of rat sighting in the facility from 11/3/22 through 7/24/23 (11/3/22, 11/13/22, 11/23/22, 12/13/22, 2/16/23, 2/20/23, 3/18/23, 3/25/23, 4/6/23, 4/22/23, 4/25/23, 7/24/23). Review of an email from the contracted pest control company dated April 19, 2023, to the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 53 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety Residents Affected - Some corporate employees noted, The best option to rid the facility of this rodent issue is a multistep process. The process recommended was to seal up any holes, openings, entry points and areas where rodents access into the building . The next step is a full trapping program for one month . On 7/31/23 through 8/3/23 multiple observations were made of rodent feces on the floor and shelves used to store food items in the kitchen, and live crawling bugs in residents' rooms, shower room, soiled and clean utility rooms. Holes observed in walls and cabinets in the soiled utility room of the memory care units were identified by staff as entry points for the rats. Ant-like insects were observed crawling on a resident's bed and wound dressings. On 7/31/23 through 8/3/23 multiple staff interviews conducted with direct care staff and dietary staff revealed an ongoing concern with roaches and rat infestation in the facility, including the kitchen, dining room and residents' rooms. Staff reported they communicated the ongoing rat sightings to the facility administration without any sign of improvement. On 8/3/23 at 12:00 p.m., the Regional Plant Operation Director verified he was aware of the sightings of rats in the facility, including the kitchen. He said he has not had any meetings with the administrative staff related to the rats in the facility. He said as of this time no one from administration has asked him what interventions he had put into place to address the staff seeing rats in the facility. He said he conducted an informal meeting with the Housekeeping Director to remind her staff to ensure they were not leaving food which the rats might be eating and remind them to do proper cleaning and disinfection in general. It was an informal meeting; he doesn't have any documentation related to the meeting. He said he has not had time to trim the overhanging branches over the building as per the multiple recommendations of the contracted pest control company on 3/24/23, 5/12/23, 6/2/23, 6/8/23, 6/15/23, and 6/29/23 to prevent ants and wildlife easier access to the building. On 8/3/23 at 12:33 p.m., the Housekeeping Manager stated, There are pest issues at facility, they called the pest guy weekly. On 8/3/23 at 12:20 p.m., the technician from the pest control company reported in a telephone interview two rodents were caught in the kitchen yesterday. Review of the Quality Assurance and Performance Improvement (QAPI) meetings from May 2023 through June 2023 showed the QAPI committee met on 5/17/23 for QAPI plan updates, and 5/18/23. The facility provided documentation of QAPI- PIP (Performance Improvement Plan) dated 5/15/23 (updated 6/7/23 and 6/28/23), an Action Plan/PIP dated 5/16/23 (updated 6/6/23, and 6/28/23) and a QAPI-PIP Action Plan dated 6/27/23. There was no documentation of discussion of evaluation of the effectiveness of the pest control program, including eradication of rats. There was no discussion in the QAPI meetings about continued foodservice operations in light of rodent infestation and the high risk of food contamination from rodent excrement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 54 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety Residents Affected - Some On 8/4/2023 at 12:45 p.m., the Administrator verified the lack of documentation of evaluation of the actions implemented to ensure the eradication of pests, including rats in the facility. She said there was a noticed increase of rodent activities in 2022 and also a noticed need for new roof. The Administrator provided a typewritten timeline, and root cause analysis documenting the steps taken to address the rats and pests. The document read, Situation: Identified an ongoing concern related to pests. Most observations include insects; however, there have been a number of observations of rodents and or rodent droppings. Initially the facility experienced a level of pests (insects and rodents' activity) in 2022 that was addressed and viewed as corrected. At the time, the determination was the need for external rodent boxes. These were added and seemingly effective with low to no further rodent activity. It was recognized that the facility had need for a new roof. There was a correlation to the need for the new roof, leaking, etc. That this had an impact of pest concerns. Quotes were received late 2022, the new roof quote was selected . roof company had to apply for permits on March 14, 2023, and the room company initiated replacement on 3/27/23. The roof completion was on 5/12/23. Additional tree work was completed on 1/2/23, in preparation for roof replacement. The Administrator said, When I got here in May of 2023, there were no QAPI minutes before me. The rodent issue was first addressed in QAPI on 7/31/2023. She said there was no current PIP for the rodent issue. She said, the Process for approving expenditures above $1500.00 was put in an email to the Corporate Regional Director of Maintenance on 7/19/2023 for approval. On 7/19/2023, the contract was approved by Corporate Director of Plant Operations for rodent/pest control. The Administrator presented a timeline of actions implemented in a root cause analysis document which listed additional services as follows: 5/12/23 added rodent station boxes. 