Health inspection·February 2, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 1/29/24 beginning at approximately 11:30 AM during the initial facility tour, it was noted that many bathroom faucets had a thick white and green powdery build-up. The bathroom ceiling vents were covered with a thick build-up of a brown substance. This was observed in patient rooms 341, 343, 345, 347, 349, 351, 353, and 355. A review of the Daily Quality Assurance Check Sheets for Light Housekeeping, dated 1/28/24 and 1/29/24, was conducted. The check sheets indicated daily cleaning of sinks and floors was checked as being done in rooms 341, 343, 345, 347, 349, 351, 353, and 355. On 1/29/24 at approximately 11:30 AM, Resident #10 was observed seated in a wheelchair that had a build-up of dust and grime on the seat, the legs, and attachments of the chair. The resident was asked about her wheelchair and indicated she would like her chair washed. The resident added that she saw the large kind of roaches in her room last night. The bathroom sink faucet of her room was observed to have a thick build-up of a greenish white powdery substance and the vent in the bathroom had brown build up on it. On 1/29/24 at approximately 11:50 AM, Resident #9 was observed wearing a hospital style gown, and had no sheets on his/her bed. Resident #211 was wearing a hospital style gown, and had no pillowcases on his pillows or sheets on his bed. His bed was visibly soiled with a grayish buildup that appeared to be old skin and dirt, and adhered to the surface of the mattress. The tube feeding pump, pole and surrounding floor was covered with a dried splattered white substance. The bathroom sink faucet of the room had a thick buildup of a greenish white powdery substance and the vent in the bathroom had brown build up on it. During the observation, a resident in the hallway could be heard asking staff if today was the day that he could wash his clothes. A staff member was heard asking another staff member if they would go check in the outside storage area to bring in more sheets. On 1/29/24 at approximately 12:10 PM, soiled wet towels were observed left on the floor in the shower room in the 100 hall. The shower room was not in use at the time. On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor who stated that facility textiles and resident laundry was being processed at a local laundromat [by facility employees]. He stated this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting but has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out, the facility was left with no operating washing machine since about November of 2023. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering of resident clothing and linens. On 1/29/24 at approximately 1:00 PM, an interview was conducted with Resident #40. He complained of seeing bugs in his room all the time. He indicated that someone comes out to spray. The man who comes out to spray never comes into the rooms when he is here. On 01/29/24 at 1:00 PM, a telephone interview was conducted with the daughter of Resident #311. She stated her father was admitted to the facility on [DATE] from the hospital following a stroke. She stated that she brought him home the very next day on 11/15/23 because her father called her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 2 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Minimal harm or potential for actual harm Residents Affected - Many screaming Get me out of here. She stated the food was terrible, the dishes were not clean, there were roaches in her father's room, and the room was so filthy she felt she had to clean it upon her father's admission. On 1/29/24 at approximately 2:50 PM, an interview was conducted with Resident #9. The surveyor noted that he had a blanket under him instead of a sheet and that he was wearing a hospital style gown. His mattress was visibly soiled with buildup. There were yellow stains on a blanket below his mattress and his room smelled of urine. He was asked if he preferred to have a blanket under him instead of a sheet. The resident indicated that his back hurts and the facility often runs out of sheets. He said the church gave him sheets to use but the facility does not keep up with laundry. He indicated that he does not like wearing the gown and wanted staff to assist him to change into his clothes and get out of bed. The bathroom sink faucet of the room had a thick build up of a greenish white powdery substance and the vent in the bathroom had brown build up on it. (Photographic evidence obtained) On 1/30/24 at approximately 10:00 AM, Residents #1, #9, and #211 were again observed wearing hospital gowns. Residents #9 preferred to wear their own clothing, but his personal clothes had not been returned from the laundry. On 1/31/24 at approximately 11:00 AM, an interview was conducted with a direct care staff member who wished to remain anonymous. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate for a long time. Frequently, there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. On 01/31/24 at approximately 2:30 PM, an interview was conducted with the significant other of Resident #211. She was asked if the resident preferred to wear a patient gown. She indicated that he prefers to wear his own clothing. The surveyor inquired about the pillows without pillowcases and mattress without a sheet on it. Resident #211's significant other indicated that the facility has seemed to be short on linen since he was admitted (about 3 weeks earlier). On 1/31/24 at approximately 4:50 PM, neither Resident #23 nor Resident #47 had a change of clothes available in their wardrobes. On 2/1/24 at approximately 9:00 AM Resident #23 and #47 were observed wearing the same clothes as the previous day. On 2/1/24 at approximately 10:00 AM during a resident care observation, staff did not have a clean fitted sheet to apply to the bed for Resident #9. The surveyor followed Nurse D, a Licensed Practical Nurse (LPN), to each of the two indoor laundry storage rooms. Each of the 2 indoor clean linen storage areas had very little clean laundry available. The first indoor storage room had about 4 bed pads, three sheets, 3 bed spreads, 15 towels, 1 patient gown and a stack of wash cloths. The other indoor linen storage area had about 5 patient gowns, about 30 towels, three bed spreads, 1 stack of bed pads, and about 15 flat sheets. The shelves were mostly bare and there were no fitted sheets in any of the indoor storage areas to apply to Resident #9's bed. (Photographic evidence obtained) On 2/2/24 at approximately 11:00 AM, an observation of the shower room on the 200 hall was conducted. The shower room contained a functional small capacity household style washer along with 2 large bins of soiled linen. The Environmental Services Manager was unable to provide specific information regarding what types of textiles were being washed in the machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 3 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Minimal harm or potential for actual harm Residents Affected - Many On 2/1/23 at approximately 3:00 PM, an interview was completed with the Infection Preventionist nurse (IP). She was asked if she does infection prevention rounds around the facility to ensure compliance with infection control processes. The IP explained that she does not do rounds. She explained that the Director of Nursing (DON) normally does infection control rounds. The DON has been out from work for about 2 weeks on extended leave. She mentioned the environmental services manager is in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. The IP was asked how the small functional washing machine in the shower room was being utilized. The IP was unable to provide specific information regarding its use. The housekeeper job description, undated, was reviewed. The section Purpose of Your Job Position documented that the primary purpose of your job position is to perform the day-to-day activities of the housekeeping department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, as may be directed by the Administrator and or the Director of Housekeeping, to assure that our facilities are maintained in a clean safe and comfortable manner. Under Housekeeping Services the document included: -Perform day-to-day housekeeping functions -Clean/polish furnishings, fixtures, ledges, room heating/cooling units etc., in resident rooms, recreational areas etc. daily as instructed. -Clean, wash, sanitize, and/or polish bathroom fixtures. Ensure that watermarks are removed from fixtures. -Clean windows/mirrors in resident rooms, recreational areas, bathrooms, and entrance/exit ways. -Clean floors to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting etc. -Clean walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting deodorizing, etc. -Remove dirt, dust, grease, film etc., from surfaces using proper cleaning/disinfecting solutions. -Clean hallways and stairways. Based on observations, resident interviews, family interviews, staff interviews, room check documentation and the housekeeping job description, the facility failed to maintain a sanitary and orderly interior, and clean linens that were in good condition. The facility failed to provide adequate housekeeping services to ensure the daily cleaning of resident rooms throughout the facility. The lack of housekeeping services affected 13 of 26 sampled residents (#1, 2, 9, 10, 16, 19, 23, 30, 40, 45, 47, 54, and #211) plus 8 additional resident rooms (341, 343, 345, 347, 349, 351, 353, and 355), the shower rooms in the 100 and 200 hallways and the baseboards in the 300 hallway. This failure had the potential to affect all 68 residents at the time of the survey. For additional laundry related concerns, please cross reference F835, F867, F880, F908 and F945. The findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 4 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Minimal harm or potential for actual harm On 1/29/24 beginning at 11:15 AM, an initial tour of the facility was conducted. The following environmental concerns were observed in resident rooms: In Resident #2's room, the overhead table had rough edges and had sticky stains on the surface, the bed's footboard was torn and the head board was separated from the bed. Residents Affected - Many In Resident #45's room, the ceiling suspended privacy curtain had red colored stains, the bed mattress had no sheets, the window blind had slats missing, the blinds cord did not work, the overhead table surface had stains, and 2 of 4 light bulbs of the overhead lamp were not working. In Resident #54's room, the cover of the resident's pillow was shredded and had no pillow case. About 6 feet of the 300 hallway baseboard was detached from the wall In Resident #19's room, the base of the overbed table was stained. In Resident #16's room, the bed linens were dirty with grainy like matter, there was no pillowcase for the pillow, a ceiling tile was dislodged, and the bathroom's mirror was splashed with a dried substance. In Resident #30's room, the floor was dirty with a sticky brown substance, the ceiling suspended privacy curtain had red stains, the pillow did not have a pillowcase, and the bathroom mirror was splashed with a dried substance. On 1/30/24 at 9:30 AM, the 300 hallway's baseboard remained detached from wall. On 2/01/24 at 9:24 AM, two days after the initial tour, the following observations were made: In Resident #2's room, the overbed table still had rough edges and the base remained stained, the footboard edges remained torn, the head board remained separated, the ceiling-suspended privacy curtain remained stained with a red-colored stain, and pillows were placed on top of a wheelchair without a pillowcase. In Resident #54's room, the overhead table's base remained stained and the shredded pillow was visible under the pillowcase. In Resident #45's room, the overbed table and base were dirty. The 300 Hallway's baseboard had orange-colored tape temporarily attaching the 6 foot loose area to the wall. In Resident #19's room, the overbed table remained dirty with a sticky substance. In Resident #16's room, the pillows had no pillowcases, the overbed table was dirty with a sticky substance, the bathroom mirror remained stained, and the ceiling-suspended privacy curtain still had red-colored stains. In Resident #30's room, the ceiling-suspended privacy curtain still had red stains. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 5 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 (Photographic evidence was obtained) Level of Harm - Minimal harm or potential for actual harm On 2/1/24 at 10:16 AM, an interview was conducted with Staff CC, housekeeping personnel (HK). He stated the ceiling-suspended privacy curtains inside residential rooms were checked every day and changed as needed by housekeeping staff. Staff CC further stated there were extra curtains available at the clean linen closet located in the 300 hallway. Residents Affected - Many On 2/1/24 at 10:20 AM, a tour of the clean linen storage room was conducted with Staff CC. There was one clean privacy curtain on a shelf. Staff CC stated, if he needed more curtains, he would get them at the laundry room. A tour of the laundry room was conducted and there were a total of 6 clean privacy curtains on a shelf. On 2/1/24 at 11:15 AM, an interview was conducted with the Environmental Services Supervisor who is also the Housekeeping Supervisor. She stated housekeeping staff check the ceiling-suspended privacy curtains and change them as needed as part of their daily tasks. She further stated housekeeping staff used a check list form. A blank check list form was provided. Upon requesting completed check lists from the last 2 weeks for all rooms and hallways, the Environmental Services Supervisor stated staff had not been filling them out. She further stated she had been very busy trying to keep up with the laundry. On 2/1/24 at 1:00 PM, the Environmental Services Supervisor provided a check list dated 1/30/24, conducted by herself, that indicated ceiling-suspended privacy curtains had been checked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 6 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few Based on observations, resident interviews, staff interviews, and clinical record review, the facility failed to implement the care plan for 2 of 2 sampled residents with Activity of Daily Living Care concerns (Resident #9 and #45). The facility identified that resident #9 needed extensive assistance with transfers, ambulation, dressing, toileting, and bathing. The facility failed to provide bathing in accordance with the resident's abilities and preferences. The facility failed to assist with ambulation (walking) and transfers out of bed since November 2023 for Resident #9. The resident was observed dressed in a hospital style gown. The facility failed to provide timely incontinence care for 12 hours the evening/night of 1/31/24 into the morning of 2/1/24. The morning of 2/1/24, during incontinence care, a new buttocks wound was discovered for Resident #9. The facility failed to provide wound care for 7 days in accordance with the care plan for resident #45. The skin around the wound was missing and yellow exudate and redness were present. The findings include: Resident #9 A review of the care plan (last updated 12/6/2023) for Resident #9 was conducted. The care plan indicated that Resident #9 needed extensive assistance with activities of daily living (ADL) transfers, ambulation, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Goals: The resident would not develop complications related to ADL performance. Resident will maintain ADL self-performance levels as evidenced by no decline in stated ADL levels through the next review date. Interventions: Staff will encourage participation in care as appropriate. Staff will ensure all needs are met. Staff will ensure the resident is dressed and groomed as appropriate. Staff will utilize task segmentation as indicated to help improve participation in ADL performance. Staff will get the resident out of bed as tolerated. Staff will encourage group exercises. The care plan indicated that Resident #9 was at risk for skin breakdown or wounds related to decreased mobility and incontinence. Goal: Resident will be free from skin breakdown or pressure by implementing prevention measures. Interventions: Completion of weekly skin assessments. Report any changes in skin status. Staff will notify the nurse immediately of any new skin breakdown, redness, bruises, blisters, or discoloration during daily care. Staff will assist to reposition or shift weight to relieve pressure as needed. Staff will provide a pressure reduction mattress, provide incontinence care after incontinent episodes, and apply barrier cream as needed. Staff was directed to assist the resident to avoid prolonged periods of skin-to-skin contact. On 1/29/24 at approximately 11:50 AM, Resident #9 was observed asleep in the bed. The bed was raised all the way up to the highest position. Resident #9 was on a pressure reducing mattress with no sheet and a grooved blanket under him. He had a patient gown on and the area around him smelled strongly of urine. On 1/29/24 at approximately 2:50 PM, Resident #9 was awake. He had a patient gown on and smelled strongly of urine. His bed did not have a sheet on it and he laid on a grooved blanket. An interview was conducted with the resident. Resident #9 immediately said that he wanted to get up out of the bed to his wheelchair. He explained that he has not seen his wheelchair for months and has been told that it is missing. He said he cannot remember the last time he was out of bed, but that it was definitely more than 2 weeks ago. He explained that he asked his Certified Nursing Assistant (CNA) if he could get up and walk yesterday, but no one ever got him up. He explained that his back is sore and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 7 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0656 Level of Harm - Actual harm his feet are swollen. He said he asked Nurse D, a Licensed Practical Nurse (LPN) in Restorative for shoes to use so he can get up in the shower chair to take showers, but has never gotten a response. He explained he has been getting bed baths since then, instead of getting him up to the shower chair. The resident explained that he almost never gets a response to his requests. Residents Affected - Few On 1/30/24 at approximately 9:18 AM, a follow up interview with Resident #9 occurred. He said that the staff did not get him