5/15/23 no activity, prevention remedies. 5/18/23 insect treatments. 5/26/23 inspected for spiders, wasps, baited for roaches. 6/2/23 insect monitor set for flying bugs, of 11 rodent stations, one is missing, moderate rodent activity. 6/8/23 treated exterior prevention for pests, rebaited rodent stations. 6/15/23 a rat was caught last evening, treated all areas for pest and roach control. 6/22/23 pest prevention. 6/29/23 low rodent activity, 2 rodent boxes missing and will be replaced. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 55 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 - Immediate jeopardy to resident health or safety 7/13/23 exterior and interior areas treated for pest prevention, discussed adding more rodent stations, had rebaited 2 weeks ago, replaced missing boxes. The Administrator said the interdisciplinary team met and held an Ad-Hoc (impromptu) meeting on 8/3/23 to discuss the ongoing pest concern at the facility. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 56 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility policy and resident and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the developement and transmission of zoonotic (animals) and vector-borne (e.g., mosquitoes, ticks, and fleas) disease and infections by rodent infestation. Residents Affected - Some The facility failed to follow infection control practices and failed maintain urinary catheter drainage in a sanitary manner for 2 (Resident #4 and Resident #5) of 2 residents reviewed for urinary catheters. The facility failed to ensure staff followed infection prevention measures by failure to follow personal protective equipment (PPE) guidelines for residents on transmission based precautions for COVID-19, and failure to handle medications in a sanitary manner. The facility became aware on 12/19/22 of a rodent infestation in the building. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of ready to use packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The failure of the facility to implement systems with effective actions to eradicate rodent infestations created a serious threat to residents health and safety due to the spread of certain diseases from direct or indirect contact with rodents and resulted in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F584, F600, F812, F835, F867, F925. Review of the Center for Disease Control (CDC) and Prevention document titled, How to Control Wild Rodent Infestations, last reviewed on January 3, 2023, noted, Rats and mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it . Rodents, such as rats, mice . are known to carry many diseases. Diseases can spread to people directly and indirectly from rodents . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 57 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Diseases spread directly by rodents . Hantavirus, Hantavirus Pulmonary Syndrome, Hemorrhagic Fever with Renal Syndrome, [NAME] Fever, Leptospirosis, Lujo Hemorrhagic Fever, Lymphocytic Choriomeningitis (LCM), Monkeypox, Omsk Hemorrhagic Fever, Rat-Bite Fever, Salmonellosis, South American Arenaviruses ([NAME] hemorrhagic fever, Bolivian hemorrhagic fever, Chapare Hemorrhagic Fever, Sabiá-associated hemorrhagic fever, and Venezuelan hemorrhagic fever), Sylvatic Typhus, Tularemia . Residents Affected - Some Diseases spread indirectly by rodents . Anaplasmosis, Angiostrongylus, Babesiosis, Borreliosis, Colorado tick fever, Cutaneous leishmaniasis, Flea-borne (Murine) Typhus, Hymenolepis diminuta, La [NAME] virus, Lyme disease, Moniliformis moniliformis, Plague, Powassan virus, Rickettsialpox, Scrub typhus, Tick-borne Relapsing Fever, Tularemia . These viral, bacterial, or parasitic diseases can cause damage or failure of the major organs; gastrointestinal infection; bloodstream infection; or severe, sometimes fatal, respiratory disease in humans. These diseases can result in serious illness or death. The CDC website (https://www.cdc.gov/hantavirus/index.html) page last reviewed November 16, 2021, noted, Each hantavirus serotype has a specific rodent host species and is spread to people via aerosolized virus that is shed in urine, feces, and saliva, and less frequently by a bite from an infected host. (accessed on 8/10/23) The facility policy Pest Control Program implemented 1/2022 documented, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is identified as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). The facility's pest sighting logbooks located at the front desk included the following entries: 11/3/22 at 6:00 a.m., rat, location found: Kitchen. 11/13/22 at 6:00 a.m., rats, location found: Kitchen. 11/23/22 at 6:30 p.m., rat, location found: Homestead dining room. 12/13/22 at 6:30 a.m., rat, location found: Kitchen. 2/16/23, (no time in the morning), rat, location found: Kitchen. 2/20/23 in the morning, rat, location found: Beverage station, department: Kitchen. 3/18/23 (no time indicated), rat, location found: Kitchen. 3/25/23 (no time indicated), rat, location found: North dining room. 4/6/23 at 6:15 a.m., rat, location found: Kitchen. 4/22/23 at 6:00 a.m., rat, location found: Kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 58 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 4/25/23 at 6:15 a.m., 3 rats, location found: Kitchen. Level of Harm - Immediate jeopardy to resident health or safety The North Unit Pest sighting log noted: 7/1/23 at 2:00 a.m., roach back hall nursing medication cart. An initial was placed next to the entry and dated 7/13/23. Residents Affected - Some 7/11/23, evening, rat, location found: room [ROOM NUMBER]. 7/24/23 at 1:30 a.m., Rats (2) in soiled utility. An initial was placed next to the entry and dated 7/28/23. 7/24/23 at 1:30 a.m., Roaches in med carts, on nurses station counters, on the floors. An initial was placed next to the entry and dated 7/28/23. Review of the contracted Pest Control company reports from 11/2022 through 7/28/23 revealed on 12/19/22 the contracted pest control company gave the facility a quote for mass rodent trapping. The contracted pest control company reports from 11/2022 through 7/28/23 noted multiple sightings of rats in the facility, including the kitchen. 3/28/23: Caught a rat on glueboard [sic] underneath kitchen equipment. Replaced with 2 more glueboards. Dining room has roof rat activity. Set out 2 large glueboards in drawer. And 4 large glueboards on floor by cabinets. Inspected rest of dining room. 4/25/23: Inspected kitchen area, last nite [sic] 3 roof rats were caught and disposed of. Will be back this Friday with a follow-up to check on kitchen. 4/28/23: There is a lot of rodent activity feeding off bait. Spoke with head chef in the kitchen and we caught 2 more roof rats in kitchen on our large glueboards. Set out 8 more large glueboards in kitchen. 6/2/23: There is moderate amount of rodent activity at this time. Spoke with front desk before leaving. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. 6/15/23: Arrived on property and spoke with front desk. Spoke with kitchen staff. They had caught a large rat last nite [sic]. There are overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building. 7/28/23: Arrived on the property and spoke with acting director . Rodent activity in building. They know exclusion is being done . Signed off on rodent issues after checking on them. There was no documentation of effective measures by the facility of ongoing measures to properly disinfect areas of rodent sightings to prevent cross contamination of food and possible spread of harmful bacteria and viruses generated from the rodent infestation in the kitchen and dry food storage area. There was no documentation in the pest control reports of inspection of the air ducts for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 59 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 presence of rodent nesting, droppings, and urine. Level of Harm - Immediate jeopardy to resident health or safety On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. Photographic evidence obtained. Residents Affected - Some On 8/2/23 4:45 p.m., The Senior Regional Director of Culinary Services stated he was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said the facility had roaches and rats. They were out anytime of the day. They are in the soiled utility room and the nourishment rooms. She reports it all the time to management. On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D said the rats and roaches were everywhere in the building, the residents' rooms, the utility rooms, and nourishment rooms. She has reported it to the management staff, but the rats are still here. She sees them any time of the day, but they are worse at night. On 8/3/23 at 9:45 a.m., Resident #89 reported he saw a rodent in his room approximately three weeks ago, and Maintenance filled the hole in the bathroom. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said about two weeks ago staff informed him they saw a rat in Resident #89's bathroom. He observed a hole in the wall, which he plugged at that time. There was no documentation that the resident's room was disinfected after the sighting of the rat. On 8/3/23 at 10:04 a.m., rodent feces were noted on the floor beneath the canned goods cart and bread cart, in the kitchen dry storage area. The Regional Hospitality Director and the Director of Food and Nutrition services verified the observation of rodent feces. They said they had swept the floor the day before. The Director of Food and Nutrition Services said a mouse ran over her foot the week before in her office located within the kitchen. She said the rodents chewed the tartar sauce packets. She cleaned the packets and wiped off the area with bleach. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said two weeks ago a kitchen staff told him they saw a rat in the kitchen. He said he conducted an informal meeting with the Housekeeping Director to remind her staff to ensure they were not leaving food which the rats might be eating and remind them to do proper cleaning and disinfection in general. It was an informal meeting; he doesn't have any documentation related to the meeting. On 8/3/23 at 12:00 p.m., the Infection Preventionist said she was extremely surprised and had never heard of rats in the facility. She said, I don't know anything about it. I certainly have never seen any; this is the first I'm hearing about it. After reviewing the content of the reports of the contracted pest control company with the Infection Preventionist, and the observation of rodent feces on the floor of the kitchen storage area, she said, I knew there were rats in the kitchen about six (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 60 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 months ago when the former Administration was here, but I was told it was taken care of. Level of Harm - Immediate jeopardy to resident health or safety On 8/4/23 at 11:55 a.m., in a telephone interview the Medical Director said the facility notified him on 8/3/23 of the rats in the kitchen and other areas. He said as long as the residents look and don't touch the rats, they are ok. He said there was no air spread of infection from the rats, It is not like years ago with the plague, that is not going to happen. The food is fine, as long as the rodent droppings don't go into the food. He said he had a meeting with the facility's team the day before and there were no rat droppings on the food, and the kitchen was cleaned the day before. When interviewed about rat droppings on food packaging the Medical Director said that was fine as long as the rodent droppings don't go into the food. He said again he met with the facility team yesterday and there were no rat droppings on the food. The plan is for the staff to write in the pest control book if they see any pests and the pest control will come. The physician said there was no chance the residents would get any infection as long as they did not touch the rats. The Medical Director said, I was told there were no rodent droppings anywhere in the kitchen. Residents Affected - Some On 8/4/23 at 3:27 p.m., the Infection Preventionist said she spoke with the Medical Director today about the rat infestation. She said the Medical Director told her, There is nothing I need to do infection control wise for the rats. She repeated, He said it really wasn't necessary for me to do anything. The Center for Disease Control and Prevention recommendation to clean up rodent urine and droppings (last reviewed January 3, 2023) noted, Step 1: Put on rubber or plastic gloves. Step 2: Spray urine and droppings with bleach solution or an EPA-registered disinfectant until very wet. Let it soak for 5 minutes or according to instructions on the disinfectant label. Step 3: Use paper towels to wipe up the urine or droppings and cleaning product. Step 4: Throw the paper towels in a covered garbage can that is regularly emptied. Step 5: Mop or sponge the area with a disinfectant. o Clean all hard surfaces including floors, countertops, cabinets, and drawers. o Follow instructions below to clean and disinfect other types of surfaces. Step 6: Wash gloved hands with soap and water or a disinfectant before removing gloves. Step 7: Wash hands with soap and warm water after removing gloves or use a waterless alcohol-based hand rub when soap is not available, and hands are not visibly soiled. The facility continued foodservice operations despite rodent infestation in the kitchen area. The facility failed to protect packaged foods, clean equipment and utensils and single service and single-use items from being contaminated with rodent excrement and failed to discard rodent contaminated foods. On 8/3/23 at 11:50 a.m., multiple ant-like crawling insects were observed crawling on Resident #2's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 61 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 bed, and on the resident's wound dressings on both ankles. Level of Harm - Immediate jeopardy to resident health or safety Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. Residents Affected - Some The resident said she requested to have her bed sheets changed since then to get rid of the ants and no one has come all morning. On 8/3/23 at 12:00 p.m., LPN Staff I was notified of the observation of the crawling insects observed on the resident's bed and her request to have her sheets changed and the pest removed. LPN Staff I said she would let the Certified Nursing Assistant know. On 8/3/23 at 3:30 p.m., Resident #2 said she felt, terrible, just terrible when the nurse told her she had ants in her bed. She said the ants were crawling in her dressing. She said, no one wants bugs in their bed. I told the nurse I wanted an aide to change my bed, but no one has come yet. On 8/3/23 at 3:45 p.m., Housekeeper Staff BB was observed cleaning Resident #2's mattress. Staff BB said there were ants in the resident's open bags of chips and in the resident's bed. On 8/3/23 at 4:00 p.m., the Director of Nursing said she was informed of the ants in Resident #2's bed and on her legs. She said she thought the ants were attracted to the Medi honey (medical grade honey) used to treat the resident's