out of bed all day. He said he told CNA L that he wanted to get out of bed. CNA L never came back to assist him out of bed. The resident explained that, if staff comes in and you are asleep, they will mark that you refused to get out of bed. He indicated that if staff comes in and wants to get him up out of bed and he asks to do it at a later time, they will also mark that he refused. Resident #9 indicated that he wants to get up. He reports he can use a trapeze bar to move himself around in the bed and help staff when they move him. On 1/30/24 at approximately 4:00 PM, Resident #9 was in bed asleep. On 1/31/24 at approximately 9:18 AM, Resident #9 stated that they did not get him out of bed yesterday. On 1/31/24 at approximately 10:23 AM, an interview was conducted with Nurse B, an LPN, who was asked why Resident #9 had not been out of bed all week. She explained that the resident is supposed to be getting out of bed, but often refuses. The surveyor asked to observe treatment of his dressing and areas. LPN B indicated that she would let the surveyor observe the application of Nystatin powder to his skin folds as ordered on the Treatment Administration Record (TAR) and wound care. LPN B did not check into why Resident #9 had not been assisted out of bed. She also did not contact the surveyor to conduct observation of application of the Nystatin powder to the resident. On 1/31/24 at approximately 10:30 AM, Staff F, a CNA, was notified that Resident #9 had been asking to get out of bed since Monday 1/29/24 and that he said he wants to get up to his wheelchair now. CNA F said therapy was supposed to work with him to get a new wheelchair because his knees don't bend and they can't be placed on the foot rests. CNA F said, I can't put him in the wheelchair. It takes a Hoyer lift and two people. He has needed new leg rests for over a month. She explained that she was told a new piece was getting ordered for the leg rests months ago because he had the money in his account to buy the pieces of equipment. She explained it has been awhile and she has heard nothing more. She said it has been awhile since he has been out of bed. CNA F was asked how long it had been since Resident #9 got out of bed, and replied that Resident #9 had not been up since November of 2023. She explained that staff often has to wake him up to get him out of bed as well. She also said that it was hard to get him rolled and changed in the bed. She was asked where his wheelchair was. CNA F and the surveyor went to find the wheelchair in storage, but the wheelchair could not be located anywhere. On 1/31/24 at 10:50 AM, LPN D approached the surveyor with a bariatric wheelchair with a padded seat. She indicated that she found Resident #9's wheelchair. She said that Resident #9 will say he wants to get up but often refuses. She explained that she has been working on getting the resident to get up on a weekly basis. The surveyor pointed out to LPN D that the care plan does not indicate that Resident #9 refuses frequently. CNA H and CNA F accompanied LPN D to the bedside of Resident #9 to assist him out of the bed. On 1/31/24 at 11:00 AM, an interview was conducted with CNA H. She was asked if she could recall the last time Resident #9 was assisted out of bed. She explained that she cannot recall specifically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 8 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0656 but said it was a long time ago. She indicated that she has trouble bending his legs and putting his legs in the wheelchair foot rests as well. Level of Harm - Actual harm Residents Affected - Few On 1/31/24 at 11:49 AM, Resident #9 was seated at a table in the cafeteria conversing with another resident. He was dressed in his clothes and he no longer smelled of urine. He was up in a wheelchair with his legs in leg rests and shoes on. The resident expressed his sincere gratitude for being allowed to get up out of bed. The resident said it had been months since he has been up. He said he asked his CNA if he could get up Monday but the CNA did not respond. Resident #9 said he asked to get up last week and the week before and no one assisted him out of bed. On 1/31/24 at 11:55 AM, CNA J had been talking to the resident. She said it has been a long time since she has seen in up in his wheelchair. CNA J was asked about the last time Resident #9 was observed out of bed. She explained that she cannot recall the last time she last saw him up. On 2/1/24 at approximately 8:30 AM, an interview was conducted with Resident #9. He said they left him up in the wheelchair all day yesterday until about 9:00 PM. He said he was hurting, but looking forward to getting out of bed next time. He indicated he might not ask to get up today because he was sore. On 2/1/24 at approximately 9:24 AM, an interview was conducted with CNA L. He was asked if he was assigned to care for Resident #9 on Monday 1/29/24. He stated he was. He was asked why he did not get Resident #9 up on Monday. CNA L indicated that did not recall Resident #9 asking to get out of bed. He explained that he had only worked at the facility for 2 weeks and had not seen Resident #9 out of bed previously. On 2/1/24 at approximately 10:10 AM, CNA I was assisting Resident #9 with oral care. The resident smelled of urine. His brief was soaked with urine and feces. The dressing on his underpad was soaked with urine. His sheets were wet. The area smelled strongly of urine and feces. CNA I removed the soaked brief and proceeded to clean him up. Resident #9 said he had not been assisted with changing his brief since about 10:00 PM last evening. CNA I was asked if she assisted Resident #9 with changing his brief yet today. CNA I indicated that she had not checked or offered to assist Resident #9 with peri care yet today. There was a dressing over an area on the buttock and there was another open area lateral to the dressing on the upper right buttock. CNA I was asked if she had seen that open area before. CNA I reported that she had not seen the area before. On 2/1/24 at approximately 1:00 PM, Nurse B, a, LPN, was notified that there was an additional open area observed during peri care. LPN B indicated that she had not previously been notified of the area. LPN B was asked if that was a new area. LPN B said she was not sure and that she will have to talk to Nurse N, a Registered Nurse (RN) Unit Manager. She came back a few minutes later and confirmed that this was a new wound. On 2/1/24 at approximately 9:00 AM, the Facility Administrator (FA) was notified that, based on interviews with staff and residents, there were concerns that Resident #9 had not been out of bed to the wheelchair since November 2023. A copy of a Physical Therapy Assessment Form dated 12/7/23 noted no decline noted at the time. The Physical Therapy Assessment form dated 1/31/24 noted Resident #9 was currently in a 23-inch manual wheelchair with a 3-inch cushion. The wheelchair was listed in working condition and it was noted that the patient was able to reach the wheelchair brakes and both brakes are listed as working. The form stated no modifications to the chair were necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 9 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0656 Level of Harm - Actual harm Residents Affected - Few On 2/1/24 at approximately 3:30 PM, an interview and medical record review was conducted with Nurse N, the RN Unit Manager. She was notified that, during an observation of peri care at approximately 10:00 AM, Resident #9 was noted to be soaked with urine and feces. The resident reported that he had not been assisted with changing his brief since about 10:00 PM the night before (about 12 hours). A new open area was found on his right outer buttock. Unit Manager N indicated that the area was a new open area. There were no new orders, documentation, or care plan revision regarding the new open area on Resident #9's buttocks. Unit Manager N indicated that the physician had not yet been notified. Unit Manager N explained that Resident #9 has a history of getting open areas on his buttocks. She indicated that he does not like to turn and often refuses. The surveyor asked Unit Manager N to point out where the care plan has been updated to include that Resident #9 refuses to turn and get out of bed. Unit Manager N reviewed the plan and stated she does not see refusals included on the care plan. Unit Manager N indicated that Resident #9 does not have much mobility. Unit Manager N was notified that an interview with several CNA staff revealed that the last time he might have been gotten out of bed to the wheelchair was in November. Unit Manager N agreed that November probably was the last time he was up. She was asked why Resident #9 had not been put in his wheelchair since November 2023. Unit Manager N said she did not know why. She explained that Nurse D, the Restorative LPN, used to get him up at least three times a week. She explained that Resident #9 can be difficult at times. He becomes agitated and yells at the staff sometimes. Resident #9 has a couple of days every month or so when he is more confused. Unit Manager N was asked if Resident #9 is getting what he needs for his nursing care and psychosocial needs. The nurse indicated that the resident was not getting his needs met. She indicated that the therapy department takes measurements and makes decisions about the type of wheel chair. She indicated that if the facility had social services in place, there might have been more assistance with the wheelchair. A review of the quarterly Minimum Data Set (MDS) information was conducted for Resident #9. On 12/7/23, the resident's Brief Interview for Mental Status (BIMS) score was 12. Section F0500 of the MDS states that it is somewhat important to go outside and get fresh air when the weather is good. On 1/31/24 at approximately 2:00 PM, a review of the medical record for Resident #9 was conducted. Resident #9 diagnoses included: Chronic Kidney disease, Hypertension, Diabetes Type II, Morbid obesity, vertigo, hyperlipidemia, neuropathy, and cognitive communication deficit. The narrative, check lists, nurses notes, and progress notes showed no documentation that the resident had been gotten out of bed at any time. Resident #45: On 1/29/24 at 11:33 am, during the initial tour, Resident #45 was observed with abrasions on the right side of face that were open to the air. Layers of skin were observed missing and yellow exudate and redness were noted. A review of Resident #45's medical record was conducted. Resident # 45's care plan was updated on 1/22/24 and stated that new orders to soak open area with 1 part water to 3 parts vinegar, cover, apply Vaseline, xeroform, non-adherent dressing twice a day and as needed. The medical record contained an undated form with education about a biopsy, aftercare instructions, and a hand-written list indicating treatment for wound care. A review of Resident #45's Treatment Administration Record (TAR) also stated to soak all areas open to bilateral arm, neck and face with 1 part water, 3 parts vinegar, pat dry, apply Vaseline, xeroform, non-adherent dressing twice a day and as needed. The TAR had a start date of 1/23/24 and has not been documented from 1/22 until 1/29. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 10 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0656 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/31/24 at 09:39 am, an interview was conducted with Unit Manager N who was also the facility's Infection Preventionist. During the interview, she reviewed Resident #45's TAR. Unit Manager N stated honestly, nurses are not doing the treatments. Unit Manager N further stated she was aware of treatments not being done and she would like to do wound care, but she was in charge of Infection control and also a unit manager. She further stated the facility was going to start monitoring compliance with treatments, she would be checking the records, provide some education, and start writing up staff that would not comply. Event ID: Facility ID: 105435 If continuation sheet Page 11 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on staff interview, family interview, medical record review, and policy review, the facility failed to develop an Advanced Directive Care Plan in accordance with the residents preferences for 1 of 2 residents reviewed for advanced directives. (Resident #59) The findings include: On 1/29/24, a record review was conducted for resident #59. The physician order form documented the residents code status as Do Not Resuscitate (DNR) on 1/11/24. A review of the care plan dated 1/18/24 documented the resident was a full code and the resident had a Power of Attorney (POA). On 1/31/24, a review of the facility policy Florida Do Not Resuscitate (DNR), effective date 9/7/23. Page 1 item 3 states The properly execute DNRO will be placed in the resident's medical record. On 1/31/24 at approximately 1:44 PM, a telephone interview was conducted with the resident's son who is the POA. The POA stated the resident is supposed to be a DNR. On 1/31/24 at approximately 2:15 PM an interview was conducted with Registered Nurse (RN) N, a Unit Manager. RN N reviewed the residents medical record and verbally agreed the resident's orders and care plans conflicted about the resident's code status. The physician ordered a DNR, but the care plans indicated the resident was a full code. RN N could not offer an explanation as to how the orders and care plans did not match. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 12 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Actual harm Based on observations, resident interviews, staff interviews and clinical record review, and the facility failed to provide necessary care and services to ensure that a resident maintains or improves abilities in activities of daily living (ADL) for 1 of 2 residents sampled for ADL care, #9. The facility failed to provide bathing and dressing assistance in accordance with the resident's abilities and preferences. The facility failed to assist with mobility (walking) and transfers out of bed since November 2023. During the survey, when the facility did assist resident #9 out of bed on 1/31/24, Resident #9 was left in a wheelchair for about 10 hours. The facility failed to provide timely incontinence care for 12 hours the evening/night of 1/31/24 and morning of 2/1/24. Residents Affected - Few This failiure resulted in the discovery of a new buttocks wound on 2/1/24. The findings include: Resident #9 On 1/29/24 at approximately 11:50 AM, Resident #9 was observed asleep in the bed. The bed was raised all the way up to the highest position. Resident #9 was on a pressure reducing mattress with no sheet and a grooved blanket under him. He had a patient gown on and the area around him smelled strongly of urine. On 1/29/24 at approximately 2:50 PM, Resident #9 was awake. He had a patient gown on and smelled strongly of urine. His bed did not have a sheet on it and he laid on a grooved blanket. An interview was conducted with the resident. Resident #9 immediately said that he wanted to get up out of the bed to his wheelchair. He explained that he has not seen his wheelchair for months and has been told that it is missing. He said he cannot remember the last time he was out of bed, but that it was definitely more than 2 weeks ago. He explained that he asked his Certified Nursing Assistant (CNA) if he could get up and walk yesterday, but no one ever got him up. He explained that his back is sore and his feet are swollen. He said he asked Nurse D, a Licensed Practical Nurse (LPN) in Restorative for shoes to use so he can get up in the shower chair to take showers, but has never gotten a response. He explained he has been getting bed baths since then, instead of getting him up to the shower chair. The resident explained that he almost never gets a response to his requests. On 1/30/24 at approximately 9:18 AM, a follow up interview with Resident #9 occurred. He said that the staff did not get him out of bed all day. He said he told CNA L that he wanted to get out of bed. CNA L never came back to assist him out of bed. The resident explained that, if staff comes in and you are asleep, they will mark that you refused to get out of bed. He indicated that if staff comes in and wants to get him up out of bed and he asks to do it at a later time, they will also mark that he refused. Resident #9 indicated that he wants to get up. He reports he can use a trapeze bar to move himself around in the bed and help staff when they move him. On 1/30/24 at approximately 4:00 PM, Resident #9 was in the bed asleep. On 1/31/24 at approximately 9:18 AM, Resident #9 stated that they did not get him out of bed yesterday. On 1/31/24 at approximately 10:23 AM, an interview was conducted with Nurse B, an LPN, who was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 13 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0676 Level of Harm - Actual harm Residents Affected - Few asked why Resident #9 had not been gotten out of bed all week. She explained that the resident is supposed to be getting out of bed, but often refuses. The surveyor asked to observe treatment of his dressing and areas. LPN B indicated that she would let the surveyor observe the application of Nystatin powder to his skin folds as ordered on the Treatment Administration Record (TAR) and wound care. LPN B did not check into why Resident #9 had not been assisted out of bed. She also did not contact the surveyor to conduct observation of application of the Nystatin powder to the resident. On 1/31/24 at approximately 10:30 AM, Staff F, a CNA, was notified that Resident #9 had been asking to get out of bed since Monday 1/29/24 and that he said he wants to get up to his wheelchair now. CNA F said therapy was supposed to work with him to get a new wheelchair because his knees don't bend and they can't be placed on the foot rests. CNA F said, I can't put him in the wheelchair. It takes a Hoyer lift and two people. He has needed new leg rests for over a month. She explained that she was told a new piece was getting ordered for the leg rests months ago because he had the money in his account to buy the pieces of equipment. She explained it has been awhile and she has heard nothing more. She said it has been awhile since he has been gotten out of bed. CNA F was asked how long it had been since Resident #9 got out of bed, and replied that Resident #9 had not been up since November of 2023. She explained that staff often has to wake him up to get him out of bed as well. She also said that it was hard to get him rolled and changed in the bed. She was asked where his wheelchair was. CNA F and the surveyor went to find the wheelchair in storage, but the wheelchair could not be located anywhere. On 1/31/24 at 10:50 AM, LPN D approached the surveyor with a bariatric wheelchair with a padded seat. She indicated that she found Resident #9's wheelchair. She said that Resident #9 will say he wants to get up but often refuses. She explained that she has been working on getting the resident to get up on a weekly basis. The surveyor pointed out to LPN D that the care plan does not indicate that Resident #9 refuses frequently. CNA H and CNA F accompanied LPN D to the bedside of Resident #9 to assist him out of the bed. On 1/31/24 at 11:00 AM, an interview was conducted with CNA H. She was asked if she can recall the last time Resident #9 was assisted out of bed. She explained that she cannot recall specifically but said it was a long time ago. She indicated that she has trouble bending his legs and putting his legs in the wheelchair foot rests as well. On 1/31/24 at 11:49 AM, Resident #9 was seated at a table in the cafeteria conversing with another resident. He was dressed in his clothes and he no longer smelled of urine. He was up in a wheelchair with his legs in leg rests and shoes on. The resident expressed his sincere gratitude for being allowed to get up out of bed. The resident said it had been months since he has been up. He said he asked his CNA if he could get up Monday but the CNA did not respond. Resident #9 said he asked to get up last week and the week before and no one assisted him out of bed. On 1/31/24 at 11:55 AM, CNA J had been talking to the resident. She said it has been a long time since she has seen in up in his wheelchair. CNA J was asked about the last time Resident #9 was observed out of bed. She explained that she cannot recall the last time she last saw him up. On 2/1/24 at approximately 8:30 AM, an interview was conducted with Resident #9. He said they left him up in the wheelchair all day yesterday until about 9:00 PM. He said he was hurting, but looking forward to getting out of bed next time. He indicated he might not ask to get up today because he was sore. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 14 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0676 Level of Harm - Actual harm Residents Affected - Few On 2/1/24 at approximately 9:24 AM, an interview was conducted with CNA L. He was asked if he was assigned to care for Resident #9 on Monday 1/29/24. He stated the he was. He was asked why he did not get Resident #9 up on Monday. CNA L indicated that did not recall Resident #9 asking to get out of bed. He explained that he had only worked at the facility for 2 weeks and had not seen Resident #9 out of bed previously. On 2/1/24 at approximately 10:10 AM, CNA I was assisting Resident #9 with oral care. The resident smelled of urine. His brief was soaked with urine and feces. The dressing on his underpad was soaked with urine. His sheets were wet. The area smelled strongly of urine and feces. CNA I removed the soaked brief and proceeded to clean him up. Resident #9 said he had not been assisted with changing his brief since about 10:00 PM last evening. CNA I was asked if she assisted Resident #9 with changing his brief yet today. CNA I indicated that she had not checked or offered to assist Resident #9 with peri care yet today. There was a dressing over an area on the buttock and there was another open area lateral to the dressing on the upper right buttock. CNA I was asked if she had seen that open area before. CNA I reported that she had not seen the area before. On 2/1/24 at approximately 1:00 PM, Nurse B, a, LPN, was notified that there was an additional open area observed during peri care. LPN B indicated that she had not previously been notified of the area. LPN B was asked if that was a new area. LPN B said she was not sure and that she will have to talk to Nurse N, a Registered Nurse (RN) Unit Manager. She came back a few minutes later and confirmed that this is a new wound. On 2/1/24 at approximately 9:00 AM, the Facility Administrator (FA) was notified that, based on interviews with staff and residents, there were concerns that Resident #9 had not been out of bed to the wheelchair since November 2023. A copy of a Physical Therapy Assessment Form dated 12/7/23 noted no decline noted at the time. The Physical Therapy Assessment form dated 1/31/24 noted Resident #9 was currently in a 23-inch manual wheelchair with a 3-inch cushion. The wheelchair was listed in working condition and it was noted that the patient was able to reach the wheelchair brakes and both brakes are listed as working. The form stated no modifications to the chair were necessary. On 2/1/24 at approximately 3:30 PM, an interview and medical record review was conducted with Nurse N, the RN Unit Manager. She was notified that, during an observation of peri care at approximately 10:00 AM, Resident #9 was noted to be soaked with urine and feces. The resident reported that he had not been assisted with changing his brief since about 10:00 PM the night before (about 12 hours). A new open area was found on his right outer buttock. Unit Manager N indicated that the area was a new open area. There were no new orders, documentation, or care plan revision regarding the new open area on Resident #9's buttocks. Unit Manager N indicated that the physician had not yet been notified. Unit Manager N explained that Resident #9 has a history of getting open areas on his buttocks. She indicated that he does not like to turn and often refuses. The surveyor asked Unit Manager N to point out where the care plan has been updated to include that Resident #9 refuses to turn and get out of bed. Unit Manager N reviewed the plan and stated she does not see refusals included on the care plan. Unit Manager N indicated that Resident #9 does not have much mobility. Unit Manager N was notified that an interview with several CNA staff revealed that the last time he might have been gotten out of bed to the wheelchair was in November. Unit Manager N agreed that November probably was the last time he was up. She was asked why Resident #9 had not been put in his wheelchair since November 2023. Unit Manager N said she did not know why. She explained that Nurse D, the Restorative LPN, used to get him up at least three times a week. She explained that Resident #9 can be difficult at times. He becomes agitated and yells at the staff sometimes. Resident #9 has a couple of days every month or so when he is more confused. Unit Manager N was asked if Resident #9 is getting what he needs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 15 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0676 Level of Harm - Actual harm for his nursing care and psychosocial needs. The nurse indicated that the resident was not getting his needs met. She indicated that the therapy department takes measurements and makes decisions about the type of wheel chair. She indicated that if the facility had social services in place, there might have been more assistance with the wheelchair. Residents Affected - Few A review of the quarterly Minimum Data Set (MDS) information was conducted for Resident #9. On 12/7/23, the resident's Brief Interview for Mental Status (BIMS) score was 12. Section F0500 of the MDS states that it is somewhat important to go to outside and get fresh air when the weather is good. On 1/31/24 at approximately 2:00 PM, a review of the medical record for Resident #9 was conducted. Resident #9 diagnoses included: Chronic Kidney disease, Hypertension, Diabetes Type II, Morbid obesity, vertigo, hyperlipidemia, neuropathy, and cognitive communication deficit. The narrative, check lists, nurses notes, and progress notes showed no documentation that the resident had been gotten out of bed at any time. A review of the care plan (last updated 12/6/2023) for Resident #9 was conducted. The care plan indicated that Resident #9 needed extensive assistance with activities of daily living (ADL) transfers, ambulation, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Goals: The resident would not develop complications related to ADL performance. Resident will maintain ADL self-performance levels as evidenced by no decline in stated ADL levels through the next review date. Interventions: Staff will encourage participation in care as appropriate. Staff will ensure all needs are met. Staff will ensure the resident is dressed and groomed as appropriate. Staff will utilize task segmentation as indicated to help improve participation in ADL performance. Staff will get the resident out of bed as tolerated. Staff will encourage group exercises. The care plan indicated that Resident #9 was at risk for skin breakdown or wounds related to decreased mobility and incontinence. Goal: Resident will be free from skin breakdown or pressure by implementing prevention measures. Interventions: Completion of weekly skin assessments. Report any changes in skin status. Staff will notify the nurse immediately of any new skin breakdown, redness, bruises, blisters, or discoloration during daily care. Staff will to assist to reposition or shift weight to relieve pressure as needed. Staff will provide a pressure reduction mattress, provide incontinence care after incontinent episodes, and apply barrier cream as needed. Staff was directed to assist the resident to avoid prolonged periods of skin-to-skin contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 16 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Based on resident interviews, staff interviews and record review, the facility failed to ensure that 1 of 1 sampled residents received assistance arranging services for evaluation and treatment of issues with vision (Resident #9). Residents Affected - Few The findings include: On 1/31/24 at approximately 11:48 AM, Resident #9 indicated that he has asked repeatedly since admission to get an eye exam. He explained that he has been having significant trouble with his eyes. The resident explained that he has told the nurses several times. A review of the record of Resident #9 was conducted. The Minimum Data Set Data (MDS) submitted on 12/17/23 indicated that Resident #9 can see fine detail including regular print in newspapers and books and that he did not use corrective lenses. A review of the face sheet for Resident #9 revealed that he was admitted 5 years ago in early 2019. Resident #9 had been diagnosed with the following conditions: Chronic Kidney disease, Hypertension, and Diabetes Type II. There were no progress notes that indicated assessment or plans for the evaluation of vision. No consults were found that indicated an evaluation was conducted by an optometrist or ophthalmologist since admission. On 1/29/23 at approximately 2:00 PM, an interview was conducted with the Facility Administrator. The Facility Administrator indicated that they have not had a social worker at the facility for quite some time. The MDS nurse has been covering social services responsibilities as far as discharges. She was asked to provide further documentation regarding other social services responsibilities. On 2/2/24 at approximately 1:30 PM, an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator and DON were notified that Resident #9 stated he has been asking to get an eye evaluation. The DON indicated that the MDS nurse has been case managing for podiatry and dental services. The DON explained that she was not aware that Resident #9 was asking for glasses. She explained that she will notify the medical director that Resident #9 needs a vision evaluation and have the CNA (Certified Nursing Assistant) schedule the appointment. The Administrator indicated that they would be hiring a scheduler for the facility soon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 17 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observations, staff interviews and review of the Director of Nursing (DON) job description, the facility failed to designate an acting DON when the facility DON was on extended leave. Residents Affected - Few The findings include: During the survey, from 1/29/24 to 2/1/24, the facility DON was not present at the facility. On 1/31/24 at 11:30 AM, an interview was conducted with the Administrator. The Administrator stated the DON had been on leave for 2 weeks and she was currently working from home. She further explained the plan was for the DON to have 2 weeks of leave and then 2 more weeks working remote from home. The Administrator was asked who was the acting DON and she replied that was herself. She was asked if she was licensed as a registered nurse and the Administrator replied she was not a nurse. On 2/01/24 at 5:42 PM, an interview was conducted with the DON via telephone. She stated her regular tasks consisted of overseeing medications, activities of daily living, care plans and nursing staff. Stated she had been on leave since 1/16/24. She further stated her return day was 2/14/24. She explained the plan was to be off for 2 weeks completely and working from home for 2 weeks. She indicated her duties while working from home were the transition to electronic medical records, working in training and policies, and answering phone calls. A review of the DON job description, undated, was conducted. The job function included supervising clinical nurses and nurse techs and carrying out the resident care policies established by the facility and duties and responsibilities included assurance with resident rights policies and working to resolve resident grievances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 18 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #311 Residents Affected - Some On 01/29/24 at 1:00 PM, a telephone interview was conducted with the daughter of Resident #311. She stated her father recently passed away at home. She stated her father was admitted to the facility on [DATE] from the hospital following a stroke. She stated that she brought him home the very next day on 11/15/23 because her father called her screaming Get me out of here. She stated the food was terrible, the dishes were not clean, her father also did not receive any of his medications during his stay at the facility. She also alleged there were roaches in her father's room, and the room was so filthy she felt she had to clean it upon her father's admission. A record review of the face sheet for Resident #311 revealed the resident was admitted on [DATE] with diagnoses including Congestive Heart Failure, Coronary Artery Disease post Coronary Artery Bypass Grafting times 3, Chronic obstructive pulmonary disease, Atrial Fibrillation (Afib), Hypertension (HTN), Hyperlipidemia (HLD), sleep apnea, prior cerebral vascular accident (CVA) (stroke) with prior retinal detachment, and recent heart failure in October of 2023. A review of the Physician Orders received from the hospital dated 11/14/23 revealed the following medications were ordered: Eliquis 2.5mg tab twice a day for Afib Aspirin 325mg tab every morning for CVA Atorvastatin 80mg every night at bedtime for Hyperlipidemia Coreg 3.125mg twice a day with meals for HTN Cyancocobalamin 2500mcg daily for a Vitamin B12 deficiency Finasteride 5mg every day for Benign prostatic hyperplasia (BPH) Lidocaine 5% patch, apply topically to neck (transdermal) every morning, off every evening for nonacute pain Namenda 10mg tab twice a day for dementia Flomax 0.4mg every day for BPH Tramadol 50mg every night at bedtime for non acute pain A review of the Medication Administration Record (MAR) revealed there were no medications administered during the time Resident #311 was at the facility on 11/14/23 or 11/15/23. (Photographic evidence obtained) On 01/30/24 at 2:54 PM, an interview was conducted with RN N about the MAR for Resident #311. She was asked why there were no medications administered for this Resident. She stated Resident #311 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 19 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 arrived at 1:30 PM on 11/14/23 and left the facility at 10:01 AM on 11/15/23. Level of Harm - Minimal harm or potential for actual harm On 01/30/24 at 03:16 PM, an interview was conducted with the Administrator about the medications ordered and provided to Resident #311. The Administrator stated that she checked with staff about this resident's medications and was told that the nurse failed to order the medications and failed to obtain the medications from the emergency kit supply for Resident #311. This nurse received a written reprimand and was provided inservice training because of this incident. At this time, the Administrator confirmed Resident #311 did not receive any medications, including the ordered blood thinners, during his stay at the facility. Residents Affected - Some On 01/31/24 at 9:12 AM, a follow up interview with the Administrator was conducted, she stated she did not have any other paperwork to include the investigation into why this happened or the personnel actions taken. Review of the Flash Inservice for Administering Medications Upon admission for LPNs and RNs provided 11/15, 11/16, 11/17, 11/18, 11/19 and 11/20/23. There are a total of 11 staff who signed as attending this inservice. Discharge medication orders upon admission 1: Transcribe to POS (Physicians Order Sheet) 2. Notify MD (Physician) 3. Fax to Pharmacy 4. Administer medication at next schedule time. 5. If not delivered from pharmacy, pull from EKit [emergency medication kit]. 6. If not available in Ekit, notify MD and responsible party 7. Document notification of MD and responsible party in nurses note 8. Initial and circle in MAR and note see nurses note on back of MAR. The document stated See Additional Information Attached Best Practice admission of Resident and their Medications reads in part . 2. The orders received prior to admission are to be transcribed to the facility's Physician's Order Sheet by DON/Designee. DON/Designee will notify MD of resident's admission and current physician orders. 3. The physician order sheet is to be copied and faxed to Pharmacy upon arrival of resident to the facility for delivery of current medications. 