wounds. She said they will be changing the resident's wound treatment. The facility policy Catheter Care revised (1/6/23), documented It is the policy of this facility to ensure residents with indwelling catheters (tube inserted into the bladder to drain urine) receive appropriate catheter care and maintain their dignity and privacy. Catheter care will be performed every shift and as needed by nursing personnel. Empty drainage bags when bag is hall-full or every 2-3 hours. Review of the clinical record showed Resident #4 had an admission date of 7/30/23 with diagnoses including neurogenic bladder caused by a cerebral vascular accident requiring an indwelling urinary catheter. Resident #4's care plan instructed staff to keep the catheter off the floor. On 7/31/23 at 9:39 a.m., Resident #4's urinary catheter drainage bag and tubing were observed on the floor. The drainage bag was completely full, and the urine was beginning to flow back into the tubing. The observation was verified by LPN Staff I. Photographic evidence obtained. Review of the clinical record showed Resident #5 had an admission date of 4/23/23 with diagnoses including urinary tract infection and obstructive and reflux uropathy requiring an indwelling urinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 62 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 catheter. Level of Harm - Immediate jeopardy to resident health or safety Resident #5's care plan instructed staff to keep the catheter off the floor. On 7/31/23 at 9:32 a.m., Resident #5's urinary catheter drainage bag and tubing were observed on the floor. Residents Affected - Some LPN Staff I confirmed the observation. Photographic evidence obtained. On 7/31/23 at 9:23 a.m., Housekeeping Staff G was observed entering the room of a resident on transmission-based precautions for Coronavirus Disease 2019 (COVID-19). The signage posted on the door instructed staff on the personal protective equipment (PPE) required to enter the room, including mask, gown, and gloves. Staff G had a KN95 mask on and no other PPE. Photographic evidence obtained. Staff G began emptying the garbage and cleaning the room. LPN Staff I was present during the observation. Housekeeper Staff G verified she failed to don the proper PPE before entering the resident's room. LPN Staff I was present during the observation. On 7/31/23 at 11:50 a.m., observed lunch tray service for the 300 hall. Observed Certified Nursing Assistant (CNA) Staff JJ, passing lunch trays. CNA, Staff JJ, entered a room to deliver lunch tray to resident #27 who was on transmission based precautions for Coronavirus disease 2019 (COVID-19). The signage posted on the resident's door indicating what Personal Protection Equipment (PPE) should be worn when entering room including eye protection. The CNA donned a gown and entered the room with the meal tray without wearing eye protection. Several minutes later the CNA came out of the room. The CNA did not remove the exposed gown, proceeded to the food service cart, and removed a meal tray for resident #71. The lunch cart contained eight meal trays when she removed the tray while wearing the exposed cover gown. The CNA returned to Resident #27's room, without wearing eye protection. CNA Staff JJ was also observed entering delivering a meal tray to Resident #84 who was on transmission based precautions for COVID-19 without wearing the posted required PPE including eye protection. On 7/31/23 at 12:05 p.m., observed CNA Staff P don PPE prior to entering Resident #65's room. The signage posted on the door clearly indicated gowns, gloves and eye protection were required for entrance. The CNA did not use eye protection and entered the resident's room. After providing set up for the resident CNA Staff P exited the room and went to lunch tray cart containing five other residents' lunch trays without changing isolation exposed gown. CNA Staff P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 63 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0880 Level of Harm - Immediate jeopardy to resident health or safety retrieved a meal tray from the meal cart and took it to Resident #28's room who was on transmission based precautions for COVID-19 without eye protection. On 7/31/23 at 12:15 p.m., CNA Staff P said, I did not know I needed to wear them, I didn't notice the signage, when asked about wearing eye precautions to enter the room of residents on transmission based precautions for COVID-19. Residents Affected - Some CNA Staff P verified she failed to change the isolation gown when going in and out of residents' rooms who were on transmission based precautions for COVID-19. CNA Staff P said, I was told that I did not need to change gowns between residents who are in the same room when they are both in isolation. On 7/31/23 at 12:30 p.m. CNA Staff JJ verified she did not wear eye precautions when going in residents' rooms who were on transmission based precautions for COVID-19 disease. She verified the rooms had the signage on the door clearly indicating to wear eye precautions. The CNA said, I was passing trays by myself. I looked in the cart for a face shield but there weren't any. So, I just did what I needed to do. When asked about leaving Resident #27's room with the contaminated gown and going to the lunch tray cart for the roommate's meal, the CNA replied, I can see now that it was wrong, I should have changed everything and washed my hands. On 8/2/23 at 10:00 a.m., observed LPN Staff I, administering medications to Resident #33. LPN Staff I placed six tablets of Vitamin D 25 mcg (micrograms) into the cap of the medication bottle. She said, I don't need all of them and placed her ungloved thumb on the pills and shook one back into the bottle. Upon interview, LPN Staff I said she shouldn't have touched the pills with her bare hands. She said, I shouldn't have done that. I know better.'' On 8/3/23 at 10:07 a.m., the observation of LPN Staff I touching the Vitamin D pills with her bare hands was shared with the DON. She said this was unacceptable and would be working with the staff for improvement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 64 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/3/23 at 11:55 a.m., live crawling brown bugs were observed in the shower room and in the clean utility room in the memory unit. Residents Affected - Some On 8/3/23 at 12:05 p.m., several brown crawling insects were observed in the memory care unit clean utility room in front of storage cabinet. On 8/3/23 at 12:20 p.m., CNA Staff FF, in the memory care unit said, I see a lot of roaches. The guy comes and sprays and it is not doing anything. I also see ants sometimes, but I see roaches every time I work. I have heard about the rats but not seen them. On 8/3/23 at 12:33 p.m., Housekeeping manager Staff U said she would expect staff to report to her if they saw roaches or bugs. She said they have a book in the front of the facility where they write the concerns. The pest guy reviews the book and then treats the identified concerns. On 8/3/23 at 1:00 p.m., RN Staff KK said, Most of the time we see roaches at nurses' stations and residents' rooms, I haven't seen rats. I have heard people saying they have seen rats mostly in the big dining room. We have a binder in the nurses' station to document if we see anything. Based on observation, interview and record review, the facility failed to ensure adequate pest control measures to eradicate an ongoing rodent infestation. On 12/19/22 the facility became aware of rodent infestation in the building, including the kitchen. The facility failed to consistently implement the recommendations from the contracted pest control company to trim back over hanging trees next to the building to prevent wildlife from getting easier access to the building. The facility failed to identify and repair all rodent entry points. The failure to implement adequate measures to eradicate and contain a rodent infestation created a serious threat to residents health and safety due to the spread of certain diseases from direct or indirect contact with rodents and resulted in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census was 86. The findings included: Cross reference to F600, F812, F835, F867, and F880. The facility policy titled Pest Control Program implemented 1/2022 stated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 65 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An effective pest control program is defined as measures to eradicate and contain common household pests, (bed buds, lice, roaches, ants, mosquitos, flies, mice, and rats). The facility will maintain a report system of issues that may arise in between scheduled visits with outside pest services and treat as indicated. Review of the pest control logbook located at the front of the facility noted on 12/13/22, 2/16/23, 2/20/23, 3/18/23, 3/25/23, 4/6/23, 4/22/23, 4/25/23, the dietary staff documented sightings of rats in the kitchen and/or the North Dining Room. The North Unit Pest sighting logbook noted on 7/11/23 a rat was observed in room [ROOM NUMBER], and on 7/24/23 two rats in the soiled utility room. The pest control company reports showed on 3/24/23, 5/12/23, 6/2/23, 6/8/23, 6/15/23, 6/29/23 the company recommended trimming back over hanging trees next to the building to prevent ants and wildlife from getting easier access to the building. On 8/3/23 at 3:01 p.m., observation of the outside of the building revealed multiple overhanging branches over building that needs to be trimmed back for preventing ants and wildlife easier access to building as per the multiple recommendations of the contracted pest control company. Photographic evidence obtained. Pest control records from 12/19/2022 through 7/28/23 noted multiple incidents of rodent sightings on the Memory Care Unit, the kitchen, and South Nursing Unit. Rodent stations, live traps and glue sticks have been placed in the kitchen and throughout the building. Roaches and ants were also identified throughout the building. The contracted Pest Control inspection report dated 7/28/23 noted, Checked all 3 logbooks and scanned them. Signed off on rodent issues after checking on them. Baited nurse main cart with roach gel for roach sightings. Lots more rodent activity this month. Review of an email from the contracted pest control company dated April 19, 2023 to the Facility Plant operations and a facility corporate employee noted the pest control company representative stated he visited the facility today and saw several openings, activity and conditions leading to the rodent activity. The representative informed (name) the best option to rid the facility of this rodent issue is a multistep process. The process recommended was to seal up any holes, openings, entry points and areas where rodents access into the building . The next step is a full trapping program for one month . Lastly, I have included extra rodent bait stations around the facility for more control and better monitoring. My recommendation is to start this exclusion right after the roofers have completed their service. This program I am sure will take an entire day. On 8/3/23 at 12:05 p.m., the Regional Plant Operation Director said he has been employed with the company since September 2022, and has been the acting Maintenance Director at the facility since the beginning of July 2023. He said he became aware of possible rat problem after they started to replace the facility roof in February 2023. The roof repair was completed several months later, sometimes in June 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 66 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some He said started emailing the pest control company in April 2023 about the rats in the facility, who gave him some recommendations about what they can do about stopping the rats from entering the facility. He said the pest control company told him the rats could not be fully removed from the facility until the new roof was completed and all entry points were sealed. The Regional Plant Operation Director said he got over a hundred rodent entry points sealed sometimes in June 2023, and the pest control company signed an eradication agreement to remove all the rats in the facility on 7/20/23. On 8/3/23 at 3:10 p.m., the Administrator said since she has been employed at the facility in May 19, 2023, the overhanging branches had not been trimmed. The facility did not complete a Pest Exclusion agreement until 7/20/23. This agreement allows the pest control company to inspect and seal all holes and cracks throughout the building to eliminate rodent points of entry even though the roof completion was on 5/12/23. On 7/31/23 at 2:57 p.m., during a kitchen tour, a large wooden trigger snap rat trap was noted on the floor located behind an open storage shelf unit. Photographic evidence obtained. On 8/2/23 4:45 p.m., The Senior Regional Director of Culinary Services stated he was told the rat trap in the kitchen was placed there as a preventative measure because there had been rat sightings in the past. On 8/3/23 at 9:25 a.m., Licensed practical Nurse (LPN) Staff I said, The rats are so bad. They have roaches and rats, but I'm more afraid of the rats. You hear them running across the ceiling. I'm so scared they are going to fall on me. They are out anytime of the day. You have to open the doors to the soiled utility room and the nourishment room really carefully because they run away from you and go into the holes in the cabinets. I report it to the management all the time. I have told the pest control and he said he can't do anything about it if the management will not pay to have the rats removed. On 8/3/23 at 9:25 a.m., observation of the South Unit soiled utility room with LPN Staff I revealed a hole in the baseboard of the wall, with a missing tile. Photographic evidence obtained. There was hole at the lower left bottom of the storage cabinet. Photographic evidence obtained. There was a hole in the baseboard where two cabinets met. Photographic evidence obtained. LPN Staff I said, I report it to the management all the time. I have told the pest control and he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 67 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0925 said he can't do anything about it if the management will not pay to have the rats removed. Level of Harm - Immediate jeopardy to resident health or safety On 8/3/23 at 9:35 a.m., Registered Nurse (RN) Staff D, said, The rats and roaches are disgusting and everywhere in the building. I have seen them in the resident rooms, in the utility rooms and nourishment rooms. They run in the ceiling, you hear scratching, and you can hear them run around up there. If it fell on me, I would be screaming. I know I have reported it to the management staff, but the rats are still here. It doesn't matter what time of day, you will see them, but they are worse at night. Residents Affected - Some On 8/3/23 at 10:04 a.m., during a follow up tour of the kitchen, rodent feces were noted on the floor beneath the canned goods cart and bread cart. The Director of Food and Nutrition Services, and Regional Hospitality Director verified the observation of the rodent feces and stated they had swept there the day before. The Director of Food and Nutrition Services stated she had a mouse run across her foot last week. On 8/3/23 at 11:50 a.m., multiple ant-like crawling insects were observed crawling on Resident #2's bed, and on the resident's wound dressings on both ankles. Photographic evidence obtained. The resident said the nurse who changed the dressings to her ankles this morning told her she had ants crawling in her bed, and on her legs. On 8/3/23 at 12:22 p.m., during a telephone interview, the technician from the contracted pest control company said two rodents were caught in the kitchen yesterday. He said he told the kitchen staff not to leave bread and other food items the rats can get into on the counters or where it would be accessible to the rats. He told them to put the bread in the refrigerator. On 8/3/23 at 12:30 p.m., the Administrator said the rat problem had been identified prior to her arrival to the facility on May 19, 2023. She said she knew the pest control came out weekly as needed. She said the Maintenance Director was in charge of pest control and had direct oversight over the building. She said she could provide a copy of the contract signed on 7/20/2023 addressing the rat problem. On 8/3/23 at 3:18 p.m., a follow up tour of the kitchen with the Senior Regional Director of Culinary Services revealed rodent feces on the floor throughout the kitchen food storage area. Rodent feces were noted on canned good items, and metal shelving racks storing canned food. Single service packages of mayonnaise stored in a basket in the kitchen were observed with visible rodent bite marks. Multiple loaves of packaged bread were observed stored on shelves in the dry storage area where the rodent feces were observed on the floor. The Senior Regional Director of Culinary Services verified the rodent feces throughout the kitchen storage area floor and metal shelves used to store food. He verified the bread; packets of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 68 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0925 mayonnaise and other food items were not stored in rodent proof containers. Level of Harm - Immediate jeopardy to resident health or safety On 8/4/23 at 12:45 p.m., the Administrator provided a timeline, and root cause analysis documenting the steps taken to address the rats and pests. The document read, Situation: Identified an ongoing concern related to pests. Most observations include insects; however, there have been a number of observations of rodents and or rodent droppings. Initially the facility experienced a level of pests (insects and rodents' activity) in 2022 that was addressed and viewed as corrected. At the time, the determination was the need for external rodent boxes. These were added and seemingly effective with low to no further rodent activity. It was recognized that the facility had need for a new roof. There was a correlation to the need for the new roof, leaking, etc. That this had an impact of pest concerns. Quotes were received late 2022, the new roof quote was selected . roof company had to apply for permits on March 14, 2023, and the room company initiated replacement on 3/27/23. The roof completion was on 5/12/23. Additional tree work was completed on 1/2/23, in preparation for roof replacement. Residents Affected - Some The root cause analysis document included a list of additional services as follows: 5/12/23 added rodent station boxes. 5/15/23 no activity, prevention remedies. 5/18/23 insect treatments. 5/26/23 inspected for spiders, wasps, baited for roaches. 6/2/23 insect monitor set for flying bugs, of 11 rodent stations, one is missing, moderate rodent activity. 6/8/23 treated exterior prevention for pests, rebaited rodent stations. 6/15/23 a rat was caught last evening, treated all areas for pest and roach control. 6/22/23 pest prevention. 6/29/23 low rodent activity, 2 rodent boxes missing and will be replaced. 7/13/23 exterior and interior areas treated for pest prevention, discussed adding more rodent stations, had rebaited 2 weeks ago, replaced missing boxes. 7/28/23 after start of exclusion, rodent activity reported, traps were not set and no rodent activity observed at this time interior. Rodent stations outside of building, lots of rodent activity, cleaned and rebaited rodent stations. The Administrator provided a receipt dated 1/2/23 from an outside tree service company listing a different address from the facility that read, Canary palm + (plus) 1 Palm. She said the receipt was from an outside company for tree trimming at the facility. On 8/10/23 at 11:57 a.m., in a telephone interview, a representative from the outside tree service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105407 If continuation sheet Page 69 of 70 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 105407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siesta Key Health and Rehabilitation Center 4602 Northgate Court Sarasota, FL 34234 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete company said on 1/2/23 the company did not provide any tree trimming services at the facility. The address listed on the receipt was private property. On 8/4/23 at 2:00 p.m., the State Survey Agency mandated that the facility cease foodservice operations due to the rodent infestations. On 8/4/23 at 6:20 p.m., the technician from the contracted pest control company said rats were entering the building through the air conditioning pipes. On July 25, 2023, he closed that hole. He said he usually gets three rats every two days. Event ID: Facility ID: 105407 If continuation sheet Page 70 of 70