4. It is the responsibility of the nurse admitting resident and performing medication pass to make sure the resident has the medications that have been ordered by MD. If a medication is due on the following medication pass and the facility has not received the medication, the nurse must pull from the facility's emergency kit. If a medication is due on the following medication pass and the facility has not received the medication, and the medication is not in the facility Ekit, it is the nurses responsibility to notify the physician and the responsible party of the unavailability of medication. Resident #211 On 1/31/24 at approximately 2:00 PM a review of the record for Resident #211 was conducted. Resident #211 had been diagnosed with the following conditions: hypertension, acute kidney injury, hypertensive neuropathy, left ventricular hypertrophy, and ischemic stroke. A review of the Medication Administration Records (MARs) for the month of January 2024 was conducted for Resident #211. There were multiple doses of medications not signed on the MAR and no corresponding documentation recorded in the medical record to explain the missed doses of medications. Resident #211 had a physician order to administer a Lovenox injection 40 mg subcutaneous every day for deep vein thrombosis prophylaxis. The MAR was not signed off and the medication was not signed out on 1/11/24, 1/12/24 or 1/21/24 at 9:00 PM. Resident #211 had a physician order to administer Minoxidil 2.5 mg 1 tablet by mouth twice a day for hypertension (HTN, high blood pressure). The MAR had doses which were circled indicating they were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 20 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 not given 1/13 at 9:00 AM and 9:00 PM and 1/14/24 at 9:00 AM and 9:00 PM with no explanation documented. Doses were not signed out on the MAR on 1/15 at 9:00 AM, and 1/17/24 at 9:00 AM. Resident #211 had a physician order to administer Isosorbide 20 mg 1 tablet by mouth three times a day for HTN. Doses were not signed out on the [DATE]/11 at 10:00 PM, 1/12 at 10:00 PM, Doses were circled indicating they were not given but no reason was listed on the back of the MAR on 1/13 at 2:00PM and 10:00 PM, 1/14 at 6:00 AM, 2:00 PM and 10:00 PM, 1/15 at 6:00 AM. Doses were not signed out on the MAR on 1/15 at 2:00 PM, 1/17 at 2:00 PM, 1/18 at 6:00 AM, 1/19 at 6:00 AM, 1/21 at 10:00 PM, and 1/22/24 at 6:00 AM and 2:00 PM. Resident #211 had a physician order on 1/19/24 to administer Vancomycin 1 Gram in 500 ml (milliliters) intravenous daily at 250 milliliters per hour. The MAR was not signed off on 1/22/24 at 9:00 AM. Resident #211 had a physician order dated 1/26/24 to increase Vancomycin to 1.25 Grams daily. The MAR was circled on 1/27/24 and 1/31/24 indicating the medication was not administered, No reason was documented. Resident #211 had a physician order to administer Clonidine 0.1 mg by mouth every 8 hours for (HTN). Doses were not signed out on the medication administration record (MAR) on 1/15 at 2:00 PM, 1/17 at 2:00 PM, 1/19 at 6:00 AM, 1/21 at 10:00 PM 1/22/24 at 6:00 AM and 2:00PM. Resident #211 had a physician order to administer Carvedilol 25 mg twice a day for HTN. Doses were not signed out on the MAR on 1/11 at 9:00 AM and 9:00 PM, 1/14 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM, and 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Losartan 100 mg 1 tablet by mouth every day for HTN. Doses were not signed out on the [DATE]/15 at 9:00 AM, 1/17 at 9:00 AM, and 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Nifedipine 10 mg 1 tablet by mouth for HTN daily. The MAR was not signed off 1/15 at 9:00 AM, 1/17 at 9:00 AM, nor 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Sodium Bicarb 650 mg 1 tablet by mouth three times a day for supplement due to renal disease. The MAR was not signed off on 1/15 at 2:00 PM, 1/17 at 2:00 PM, 1/21 at 9:00 PM, or 1/22/24 at 6:00 AM and 2:00 PM. Resident #211 had a physician order to administer Sucralfate 1 GM by mouth at meals and bed time for gastrointestinal bleed. The MAR was not signed off 1/11 at 9:00 PM, 1/12 at 9:00 PM, 1/15 at 11:30 AM and 4:30 PM, 1/17 at 11:30 AM and 4:30 PM, 1/19 at 6:00 AM, 1/21 at 9:00 PM, and 1/22/24 at 6:00 AM 11:30 AM and 4:30 PM. Resident #211 had a physician order to administer Doxazosin 4mg, 2 tablets (8mg) daily for urinary retention. The MAR was not signed off on 1/15, 1/17 at 9:00 AM, and 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Folic Acid 400mg 1 tablet by mouth daily for supplement. The MAR was not signed off on 1/15 at 9:00 AM, 1/17 at 9:00 AM, nor 1/21/24 at 9:00 AM. Resident #211 had a physician order to administer Vitamin C 500 mg 1 tab by mouth twice a day for supplement. The MAR was not signed off on 1/15 at 9:00 AM, 1/21 at 9:00 AM, and 1/22/24 at 9:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 21 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Resident #211 had a physician order to administer Thiamine 100mg 1 tablet by mouth every day for supplement. The MAR was not signed off on 1/15 at 9:00 AM, 1/17 at 9:00 AM, nor 1/22/24 at 9:00 AM. Resident #211 had a physician order to administer Atorvastatin 40 mg 1 tablet by mouth at bedtime for hyperlipidemia, The MAR was not signed off on 1/10 at 9:00 PM, 1/11 at 9:00 PM, nor 1/21/24 at 9:00 PM. Residents Affected - Some Resident #211 had a physician order for Duo Neb nebulizer treatments to be given every 6 hours for 10 days for shortness of breath (SOB) and wheezing. The MAR was not signed off on 1/22/24 for doses at 12:00 AM, 5:00 AM, 12:00 PM, and 6:00 PM were not signed out. Resident #211 had a physician order to administer Norco tablets 5mg/325 mg of acetaminophen for pain three times a day. The MAR was not signed off, and doses were not signed out on 1/21 at 10:00 PM, and 1/22/24 at 6:00 AM and 2:00 PM. Resident #211 had a physician order to flush the Peripherally Inserted Central Catheter (PICC) line every shift. The MAR was not signed off 1/21 on 7PM -7AM shift and 1/22/24 on 7AM -7PM shift. Resident #211 had a physician order to flush the PICC line with 5cc of heparin flush daily. The MAR was not signed off on 1/22/24. Resident #211 had a physician order to administer Meropenem 500mg/100ml intravenous every 6 hours for osteomyelitis. The MAR was not signed off on 1/20 at 12:00 PM or 6:00 PM, nor 1/22/24 at 12:00 AM, 6:00AM, 12:00 PM or 6:00 PM. Resident #211 had a physician order to check the residents blood pressure each shift. There was no pulse and blood pressure recorded on 1/12 on either shift, 1/13 7PM-7AM, 1/14 7PM-7AM, 1/15 7AM-7PM, 1/17 7AM-7PM, and 1/22 7AM-7PM. On 1/20/24 a blood pressure of 165/95 was recorded, 1/21/24 a blood pressure was recorded at 160/100 and on 1/24/24 a blood pressure of 202/100 is recorded. There was no recorded time for any of the blood pressure readings and no documentation that the physician had been notified. Resident #9 On 1/30/24 at approximately 4:00 PM an interview was conducted with Resident #9. He indicated that receiving staff assistance takes a long time. He said everything does not always get done as it should. The resident indicated that he does not always get all prescribed treatments or assistance with getting up out of bed. He explained that the staff will say that he is asleep and refuses but that is not the case. On 1/31/24 at approximately 2:00 PM, a review of the clinical record for Resident #9 was conducted. Resident #9 had diagnoses which included: Chronic Kidney disease, Hypertension (high blood pressure), Diabetes Type II, hyperlipidemia, and hypothyroidism. A review of the Medication Administration Records (MARs) for the month of January 2024 was conducted for Resident #9. There were multiple doses of medications not signed on the MAR and no explanation recorded in the medical record to explain the missed doses of medications. Resident #9 had a physician order to receive amlodipine tablet 10 mg by mouth every night at bedtime for hypertension (HTN). The MAR was not signed off on 1/21/24 at 9:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 22 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Resident #9 had a physician order to receive Tylenol/codeine 300/30 mg 1 tablet by mouth twice daily for pain. The MAR was not signed off on 1/14 at 9:00 AM and 1/17 at 9:00 AM, 1/21 at 9:00 PM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to take Atorvastatin 20 mg 1 tablet by mouth every night at bedtime for hyperlipidemia. The MAR was not signed off on 1/21/24 at 9:00 PM. Resident #9 had a physician order to receive Azelastine Spray 0.1% 2 sprays each nostril once daily for allergic rhinitis. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Vitamin D 1000 units, 1 capsule by mouth once daily for vitamin deficiency. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Docusate Sodium 100mg tablet twice daily for constipation. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM and 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Flonase Spray 50 micrograms 2 sprays each nostril once a day for allergic rhinitis. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Folic Acid 400 micrograms was to be taken once daily for anemia. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Lasix 80 mg 1 tablet by mouth twice a day for Congestive Heart Failure and edema. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Gabapentin 300 mg 1 capsule twice a day for neuropathy. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Glipizide 10 mg 1 tablet by mouth twice daily for diabetes. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Iron tablet 325 mg one tablet three times a day for anemia. The MAR was not signed off on 1/8/24 at 2:00 PM. Resident #9 had a physician order to receive Levothyroxine tab 88 micrograms, one tablet by mouth once daily for hypothyroidism. The MAR was not signed off on 1/22/24 at 6:00 AM. Resident #9 had a physician order to receive Loratadine 10 mg 1 tablet by mouth once daily for allergic rhinitis. The MAR was not signed off on 1/21/24 at 9:00 PM. Resident #9 had a physician order to receive Meclizine 25 mg 1 tablet by mouth twice a day for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 23 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 vertigo. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Omega 3 acid cap 1 GM twice a day for hyperlipidemia. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/18 at 9:00 PM,1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Multivitamin with mineral 1 tablet by mouth once daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive MiraLAX Dissolve 17 Grams in 6-8 ounces of water/juice and give by mouth twice daily was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, 1/21 at 9:00 PM or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Flomax 0.4 mg capsule by mouth once daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive Vitamin D3 50,000, units one capsule weekly on Wednesdays. The MAR was not signed off on 1/17/24 at 9:00 AM. Resident #9 had a physician order to receive Vitamin C 500 mg 1 tablet by mouth once daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to receive ferrous sulfate 325 mg 1 tablet by mouth daily. The MAR was not signed off on 1/8 at 9:00 AM, 1/15 at 9:00 AM, 1/17 at 9:00 AM, or 1/22/24 at 9:00 AM. Resident #9 had a physician order to screen for pain every shift and record this was not signed off on 1/8 7AM-7PM shift, 1/15 7AM-7PM shift, 1/17 7AM-7PM shift, and 1/22/24 7AM -7PM shift. Resident #9 had a physician order to receive 10 units of Baslagar (insulin Glargine) by subcutaneous injection once daily for Diabetes Type II. The was not signed off on 1/22/24. Resident #9 had a physician order to check for bowel movement every shift and give laxative as ordered. The MAR contains no documentation on 1/4 7PM-7AM, 1/8 7 AM-7 PM, 1/15 7AM-7PM, 1/17 7AM-7PM, 1/21 7PM-7AM, and 1/22/24 7AM-7PM. On 1/31/24 at approximately 3:30 PM, an interview was conducted with RN N who was shown the MAR for Residents #211 and #9. RN N explained that the doses should have been addressed and signed by the nurses responsible for giving the medications and treatments or an explanation documented on the back of the MAR. A copy of the Medication Administration Policy and Pharmacy Contract was requested from the Facility Administrator. On 1/31/24 a review of the Medication Administration Policy dated 8/7/2023 was conducted. The policy directed nurses to document necessary medication administration /treatment information when medications are given. (e.g. when mediations are given, injection site of a medication, when medications are refused.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 24 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Based on record reviews, staff interviews, resident and family interviews, review of November 2023 medication training, and policy review, the facility failed to ensure procedures were in place and followed to assure the accurate administering of all drugs 5 of 21 residents sampled for Medication Administration Records (#9, #35 #45, #211 and #311 ). Residents Affected - Some The findings include: Resident # 45 A review of Resident #45's medical record was conducted. Resident #35 had diagnoses including dementia and end stage renal disease. Physician's orders included Paxil 20 mg (milligrams) for anxiety at 9 PM, Donepezil 10 mg for dementia at bedtime, and Haloperidol 0.5 mg for mild psychosis at bedtime. A review of the Medication Administration Records (MAR) revealed Paxil 20 mg was not documented as given on 1/17/24 and 1/22/24, Donepezil 10 mg was not documented on 1/21/24, and Haloperidol 0.5 mg was not documented on 1/21/24. Resident # 35 A review of Resident #35's medical record was conducted. Resident #45 had diagnoses including hypertension, mood disorder, major depressive disorder, kidney disease and cerebrovascular disease. Physician's orders included Norvasc 10 mg for hypertension daily in the morning, Depakote 250 mg daily in the morning for mood, and Furosemide 20 mg once daily for edema. A review of MAR revealed Norvasc 10 mg , Depakote 250 mg, Furosemide 20 mg were not documented on 1/8, 1/14, 1/15, 1/17, and 1/22/24. On 1/31/24 at 09:39 AM, an interview was conducted with Staff N, Registered Nurse (RN), who was also facility's Infection Preventionist and Unit Manager. During the interview, she reviewed Resident # 35 and #45's MARs. RN N stated she had been telling the nurses to complete the MAR documentation because she was aware it was not being done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 25 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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. Based on observation, staff interviews, and facility policy review, the facility failed to appropriately store medications. The findings include: On 2/01/24 at 1:08 PM, an observation was conducted of the facility's 200 hallway. The hallway did not have any rooms currently occupied by residents. There was a double door to access the hallway that was unlocked. There were some cardboard boxes in the middle of the hallway. One of the boxes contained dozens of bottles of various medications. (Photographic evidence was obtained) On 2/01/24 at 04:48 PM, an interview was conducted with Staff N, a Registered Nurse (RN) and unit manager. She stated all medications are securely stored inside the medication rooms or inside the medication carts. At this point, RN N was made aware of the medications inside the box at 200 hallway. She looked at the medication box and stated those were over the counter medications and should not be there. On 2/01/24 at 5:59 PM, a telephone interview was conducted with the facility's Director of Nursing (DON). During the interview, she was made aware of the medications stored in the 200 hallway and stated that should not have happened. A review of the facility's policy titled Medication Storage dated 12/8/23 was conducted. The policy stated that all medications shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 26 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, resident interview, staff interview and review of the 2022 Food Code from the United States Public Health Service Food and Drug Administration, the facility failed to ensure chicken was thoroughly cooked the evening of 1/31/24. This affected 5 observed dinner trays, including the tray served to resident #9. The findings include: On 1/31/24 at approximately 6:00 PM, resident #35 requested the survey staff to view the chicken dinner recently served to resident #9. Resident #35 stated that this is the crap food they serve us. An observation of the dinner tray served to resident #9 found a significantly uncooked dark meat chicken quarter. The chicken meat was pink to red and blood was visible. Staff AA, a Certified Nursing Assistant (CNA) was in the room and observed to cover the tray. CNA AA confirmed that the chicken was completely raw and she wouldn't eat it herself. Facility staff became alerted to the undercooked chicken, and began checking and removing affected resident trays. Two additional resident trays with partially eaten food were observed, one was returned to the tray care and the other was placed under a rolling table by the nurse's station on the 100 hall. On both trays, the chicken was visibly undercooked, pink to red in color, and still had some blood on it. (Photographic evidence obtained) On 1/31/24 at approximately 6:22 PM, an interview with the Facility Administrator was conducted. The Administrator stated she did not know how this could've happened. She stated it must have been only one plate with raw chicken. When informed that more than one tray had been spotted by the survey team, the Administrator cut open a small chicken wing to show us it was cooked properly. In the nursing station where the interview was conducted, a dinner tray located at the bottom of a table was spotted. The tray contained an uneaten piece of chicken, but the other food items had been consumed. The surveyor directed the Administrator to the significantly undercooked chicken that was on the plate, and the Administrator stated she did not know how that could have happened. On 1/31/24 at 6:11 PM, an interview was held with Staff FF, a facility cook. When asked what the process is to make sure chicken is cooked all the way, he stated he takes the temperature of all the big pieces. He stated he did not know how this happened, he has received several plates back to cook longer. He also stated that, when something is raw, he shuts down the line and cooks everything longer. When asked who plated that night, he stated he did, but did not see the raw chicken. The surveyor asked [NAME] FF how this could happen if he was checking the temperatures of all the larger chicken pieces? [NAME] FF replied that someone must have grabbed a bag of frozen chicken and added it to the defrosted ones. The surveyor asked, Who could have done that?, and [NAME] FF replied, no one, and that he was the only one that defrosts frozen meats. [NAME] FF confirmed he was the only one plating food that night. The cooked food temperature log from dinner was requested for review. [NAME] FF stated he did not have a temperature log for the chicken. He stated that he tested it as he was plating, but he did not record it anywhere. On 2/1/24 at 9:01 AM, the Facility Administrator provided a food temperature chart. When asked if she had policies and procedures for the kitchen and food preparation, she stated that they did not have policies and procedures related to the kitchen; however, she provided a temperature chart showing the safe cooking temperatures of foods including chicken. When asked for the grievances regarding the raw chicken, she stated her staff had chosen not to file any grievances. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 27 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the 2022 Food Code, Recommendations of the United States Public Health Service Food and Drug Administration. In the section about Hazard Analysis Critical Control Points (HACCP), the Food Code advises that Salmonella spp. and Campylobacter, as well as spore-formers, such as Bacillus cereus and Clostridium perfringens, are significant biological hazards in chicken. The control measure used to kill pathogens is cooking to the proper temperature. Chicken requires a final internal temperature of 165 degrees Fahrenheit to control the pathogen load for Salmonella spp. Monitoring activities need to be in place to ensure Chicken cooked is to 165 degrees Fahrenheit. Examples of monitoring activities include visual observations and measurements of time and temperature. Monitoring the internal temperature of a select number of chicken pieces immediately following the cook step would be an example of a monitoring activity. Alternatively, the temperature of an oven or fryer and the time required to reach an internal temperature of 165 degrees Fahrenheit could also be monitored. Event ID: Facility ID: 105435 If continuation sheet Page 28 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 of laundry storage and laundry procedures, staff interviews, review of the laundry policy, review of laundry training, and review of job descriptions, the facility Administration failed to provide oversight in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable level of well-being for all 68 residents in the facility. Administrative staff failed to ensure that essential equipment, washing machines, were in working order and facility textiles and resident clothes were stored, sorted, processed and transported in a manner to prevent cross-contamination in accordance with facility policy. The facility failed to ensure that the facility Infection Preventionist had oversight of the laundry procedures. The facility failed to update their laundry procedures to ensure hygienic laundry after both facility washing machines failed, and the facility made the determination to utilize a local laundromat. Residents Affected - Many The facility had 2 commercial grade washing machines, one broke in December 2022 and the second broke on or before November 2023 (exact date could not be determined). Soiled laundry (linens, towels, resident clothing, mop heads, rags etc) was being transported to a local laundromat in a pick-up truck bed. Soiled linens were visibly contaminated with feces and urine. The laundromat used both large capacity front loading washing machines and typical household style top-loading washing machines. No information was provided that the washing machines had an extractor (device that removes larger debris). The facility ran out of commercial laundry detergent on 1/28/24 and was observed to be substituting consumer products. The wet laundry was placed in clear plastic bags and transported back to the facility in the same vehicle where it remained bagged until a dryer was available, often the next day. Clean wet linen was observed stored in containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. Cross reference to F867, F880,

F908 and F945. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. The findings include: Previous Complaint Survey from 2/2/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11]: During a previous complaint survey conducted on 1/31/23 through 2/2/23, the facility was cited for noncompliance at F584 for a lack of available linen supply. During the survey, observations of the linen supply closets on 1/31/23 at approximately 11:05 AM found no clean sheets, washcloths, or towels available. Interviews with 4 staff members and 5 residents identified a lack of linens as a concern. On 1/31/23 at approximately 11:18 AM, the Environmental Services Director stated the facility had 1 out of 2 washing machines not functioning. She stated that the facility had ordered parts for the machine. During a follow up interview on 1/31/23 at approximately 11:51 AM, the Environmental Services Director stated the washing machine had not been functional since about the last week of December 2022. See Statement of Deficiencies Form CMS-2567, Survey Event ID # 8Q7X11 dated 2/2/2023. Current Survey, 2/2/24: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 29 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Many During the initial tour of the facility on 01/29/24 between 11:15 AM and 11:50 AM, linen issues were observed. Resident #54 had no pillowcase on the pillow, and the pillow cover was shredded. Resident #16's linen appeared dirty with a grainy like matter and there was no pillowcase on the pillow. Resident #30 had no pillowcase on the pillow. Resident #45 had no pillowcases on their pillows. Residents #1, #9, and #211 were observed to be wearing hospital style gowns. Additionally, Resident #9 had no pillowcases on his pillows and no bottom sheet on his bed. Resident #211 had no sheets on his/her bed. During the observations, a resident in the hallway could be heard asking staff if today was the day that he could wash his clothes, and a staff member was heard asking another staff member if they would go check in the outside storage area to bring in more sheets. On 1/29/24 at 12:00 PM, an interview was conducted with Resident #46. She stated her only concern was related to the non-functional washing machines. She further stated sometimes it took 10 days to get back her clothes and because of that she had to wear her same clothes for a couple of days. On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor who stated that facility textiles and resident laundry was being processed at a local laundromat [by facility staff]. He stated this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting but has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out, the facility was left with no operating washing machine since about November of 2023. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering of resident clothing and linens. On 1/31/24 at 9:49 AM, an interview was conducted with Staff N, a Registered Nurse (RN). She stated the facility had been saying they were going to fix the washing machines before the new company took over, and it was not being done. She further stated it used to take 3 days turn around and now was 1 to 2 weeks. On 1/31/24 at approximately 11:00 AM, an interview was conducted with an anonymous direct care staff member. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate. Frequently there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. During the tour of the facility laundry area on 2/1/24 beginning at approximately 10:21 AM, the area appeared disorganized and numerous potential infection control issues were identified. In the soiled laundry area, on the concrete floor there were 2 piles of soiled linens and clothing. The soiled linen was saturated with urine and feces. There was a portable rack of clean clothes that were hanging and a basket with partially folded clothes. The small sink in the room was surrounded by laundry and inaccessible for handwashing. Outdoors, there was a pile of approximately 8 bags containing clean wet linen stacked on a wooden pallet and a cart where clean dry resident clothes were stored outside. Tree leaves were observed to be underneath the linen. In the clean side of the laundry area, there were 4 bins of wet laundry waiting to be dried. The bins were labeled Soiled Linen. The Environmental Services Manager said they were left over from yesterday at approximately 6:00 PM that had not yet been dried. Clean resident clothes were folded and sorted on a table that did not have a barrier present, according to the facility policy. The Environmental Services Manager explained that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 30 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Many washers have not been working at the facility for several months. She indicated that the facility has had trouble maintaining both washers and dryers over the past year. Since the washers broke, they have been taking laundry to the local public laundromat to wash, then bringing the wet laundry back to the facility to dry 7 days a week. The Environmental Services Manager explained that they ran out of commercial laundry detergent on 1/28/24. They have since been using ½ cup of Tide detergent and ½ cup of bleach per load in the washers at the laundromat. She was unable to verbalize how those amounts were determined. She indicated that the laundromat washers might have a 35-gallon capacity. She was asked to describe the type and capacity of the washers at the laundromat. The manager was unable to provide specific information regarding type, manufacture, or recommendations for detergent and/or hot water temperatures for washers at the laundromat. Refer to F880 for further details. The facility laundry policy was requested for review. The Laundry Services Policy dated 12/8/23 stated soiled and clean linen should be separated at all times. The policy directed staff not to place clean linen in contaminated areas or transport clean linen in containers designated for soiled linen. Employees sorting or washing linen must wear a gown and gloves. The policy directed employees to not leave damp linen in laundry machines overnight. The policy recommended that staff follow manufacturer instructions (instructions from equipment, detergent, rinses etc.) for all laundry processing. The policy directed staff to keep soiled and clean linen and their respective hampers and laundry carts separated at all times. Staff processing clean linen were directed to place a barrier on the sorting folding table before placing any clean linen or clothing items. The laundry services policy did not address any procedures regarding utilizing the local laundromat. During the survey, from 1/29 to 2/1/24, the facility Director of Nursing (DON) was not present at the facility. On 1/31/24 at 11:30 AM, an interview was conducted with the Administrator who stated the DON was on leave for the past 2 weeks and would be working from home for at least 2 more weeks. The Administrator stated that she was serving as the Acting DON, even though she was not a nurse. On 2/01/24 at 05:42 PM, an interview was conducted with the DON via telephone. She stated her regular tasks consisted of overseeing medications, activities of daily living, care plans and nursing staff. Stated she had been on leave since January 16th, 2024. She further stated her return day was February 14th. The DON did not mention any duties related to laundry oversight. An interview was conducted with the facility Administrator on 2/1/24 at approximately 3:42 PM. She stated he started working at the facility on December of 2023. The Administrator stated that the washing machines were not working when she started the position. She stated that parts were ordered. The Administrator was unable to provide exact dates for when each washer became non-functional. She was unable to provide the manufacturer recommendations from the washing machines at the local laundromat. She was asked to provide dates that machines broke along with invoices regarding repairs. The Administrator provided some emails indicating the status of machine part orders. The first email was dated 9/21/23 to the previous administrator stating a screen kit, washer extractor keyboard, mini switch, microswitch drive and a fuse had been delivered. On 10/9/23 there is an email indicating that a 3-inch drain valve was shipped to the facility. An email on 11/14/23 indicating parts on backorder. There was also an invoice for a certified used washer ordered on 1/15/24. Laundry Training: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 31 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Many On 2/1/24 at about 1:20 PM, The Environmental Services Manager was asked to provide a list of employees that were assisting with processing laundry. She explained that she, Laundry Worker A, Maintenance Worker K, and the Maintenance supervisor were assisting with transporting and processing soiled linens at the laundromat. The Environmental Services Manager was asked to provide evidence of training for the employees who were processing laundry for the facility. On 2/1/24 at approximately 3:00 PM, an interview was completed with the Infection Preventionist Nurse (IP) who stated that the Environmental Services Manager was in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. The IP nurse was asked who was responsible for providing education regarding handling laundry. The Infection Preventionist Nurse indicated that she was unsure who did the training, but it was probably the Environmental Services Supervisor. The IP nurse was shown images of bins labeled soiled linen which contained clean wet laundry that had waited all night before being placed in dryers. The Infection Preventionist Nurse indicated that clean linen should never be stored in bins that are labeled soiled linen and that clean linen should be processed in an area that does not contain contaminated laundry. On 2/1/24 at approximately 4:36 PM, an interview was conducted with the Administrator. She was asked who provides the education for laundry serves. The Administrator explained that she would find out who is responsible. The Administrator was asked when she last toured laundry area, and replied that she toured the laundry when she first came on board (in December). She stated that nothing caught her eye that was off. The Administrator was shown photographs of laundry on the ground being sorted out of bags. The Administrator stated that it should not be like that, and that she would find out who is responsible for education. On 2/1/24 at approximately 4:00 PM, an interview was conducted with the Environmental Services Supervisor who is also the Housekeeping Supervisor. She provided the latest training regarding handling infectious laundry, dated 4/25/2023. Three employees signed that they completed the training. Laundry Worker A, another employee who was no longer employed and Housekeeping Staff Member P. Maintenance Worker K and the Maintenance supervisor did not sign that they had received the training. Per the in-service materials, to prevent microbial contamination of laundry equipment staff should: -remove solids such as feces or vomit before the wash/dry cycle. -follow manufacturer recommended temperature, detergent and laundry additive guidelines. -do not leave damp textiles in machines overnight. The inservice advised that a temperature of at least 160 degrees Fahrenheit for a minimum of 25 minutes was commonly recommended for washing laundry. Chlorine bleach becomes activated at water temperatures of 135-145 degrees Fahrenheit. The training materials were based on CDC guidance. An interview with the Medical Director was conducted on 1/31/2024 at 11:15 AM. The Medical Director acknowledged that the problem with the laundry has been going on for months. He stated that the facility was under new ownership, and they are working on identifying and correcting the issues. There were a lot of things to fix, and the new owners were working on it. The medical director stated that the facility has a good amount of staff for the first time in years. Job Descriptions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 32 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Many The job description for the Registered Nurse Infection Preventionist (RN IP), undated, under Job Functions: The RN IP is responsible for planning organizing and directing the functions for the infection prevention and control program (IPCP). Under Duties and Responsibilities: Oversight of the IPCP to include preventing identifying, controlling, reporting and investigating infections and communicable diseases for all residents staff and visitors of the centers following local, state and national guidelines as well as recognize best practices. Education enforcement and reinforcement of the written standards of the program as outlined in the infection control policies and procedures and as directed by the center infection control program risk assessment. Collaborate with center leadership and the medical director to develop, implement, evaluate and reevaluate the annual infection control and prevention goals and plans. Develop and present infection control education during orientation, annual review, and department specific and as needed. Make recommendations for changes to infection control and prevention policies and procedures. Under the section Working Conditions: Works in office areas as well as throughout the center (i.e. medication rooms, nurses stations, laundry, kitchen, resident rooms, etc.) The job description for the Director of Environmental Services, undated, duties included: Planning, organizing and directing housekeeping and laundry personnel. Ensuring jobs are completed efficiently and within regulatory guidelines optimizing your personal skills and the environmental personnel. Inspects rooms, corridors and facility for cleanliness or other concerns. Performs other related duties as assigned by facility to assist all departments and facility administration in providing a clean, home-like and caring environment for facility residents and staff. The job description for Executive Director (Administrator), undated, under Purpose of Your Job Position: The primary purpose of the executive director is to direct day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. Under Job Functions: Supervises the Director of Clinical Services and the Director of Environmental services. Under Duties and Responsibilities: Schedule regular meetings with direct reporting staff to provide supervision, ensure communication, and to monitor facility operations. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. Ensure a safe, clean, and comfortable environment for residents, visitors and staff. The job description for the Director of Nursing, undated, listed under Job Function Supervising clinical nurses and nurse techs and carrying out the resident care policies established by this facility. Duties and Responsibilities included assurance with resident rights policies and work to resolve resident grievances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 33 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Review of the Flash Inservice for Administering Medications Upon admission for LPNs and RNs provided 11/15, 11/16, 11/17, 11/18, 11/19 and 11/20/23. There are a total of 11 staff who signed as attending this inservice. Discharge medication orders upon admission 1: Transcribe to POS (Physicians Order Sheet) 2. Notify MD (Physician) 3. Fax to Pharmacy 4. Administer medication at next schedule time. 5. If not delivered from pharmacy, pull from EKit [emergency medication kit]. 6. If not available in Ekit, notify MD and responsible party 7. Document notification of MD and responsible party in nurses note 8. Initial and circle in MAR and note see nurses note on back of MAR. The document stated See Additional Information Attached Best Practice admission of Resident and their Medications reads in part . 2. The orders received prior to admission are to be transcribed to the facility's Physician's Order Sheet by DON/Designee. DON/Designee will notify MD of resident's admission and current physician orders. 3. The physician order sheet is to be copied and faxed to Pharmacy upon arrival of resident to the facility for delivery of current medications. 4. It is the responsibility of the nurse admitting resident and performing medication pass to make sure the resident has the medications that have been ordered by MD. If a medication is due on the following medication pass and the facility has not received the medication, the nurse must pull from the facility's emergency kit. If a medication is due on the following medication pass and the facility has not received the medication, and the medication is not in the facility Ekit, it is the nurses responsibility to notify the physician and the responsible party of the unavailability of medication. Based on resident interview, staff interview, review of Treatment Administration records (TAR), clinical record review, and review of staff training from November 2023, the facility failed to ensure accurate medical record documentation (TAR) for 2 of 21 residents sampled for Medication Administration Records (#9 and #211). The findings include: Resident #211 On 1/31/24 at approximately 2:00 PM, a review of the Treatment Administration Record (TAR) for Resident #211 for the month of January 2024 was conducted. There were multiple treatments not signed on the TAR, and no explanation recorded in the medical record to explain the missed treatments. Resident #211 had a physician order to cleanse the sacral wound with normal saline, pat dry, apply skin prep to peri wound then apply wet to dry dressing to wound bed cover with dry dressing on 7PM-7AM shift daily and as needed. The TAR was not signed off that this had been done on 1/11, 1/23, 1/14, 1/18, 1/21, 1/24, 1/25, 1/27, 1/28, or 1/29/24. Resident #211 had a physician order to check dressing to sacrum every shift for soilage and dislodgement on both shifts. The TAR was not signed that this had been done on 1/11 7PM-7AM, 1/12 neither shift, 1/14 7PM-7AM, 1/15 7AM-7PM, 1/17 neither shift, 1/18 neither shift, 1/20 7AM-7PM, 1/21 7PM-7AM, 1/22 7AM-7PM,1/23 7AM-7PM, 1/24 neither shift, 1/25 neither shift, 1/26 7AM-7PM, 1/27 7AM-7PM, or 1/28/24 7AM-7PM. Resident #211 had a physician order to apply skin prep to the left heel every shift and as needed on 7PM-7AM shift. The TAR was not signed off indicating it was done on 1/11, 1/12, 1/14, 1/18, 1/21, 1/24, 1/25, 1/26, 1/27, 1/28, or 1/29/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 34 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #211 had a physician order to cleanse wound right heel with normal saline pat dry apply calcium alginate to wound bed apply skin prep to peri wound cover with dry dressing daily and as needed on 7PM-7AM shift. The TAR was not signed off indicating that it was done on. 1/11, 1/12, 1/14, 1/18, 1/21, 1/24, 1/25, 1/26, 1/27, 1/28, nor 1/29/24. Resident #211 had a physician order to check dressing to the right heel every shift for soilage and dislodgement on both shifts. The TAR was not signed that this had been done on 1/10 7PM-7AM, 1/11 neither shift, 1/12 neither shift, 1/14 7PM-7AM, 1/15 7AM-7PM, 1/17 7AM-7PM , 1/18 neither shift, 1/20 7AM-7PM, 1/21 7PM-7AM, 1/22 7AM-7PM,1/23 7AM-7PM, 1/24 neither shift, 1/25 neither shift, 1/26 neither shift, 1/27 neither shift, 1/28 neither shift, or 1/29/24 7PM-7AM shift. Resident #211 had a physician order to check gastrostomy tube for placement every shift after administering feeding and as needed. The MAR was not signed off on 1/10/24 on either shift, 1/11 on either shift and 1/12 on 7PM-7AM shift, 1/15 on 7AM-7PM , 1/17 on & AM -7PM, 1/21 7PM-7AM, 1/22 &PM-7 AM, or 1/27/24 on 7PM-7AM shift. Resident #9 On 1/31/24 at approximately 2:00 PM a review of the Treatment Administration Record (TAR for Resident #9 for the month of January 2024 was conducted. There were multiple treatments not signed on the TAR and no explanation recorded in the medical record to explain the missed treatments. On 1/30/24 at approximately 4:00 PM an interview was conducted with Resident #9. He indicated that receiving staff assistance takes a long time. He said everything does not always get done as it should. The resident indicated that he does not always get all prescribed treatments or assistance with getting up out of bed. He explained that the staff will say that he is asleep and refuses but that is not the case. Resident #9 had a physician order to receive nystatin powder1000 under bilateral breast and abdominal folds twice daily as needed antifungal topical preventative. The Treatment Record (TAR) was not signed off on 1/1, 7PM-7AM shift, 1/2 7PM-7AM shift, 1/4 7 PM-7 AM shift, 1/6 7AM-7PM shift, 1/8 both shifts, 1/9 7PM-7AM shift, 1/11 7PM-7AM shift, 1/12 7AM-7PM shift, 1/14 7PM-7AM shift, 1/15 7 AM-7PM shift, 1/17 7 AM-7 PM shift, 1/18 either shift, 1/20 7 AM-7PM, 1/21 7PM-7AM shift, 1/22 7 AM-7 PM shift, 1/23 7 AM-7 PM, 1/24 neither shift, 1/24 neither shift, 1/26 7 AM-7 PM, 1/27 neither shift, 1/17 neither shift, 1/28 neither shift, and 1/29/24 7 PM-7 AM. Resident #9 had a physician order to receive nystatin powder1000 under bilateral knee folds every shift as needed. The TAR was not signed off on 1/1, 7 PM-7AM shift, 1/2 7PM-7AM shift, 1/6 7AM-7PM shift, 1/8 neither shift, 1/9 7PM-7AM, 1/11 7PM-7AM shift, 1/12 7AM-7PM, 1/14 7PM-7AM shift, 1/15 7 AM-7PM shift, 1/17 7 AM-7 PM shift, 1/18 either shift, 1/20 7 AM-7PM, 1/21 7PM-7AM shift, 1/22 7 AM-7 PM shift, 1/23 7 AM-7 PM, 1/24 neither shift, 1/24 neither shift, 1/26 7 AM-7 PM, 1/27 neither shift, 1/28 neither shift, and 1/29/24 7 PM-7 AM. Resident #9 had a physician order to cleanse the area to right buttock and under abdominal fold with normal saline pat dry cover with dry dressing at bedtime. Diagnosis open area. The TAR was not signed off on 1/1, 1/2,1/3, 1/4, 1/8, 1/9, 1/11, 1/12, 1/14, 1/18, 1/21, 1/24,1/25,1/27,1/28, and 1/29/24. Resident #9 had a physician order to receive weekly skin audits during Friday shift on 7PM- 7AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 35 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 shift was not signed off on the TAR on 1/12/24. Level of Harm - Minimal harm or potential for actual harm On 1/31/24 at approximately 3:30 PM an interview was conducted with Nurse N, Registered Nurse (RN) who was also the Unit Manager and facility Infection Preventionist. She was shown the MAR and TARs for resident #211 and #9. RN N explained that the doses should have been addressed and signed by the nurses responsible for giving the medications and treatments or an explanation given on the back of the MAR/TAR. Residents Affected - Some On 1/31/24 a review of the Medication Administration Policy dated 8/7/2023 was conducted. The policy directs nurses to document necessary medication administration /treatment information when the medications/treatments are given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 36 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on staff interviews and record review of the payroll-based journal (PBJ) Staffing Data Reports for Quarter 3 and Quarter 4 2023, the facility failed to accurately submit staffing information to CMS (Centers for Medicare and Medicaid). The findings include: A review of the fiscal year PBJ Staffing Data Report, form 1705D, for the 4th Quarter in 2023 (July 1 September 30, 2023) found low weekend staffing, no Registered Nurse (RN) hours, and a failure to have Licensed Nursing coverage 24 hours a day. On 1/29/24 at 4:11 PM, an interview was conducted with the Administrator. She stated the PBJ was not submitted appropriately. She further stated that it was not possible that the facility did not have an RN or Licensed Nursing coverage from 7/1/23 until 9/16/23. On 2/02/24 at 2:49 PM, a follow up interview was conducted with the Administrator. She stated the PBJ was not properly filled out because the previous owner would not provide the data to the new company's corporate office and would disregard corporate requests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 37 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, staff interviews, resident interviews, and quality assurance performance improvement plan (QAPI) review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to ensuring an adequate supply of clean linens was readily available for resident use and care; ongoing housekeeping and maintenance issues throughout the facility; maintaining essential equipment (washing machines) in good operating order; and infection control processes and training related to laundry processing. Concerns were previously identified with clean linen availability, broken laundry equipment and the QAPI processes during a complaint investigation ending a year ago on 2/02/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11. Citations were issued at F584 (Environment) and F867 (QAPI). The facility had 2 commercial grade washing machines, one broke in December 2022 and the second broke on or before November 2023 (exact dates could not be determined). Soiled laundry (linens, towels, resident clothing, mop heads, rags etc) was being transported to a local laundromat in a pick-up truck bed. Soiled linens were visibly soiled contaminated with feces and urine. The laundromat used both large capacity front loading washing machines and typical household style top-loading washing machines. No information was provided that the washing machines had an extractor (device that removes larger debris). The facility ran out of commercial laundry detergent on 1/28/24 and was observed to be substituting consumer products. The wet laundry was placed in clear plastic bags and transported back to the facility in the same vehicle where it remained bagged until a dryer was available, often the next day. Clean wet linen was observed stored in containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. Cross reference to F835, F880, F908 and F945. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. The findings include: Previous Complaint Survey from 2/2/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11]: During a previous complaint survey conducted on 1/31/23 through 2/2/23, the facility was cited for noncompliance at F584 and F867 for a lack of available linen supply due in part to broken laundry equipment. During the survey, observations of the linen supply closets on 1/31/23 at approximately 11:05 AM found no clean sheets, washcloths, or towels available. Interviews with 4 staff members and 5 residents identified a lack of linens as a concern. On 1/31/23 at approximately 11:18 AM, the Environmental Services Director stated the facility had 1 out of 2 washing machines not functioning. She stated that the facility had ordered parts for the machine. During a follow-up interview on 1/31/23 at approximately 11:51 AM, the Environmental Services Director stated the washing machine had not been functional since about the last week of December 2022. The administrator at that time stated that parts were ordered for the broken washing machine on 1/9/2023. See Statement of Deficiencies Form CMS-2567 dated 2/02/2023, Survey Event ID #8Q7X11. As of the current survey ending 2/02/2024, the facility was unable to provide evidence that the washing machine has been fixed or functioning since December 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 38 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Current Survey, ending 2/2/24: Level of Harm - Immediate jeopardy to resident health or safety During the initial tour, 4 residents were observed without pillowcases on their pillows and 2 without sheets on their bed. Cleanliness and maintenance issues were identified in numerous resident rooms, 3 residents and/or family members described laundry concerns (cross reference F908, F584 and F880). Both facility washing machines had been broken since at least November 2023, and the facility was transporting soiled laundry to a local laundromat and then transporting the clean, wet linen back to the facility for drying (cross reference F908). An observation of laundry processes on 2/1/2024 beginning at 10:21 AM, which found the laundry area disorganized and evidence of cross contamination was observed. Some of the concerns included soiled linen piled on the concrete floor and in bags in both the soiled area and outside on the grounds. Clean wet linens were bagged up and placed in bins labeled Soiled Linen, and piled outside on a wooden pallet awaiting to be dried (cross reference F880). A lack of staff training related to laundry procedures was identified (cross reference F945). Residents Affected - Many On 02/02/24 at 1:29 PM, an interview regarding Quality Assurance and Program Improvement (QAPI) processes was conducted with the Administrator and the Director of Nursing (DON), who stated the QAPI team meets quarterly and as needed, with the most recent meeting on 1/16/24. The sign in sheet was provided. The Administrator stated the Maintenance and Housekeeping staff responsible for laundry attend each meeting as well. When asked how the QAPI process is implemented in order to resolve an issue, the DON stated they do ad hoc QAPI meetings and create a performance improvement plan, and the plan stays open until the issue is resolved. The DON stated if the issue is not resolved, then they add additional interventions and extend the date of completion. The QAPI team was asked what has been done to address the issue of not having laundry services available in the building. The staff replied that the facility has hired additional laundry staff and created a different drop time schedule so they could provide linen at different times throughout the day. She stated they do audits of laundry in the clean linen room as to what linens are available and communicate with the Environmental Director, who tells us what she ordered as far as linens each month and orders more. The QAPI team was asked about the issues with washing the linens, and they replied that they have been working with corporate to get the part for the washer that has been broken for over a year and have finally purchased a refurbished washing machine to replace the second and final washer. In the meantime, they have been transporting the clothes and linens to the local laundromat. The QAPI team was asked to provide evidence that the laundry issues had been discussed in QAPI since December 2022. The Administrator stated that the previous owner would not cooperate with purchasing the equipment or share any information related to previous QAPI meetings/discussions. The Administrator was asked about the part for Washer 1 that was supposed to arrive back in December 2023; the Administrator replied that the wrong part arrived and they had to again order the correct part, which still has not been delivered. The Administrator provided meeting minutes from 1/16/24, which revealed the QAPI team discussed linen inventory, were notified by Corporate that the washing machine was ordered and a check was cut on 1/15/24 for the new machine. There were no other details about the status of the washing machine purchase and the purchase of the part for the first washer that had been inoperable since December 2022. Review of the invoice dated 1/15/24 revealed a Certified Used Washer was purchased for $6989.99 with anticipated deliver in February 2024. Review of an email dated 11/30/23 at 9:19 AM revealed order #1000729908 for the part to fix Washer 1 was paid via credit card in the amount of $1596.45 with an expected delivery between 12/11/23 and 12/18/23. This part had not yet arrived. The Administrator and DON confirmed the QAPI process for ensuring the laundry equipment was addressed failed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 39 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 The Administrator was unable to provide any QAPI agendas or other QAPI evidence from monthly QAPI meetings between February 2023 and January 2024. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 40 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Based on observation of laundry storage and laundry procedures, staff interviews, review of facility laundry policy, facility laundry inservices, and a review of the Centers for Disease Control (CDC) guidelines, the facility failed to ensure that facility textiles and resident clothes were stored, sorted, processed and transported in a manner to prevent cross-contamination in accordance with facility policy and recommendations by the CDC. The facility failed to ensure that the facility's Infection Preventionist had oversight of the laundry procedures. The facility failed to update their laundry procedures to ensure hygienic laundry after both facility washing machines failed, and the facility made the determination to utilize a local laundromat. This failure had the potential to affect all 68 residents at the time of the survey. Additionally, the facility failed to ensure appropriate infection control practices were followed for 1 of 1 fingerstick blood glucose checks observed (Resident #10). Residents Affected - Many The facility had 2 commercial grade washing machines, one which became non-functional in December 2022 and the second which became non-functional in November 2023. Soiled laundry (linens, towels, resident clothing, mop heads, rags, etc.) were observed being transported to a local laundromat in the bed of a pick up truck. Soiled linens were visibly contaminated with feces and urine. The laundromat had both large capacity front loading washing machines and typical household style top loading washing machines. No information was provided that the washing machines had an extractor (device that removes larger debris). The facility ran out of commercial laundry detergent on 1/28/24 and was observed to be substituting consumer household-grade products. The wet laundry was placed in clear plastic bags and transported back to the facility in the same vehicle where it remained bagged until a dryer was available, often the next day. Clean wet linen was observed stored in containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. The laundry situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. Cross reference to F835, F867, F908 and F945. The findings include: On 1/29/24 at approximately 12:10 PM, during the initial facility tour, soiled wet towels were observed on the floor in the shower room. The shower room was not in use at the time. (Photographic evidence obtained) On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor, who stated that facility textiles and resident laundry was being processed at a local laundromat [by facility staff]. He stated that this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting but it has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out about November of 2023, the facility was left with no operating washing machines. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering resident clothing and linens. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 41 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 On 1/31/24 at approximately 11:00 AM, an interview was conducted with an anonymous direct care staff member. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate. Frequently there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. Residents Affected - Many On 2/1/24 at approximately 10:00 AM, during a resident care observation, staff did not have a clean fitted sheet to apply to the bed for Resident #9. The surveyor followed Licensed Practical Nurse D (LPN D) to each of the two indoor laundry storage rooms. Each of the 2 indoor clean linen storage areas had very little clean laundry available. The shelves were mostly bare and there were no fitted sheets in any of the indoor storage areas to apply to Resident #9's bed. On 2/1/24 at approximately 10:21 AM, Certified Nursing Assistant (CNA) F then escorted the surveyor outside of the facility to check for clean linen in the facility laundry room. Laundry Worker A was observed sitting on a bucket sorting loose linen that was saturated with urine and feces. The linen was piled on the concrete floor in the soiled linen room. Laundry Worker A was wearing gloves, but had no other personal protective equipment (PPE) over her clothing. There was another large pile of resident clothes mixed with soiled linen lying on the concrete floor in the corner behind Laundry Worker A and 4 bags of soiled linen in front of her. There was a portable rack that had both hanging clothes and partially folded clothes in an attached metal linen basket in the soiled laundry room. The hanging and partially folded clothes were clean. The small sink in the room was surrounded by laundry and inaccessible for handwashing. Used gloves were laying on the concrete floor next to the soiled laundry. Outside of the soiled laundry room there were 2 bins labeled soiled laundry containing bags of soiled laundry. There were 11 clear garbage bags of soiled laundry on the ground extending out the open laundry door to the outdoors. Also outdoors, approximately 8 bags containing clean wet linen were observed stacked on a wooden pallet. Additional unbagged linens were observed on top of the bagged linen. There was a broom and a trashcan lid resting on the linen, a box of clean gloves sitting on the pallet and 2 used gloves on the ground next to the pallet along with multiple tree leaves. (photographic evidence obtained) The Environmental Services Manager was in the area at the time of the laundry room observation, and an interview was conducted during the observation. She explained that they had been transporting the laundry to the laundromat in the back of a pickup truck that was parked nearby. The pickup truck bed was observed with dirt and debris, used gloves and had multiple bottles of Tide Simply All in One and household bleach containers. Some of the chemical containers were empty. The Environmental Services Manager explained that the washers have not been working at the facility for several months. She indicated that the facility has had trouble maintaining both washers and dryers over the past year. Since the washers broke, they have been taking laundry to the local public laundromat to wash. The facility will then bring the wet laundry back to the facility to dry 7 days a week. The Environmental Services Manager explained that they ran out of commercial laundry detergent on 1/28/24. They have since been using 1/2 cup of Tide [detergent] and 1/2 cup of bleach per load in the washers at the laundromat. She was unable to verbalize how those amounts were determined. She indicated that the laundromat washers might have a 35-gallon capacity. The surveyor asked if the facility has run out of commercial detergent and laundry sanitizer in the past. The Environmental Services Manager replied yes, and stated they have had to utilize the Tide and bleach in the past when they had run out of commercial detergent and sanitizer. She was asked to describe the type and capacity of the washers at the laundromat. The manager was unable to provide specific information regarding type, manufacture, or recommendations for detergent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 42 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 and/or hot water temperatures for washers at the laundromat. Level of Harm - Immediate jeopardy to resident health or safety On 2/1/24 at Approximately 10:29 AM, when the surveyor entered the clean side of the laundry area where the dryers were located, there were 4 bins of wet laundry waiting to be dried. The bins were labeled Soiled Linen. Clean and dry linen and clothes were being sorted and folded in the same room where these 4 bins were located. The surveyor asked how long those linens have been waiting to be dried. The Environmental Services Manager said they were left over from yesterday at approximately 6:00 PM. Clean resident clothes were folded and sorted on a table that did not have a barrier present. Outside the laundry area, there was a bin marked trash stored next to a cart where clean dry resident clothes were stored. Tree leaves were observed to be underneath the linen. (Photographic evidence was obtained) Residents Affected - Many On 2/1/24 at about 1:20 PM, the surveyor observed the washed wet bagged laundry loaded in the back of the same pickup truck upon return from the laundromat. There was no indication that the bed of the truck had been cleaned after the soiled linen was transported and before the wet washed laundry was loaded. The bed of the truck appeared the same as the prior observation, with dirt, debris, and empty bleach and detergent containers. The Environmental Services Manager was asked about cleaning the truck bed. She indicated that they are wiping out the truck bed using a small bottle of Broadside sanitizer spray. The Environmental Services Manager was asked to provide a list of employees that were assisting with processing laundry. She explained that she, Laundry Worker A, Maintenance Worker K, and the Maintenance Supervisor were assisting with transporting and processing soiled linens at the laundromat. The Environmental Services Manager was asked to provide evidence of training for the employees who were processing laundry for the facility. Evidence of a flash in-service training entitled Infection Control in Laundry dated 4/17/23 (several months before the facility was using the local laundromat) was provided. The accompanying training materials were based on CDC guidance. Three employees signed that they completed the training. Laundry Worker A, another employee who was no longer employed, and Housekeeping Staff Member P were listed as attending these inservices. Maintenance Worker K and the Maintenance Supervisor did not sign that they had received the training. Per the in-service materials, to prevent microbial contamination of laundry equipment staff should: -remove solids such as feces or vomit before the wash/dry cycle. -follow manufacturer recommended temperature, detergent and laundry additive guidelines. -do not leave damp textiles in machines overnight. The inservice advised that a temperature of at least 160 degrees Fahrenheit for a minimum of 25 minutes was commonly recommended for washing laundry. Chlorine bleach becomes activated at water temperatures of 135-145 degrees Fahrenheit. On 2/1/24 at approximately 2:30 PM, during a second interview with the Maintenance Supervisor, he indicated that he had training regarding processing laundry but could not recall exactly when the training occurred or give details related to the training. On 2/1/24 at approximately 3:00 PM, an interview was completed with the Infection Prevention Nurse (IP). She was asked if she does infection prevention rounds around the facility to ensure compliance with infection control processes. The IP explained that she does not do rounds. She explained that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 43 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Residents Affected - Many the Director of Nursing (DON) normally does infection control rounds. The DON has been out from work for several weeks on extended leave. She mentioned the Environmental Services Manager was in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. She was asked how long the facility has had trouble with the laundry equipment. The IP indicated that the facility has had trouble with laundry equipment for over a year. First the dryers were broken and now the washers were not working. She was asked if anyone has made her aware that the facility is out of commercial laundry detergent. The IP indicated that she had not been notified and was not aware. She indicated that there was one small household sized functional washer in the shower room that was purchased previously and she did not know how the washer was currently being utilized. She was asked if anyone at the Health Department was notified that the facility was laundering their textiles and resident clothing at a local laundromat. She reported that the health department had not been notified. The IP nurse was also asked who was responsible for providing education regarding handling laundry. The Infection Control Nurse indicated that she was unsure who did the training, but it was probably the Environmental Services Supervisor. The IP nurse was shown images of bins labeled soiled linen which contained clean wet laundry that had waited all night before being placed in dryers. The Infection Control Nurse indicated that clean linen should never be stored in bins that are labeled soiled linen and that clean linen should be processed in an area that does not contain contaminated laundry. An interview was conducted with the facility Administrator on 2/1/24 at approximately 3:42 PM. She stated she started working at the facility in December of 2023. The washing machines were not working when she started the position. She stated that parts were ordered. She was unable to verbalize when the second washer broke. On 2/1/24, a review of the Laundry Services Policy (dated 12/8/23) was conducted. The policy stated soiled and clean linen should be separated at all times. The policy directed staff not to place clean linen in contaminated areas or transport clean linen in containers designated for soiled linen. The policy directed staff to wash their hands after handling soiled linen and before handling clean linen. Staff should consider all soiled linen to be potentially infectious and handle it with standard precautions. All soiled linen should be placed directly into covered containers designated for soiled linen. Handle soiled linen as little as possible and prevent agitation. Employees sorting or washing linen must wear a gown and gloves. The policy directed employees to not leave damp linen in laundry machines overnight. The policy recommended that staff follow manufacturer instructions (instructions from equipment, detergent, rinses etc.) for all laundry processing. The policy directed staff to keep soiled and clean linen and their respective hampers and laundry carts separated at all times. Mops are to be washed separately from linens and kept in separate laundry carts. Staff processing clean linens were directed to place a barrier on the sorting folding table before placing any clean linen or clothing items. The laundry services policy did not address any procedures regarding utilizing the local laundromat. On 2/1/24 a review of the job description for laundry services workers, undated, was conducted. The job description stated that laundry workers should participate in an in-service training program prior to performing tasks that involve potential exposure to blood, body fluids, or hazardous chemicals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 44 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 Residents Affected - Many A review of the Infection Control Guidelines policy, dated April 2013, was conducted. The policy directed staff members to wear personal protective equipment as necessary to prevent exposure to body fluids and other potentially infectious materials. A review of Policies and Practices-Infection Control (dated October 2018) was conducted. The policy indicated that infection control policies and practices apply equally to all personnel. Objectives of infection control policies and practices are to prevent, detect, and control infections in the facility and maintain a safe sanitary and comfortable environment for personnel residents visitors and the general public. The policy stated that all personnel with be trained on infection control policies and practices upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of resident contact and job responsibilities. The administrator or governing board, through Quality Assurance and Performance Improvement and the Infection Control Committee, has adopted the infection control policies and practices. Inquiries concerning infection control policies or facility practices should be referred to the Infection Preventionist or the Director of Nursing Services. A review was conducted of the Centers for Disease Control and Prevention (CDC) laundry guidelines, Appendix D - Linen and laundry management, accessed on 2/2/24. https://www.cdc.gov/hai/prevent/resource-limited/laundry.html. Under the section, Best practices for linen (and laundry) handling: -If there is any solid excrement on the linen, such as feces or vomit, scrape it off carefully with a flat, firm object and put it in the commode or designated toilet/latrine before putting linen in the designated container. -The effectiveness of the laundering process depends on many factors, including: time and temperature; mechanical action; water quality (pH, hardness); volume of the load; extent of soiling model/availability of commercial washers and dryers -Always use and maintain laundry equipment according to manufacturer's instructions. -Best practices for personal protective equipment (PPE) for laundry staff: a. Practice hand hygiene before application and after removal of PPE. b. Wear tear-resistant reusable rubber gloves when handling and laundering soiled linens. c. If there is risk of splashing, for example, if laundry is washed by hand, laundry staff should always wear gowns or aprons and face protection (e.g., face shield, goggles) when laundering soiled linens. Best practices for laundering soiled linen: a. Follow instructions from the washer/dryer manufacturer. b. Use hot water (70-80°C for 10 minutes) [158-176°F]) and an approved laundry detergent. c. Disinfectant are generally not needed when soiling is at low levels. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 45 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 d. Use disinfectant on a case by case basis, depending on the origin of the soiled linen (e.g., linens from an area on contact precautions). e. Dry linens completely in a commercial dryer. Best practices for management of clean linen: Residents Affected - Many a. Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. b. Each floor/ward should have a designated room for sorting and storing clean linens. c. Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (e.g., at least once daily) cleaned with a neutral detergent and warm water solution. Blood Glucose Monitoring: On 1/30/24 at 11:30 AM, Registered Nurse O (RN O) was observed performing a blood glucose check on Resident #10. RN O was observed washing her hands, then touching the bathroom door and then donning gloves. After gloves were donned, RN O touched the diabetic flow sheet, gathered alcohol wipes, glucometer strip, gauze and lancet, and placed them on top of a paper towel. She wiped the glucometer with disinfectant wipes, placed the glucometer on top of the paper towel, and then used gauze to dry the glucometer within a few seconds of wiping the glucometer with the disinfectant. She doffed gloves, followed by donning new gloves and grabbed the glucometer, alcohol wipe, lancet and glucometer strip. She entered the resident's room and placed the glucometer on the resident's bed cover. On 01/30/24 at 11:40 AM, an interview was conducted with RN O regarding infection control concerns observed during the blood glucose check. RN O stated she should have been careful not to touch the bathroom door after washing her hands, or wash her hands again before donning gloves. She further stated she should have left the glucometer air dry instead of using the gauze and she should have not left the glucometer on top of the resident's bed cover, instead, she should have used a clean surface. A review of disinfectant product instruction found a recommended 3 minute wet contact time. A review of the facility's skill competency assessment for glucometer, undated, stated to inspect, clean and disinfect the glucometer utilizing disinfectant wipe per manufactures recommended wet time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 46 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0908 Keep all essential equipment working safely. Level of Harm - Immediate jeopardy to resident health or safety Based on observations, resident interviews, staff interviews, ombudsman interview, and review of facility provided documentation, the facility failed to maintain 2 of 2 laundry washing machines in good repair. Both of the facility washing machines have been non-functional since at least November 2023 (exact date could not be determined). The first washing machine became non-functional in the month of December 2022 (exact date could not be determined) and remained broken. Staff were unable to demonstrate the specific date the second washing machine broke. Invoices indicated that parts were ordered both in September 2023 and November 2023. Observations found a lack of readily available linens in 2 of 2 linen closets, resident beds with missing sheets and pillowcases, residents observed without a change of clothing in their closets, and residents wearing hospital gowns. This failure had the potential to affect all 68 residents residing in the facility at the time of the survey. Residents Affected - Many Due to the lack of washing machines, facility staff were transporting soiled laundry to a local laundromat for washing, then bringing the wet laundry back to dry. However, not all the wet laundry could be dried at once, so some of the clean wet laundry was stored wet, often overnight. The laundry was not being handled, stored, processed, and transported in a manner to prevent the spread of infection. Soiled laundry was observed on the ground and in bins in facility shower rooms and in the dirty side of the laundry room. Soiled laundry was also observed in clear plastic bags in both the laundry room and outside on facility grounds waiting transport to the laundromat. Soiled linens were visibly contaminated with feces and urine. Washed linen was placed in clear plastic bags for transport back to the facility for drying. The bags of wet washed linen were observed inside containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. The lack of washing machines has affected the quality of life for residents, in that they have to wear hospital gowns and/or the same personal clothing on repeated days because their personal clothing has not returned from the laundry timely. Additionally, the residents showering frequency was affected by the availability of clean linens in the facility. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. Cross reference to F835, F867, F880 and F945. The findings include: Previous Complaint Survey from 2/2/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11]: During a previous complaint survey conducted on 1/31/23 through 2/2/23, the facility was cited at for noncompliance at F584 for a lack of available linen supply. During the survey, observations of the linen supply closets on 1/31/23 at approximately 11:05 AM found no clean sheets, washcloths, or towels available. Interviews with 4 staff members and 5 residents identified a lack of linens as a concern. On 1/31/23 at approximately 11:18 AM, the Environmental Services Director stated the facility had 1 out of 2 washing machines not functioning. She stated that the facility had ordered parts for the machine. During a follow up interview on 1/31/23 at approximately 11:51 AM, the Environmental Services Director stated the washing machine had not been functional since about the last week of December 2022. See survey Statement of Deficiencies Form CMS-2567 dated 2/2/2023, Survey Event ID # (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 47 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0908 8Q7X11. Level of Harm - Immediate jeopardy to resident health or safety Current Survey, 2/2/2024: Residents Affected - Many On 1/29/24 between 11:15 AM and 11:50 AM, during an initial tour of the facility, linen issues were observed. Resident #54 had no pillowcase on the pillow, and the pillow fabric cover was shredded. Resident #16's bed sheet appeared dirty with a grainy like matter and there was no pillowcase on the pillow. Resident #30 had a pillow without a pillowcase. Resident #45 had no pillowcases on the pillows. Residents #1, #9, and #211 were observed to be wearing hospital style gowns. Resident #9 preferred to wear their own clothing; however, their personal clothes were not returned from the laundry. Additionally, Resident #9 had no pillowcases on his pillows and no bottom sheet on his bed. Instead, Resident #9, who had a history of pressure ulcers, was observed laying on top of a blanket without bed sheets on the bed. Resident #211 had no sheets on their bed. During the observations, a resident in the hallway could be heard asking staff if today was the day that he could wash his clothes, and a staff member was heard asking another staff member if they would go check in the outside storage area to bring in more sheets. On 1/29/24 at 12:00 PM, an interview was conducted with Resident #46. She stated her only concern was related to the non-functional washing machines. She further stated sometimes it took 10 days to get back her clothes and, because of that, she had to wear the same clothes a couple of extra days. On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor. He indicated that facility textiles and resident laundry was being processed at a local laundromat [by facility staff]. He mentioned that he has been helping with processing laundry on the weekends, and that the task is disgusting but has to be done. He indicated that the facility has had issues with processing laundry for a long time, at least 3 months, ever since the only remaining working washing machine went down. Prior to this, the facility had another washing machine that went down, and they had been waiting on a part they ordered to arrive for about 9 months. When the second machine went out, the facility was left with no operating washing machine, since about November of 2023. On 1/29/24 at approximately 2:50 PM, an interview was conducted with Resident #9, who had been observed during the initial tour. Resident #9 continued to have a blanket under him instead of a sheet, and he was wearing a hospital gown. Resident #9 stated that the facility often runs out of sheets. He said the church gave him sheets to use, but the facility does not keep up with laundry. He indicated that he does not like wearing the gown and wanted staff to assist him to change into his clothes. The next day, on 1/30/24 at approximately 10:00 AM, Residents #1, #9, and #211 were again observed wearing hospital gowns. Residents #9 stated he preferred to wear his own clothing; however, his personal clothes had not returned from the laundry. On 1/31/24 at 9:34 AM, an interview was conducted with Staff B, a Licensed Practical Nurse (LPN). She stated she had concerns about the lack of linens. She states it had been going on for a long time. On 1/31/24 at 9:49 AM, an interview was conducted with Staff N, a Registered Nurse (RN). She stated the facility had been saying they were going to fix the washing machines before the new company took over, but it was not being done. She further stated it used to take 3 days to turn around laundry and now was 1 to 2 weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 48 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0908 Level of Harm - Immediate jeopardy to resident health or safety On 1/31/24 at approximately 11:00 AM, an interview was conducted with an anonymous direct care staff member. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate. Frequently there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. Residents Affected - Many On 01/31/24 at approximately 2:30 PM, an interview was conducted with the significant other of Resident #211. She was asked if the resident preferred to wear a patient gown. She indicated that he prefers to wear his own clothing. The surveyor inquired about the pillows without pillowcases and mattress without a sheet on it. Resident #211's significant other indicated that the facility has seemed to be short on linen since he was admitted about 3 weeks earlier. On 1/31/24 at approximately 4:50 PM, neither Residents #23 nor Resident #47 had a change of clothes available in their wardrobes. On 2/1/24 at approximately 9:00 AM, Residents #23 and #47 were observed wearing the same clothes as the previous day. On 2/1/2024 at 7:44 AM, the local Long Term Care Ombudsman reported laundry issues at the facility during visits on 1/5/2024 and 1/11/2024. During the visit on 1/05/2024, Resident #13 reported that the facility did not have enough clean linens. Resident #13 reported that the lack of linens was reducing the number of showers, and caused issues getting back to bed because they had to wait on linens. During her visit of 1/05/2024, the Ombudsman assisted Resident #13 in filing a grievance. During a follow-up visit on 1/11/2024, neither the Administrator nor the Director of Nursing could find the grievance, so the Ombudsman assisted Resident #13 on completing them a second time. On 2/01/24 at 9:24 AM, two days after the initial tour, Resident #16 was again observed to have pillows without pillowcases and Resident #45 had 2 pillows placed on top of a wheelchair without pillowcases. On 2/1/24 at approximately 10:00 AM during a resident care observation, staff did not have a clean fitted sheet to apply to the bed for Resident #9. The surveyor followed Licensed Practical Nurse D (LPN D) to each of the two indoor laundry storage rooms. Each of the 2 indoor clean linen storage areas had very little clean linens available. The first indoor storage room had about 4 bed pads, three top sheets, 3 bed spreads, 15 towels, 1 patient gown and a stack of wash cloths. The other indoor linen storage area had about 5 patient gowns, about 30 towels, three bed spreads, 1 stack of bed pads and about 15 flat sheets. The shelves were mostly bare and there were no fitted sheets in any of the indoor storage areas to apply to Resident #9's bed. (photographic evidence obtained). An interview was conducted with the facility Administrator on 2/1/24 at approximately 3:42 PM. She stated she started working at the facility on December of 2023. The washing machines were not working when she started the position. She stated that parts were ordered. The Administrator was unable to provide exact dates for when each washer became non-functional. She was asked to provide dates that machines broke along with invoices regarding repairs. The Administrator provided some emails indicating the status of machine part orders. The first email was dated 9/21/23 to the previous administrator stating a screen kit, washer extractor keyboard, mini switch, microswitch drive and a fuse had been delivered. On 10/9/23 there is an email indicating that a 3-inch drain valve was shipped to the facility. An email on 11/14/23 indicating parts on backorder. There was also an invoice for a certified used washer ordered on 1/15/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 49 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/29/24 at 1:00 PM, a telephone interview was conducted with the daughter of Resident #311. She stated her father was admitted to the facility on [DATE] from the hospital following a stroke. She stated that she brought him home the very next day on 11/15/23 because her father called her screaming Get me out of here. She stated there were roaches in her father's room, and the room was so filthy she felt she had to clean it upon her father's admission. Residents Affected - Few Based on observations, resident and family interviews and staff interviews, the facility failed to maintain an effective pest control program. The findings include: On 1/29/24 at approximately 11:30 AM, Resident #10 was interviewed. The resident stated that she saw the large kind of roaches in her room last night. On 1/29/24 at approximately 1:00 PM, an interview was conducted with Resident #40. He complaint of seeing roaches in his room all the time. He indicated that someone comes out to spray, but stated that the man who comes out to spray never comes into resident rooms when he is here. On 01/30/24 at 09:23 AM, a roach was observed in room [ROOM NUMBER]. An interview was conducted immediately with staff BB, a certified nursing assistant (CNA), who was in the room at the time. When asked if she sees roaches often, CNA BB replied, Roaches are a common problem here. CNA BB also stated that roaches are seen daily. Per CNA BB, housekeeping has just three employees, and they cannot keep up. She also stated, I clean every day because the residents deserve better, I can't just walk away from a room that is filthy or let them use a restroom that has urine on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 50 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0945 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on observation of laundry storage and laundry procedures, staff interviews, review of facility laundry policy, and facility laundry staff training, the facility failed to ensure that staff were trained in infection control processes related to the laundering of linens and resident clothing to prevent cross-contamination. Both of the facility laundry machines (2 of 2) have been non-functional since at least November 2023. Facility staff are transporting soiled laundry to a local laundromat for washing, then bringing the wet laundry back to dry. However, not all the wet laundry could be dried at once, so some of the clean wet laundry was stored wet, often overnight. The laundry was not being handled, stored, processed, or transported, in a manner to prevent the spread of infection. On 2/1/2024, clean wet linens were observed in clear plastic bags that were stored inside bins labeled Soiled Linen and clean wet linens were observed outside stacked on a wooden pallet. Dirty linens were observed on the floor in both a shower room, and piled on the floor on the dirty side of the laundry room, and in clear bags both inside the laundry room and outside on the facility grounds awaiting transport to the laundromat. The facility failed to ensure that the facility Infection Preventionist had oversight and provided training for laundry procedures. This failure had the potential to affect all 68 residents at the time of the survey. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. Cross reference F835; F867; F880 and F908. The findings include: On 1/29/24 at approximately 12:10 PM, soiled wet towels were observed on the floor in the shower room. The shower room was not in use at the time. (Photographic evidence obtained) On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor who stated that facility textiles and resident laundry was being processed [by facility staff] at a local laundromat. He stated this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting, but it has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out, the facility was left with no operating washing machine since about November 2023. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering of resident clothing and linens. On 2/1/24 at approximately 10:21 AM, Certified Nursing Assistant (CNA) F escorted the surveyor outside of the facility to the facility laundry room. Laundry Worker A was observed sitting on a bucket sorting loose linen that was saturated with urine and feces. The linen was piled on the concrete floor in the soiled linen room. Laundry Worker A was wearing gloves, but had no other personal protective equipment (PPE) over her clothing. There was another large pile of resident clothes mixed with soiled linen lying on the concrete floor in the corner behind Laundry Worker A and 4 bags of soiled linen in front of her. There was a portable rack that had both hanging clothes and partially folded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 51 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0945 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many clothes in an attached metal linen basket in the soiled laundry room. The hanging and partially folded clothes appeared clean. The small sink in the room was surrounded by laundry and inaccessible for handwashing. Used gloves were laying on the concrete floor next to the soiled laundry. Outside of the soiled laundry room there were 2 bins labeled soiled laundry containing bags of soiled laundry. There were 11 clear garbage bags of soiled laundry on the ground extending out the open laundry door to the outdoors. Also outdoors, approximately 8 bags containing clean wet linen were observed stacked on a wooden pallet. Additional unbagged linens were observed on top of the bagged linen. There was a broom handle resting on both the bagged and unbagged linen, a trash can lid resting on the bagged linen, a box of clean gloves sitting on the pallet and 2 used gloves on the ground next to the pallet along with multiple tree leaves. The Environmental Services Manager was at the time of the laundry room observation, and an interview was conducted during the observation. She explained that they had been transporting the laundry to the laundromat in the back of the pickup truck that was parked nearby. The pickup truck bed was observed with dirt and debris, used gloves and had multiple bottles of Tide Simply All in One and household bleach containers. Some of the chemical containers were empty. The Environmental Services Manager explained that the washers have not been working at the facility for several months. She indicated that the facility has had trouble maintaining both washers and dryers over the past year. Since the washers broke, they have been taking laundry to the local public laundromat to wash. Then bringing the wet laundry back to the facility to dry 7 days a week. The Environmental Services Manager explained that they ran out of commercial laundry detergent on 1/28/24. They have since been using ½ cup of Tide [detergent] and ½ cup of bleach per load in the washers at the laundromat. She was unable to verbalize how those amounts were determined. She indicated that the laundromat washers might have a 35-gallon capacity. The surveyor asked if the facility has run out of commercial detergent and laundry sanitizer in the past. The Environmental Services Manager replied yes, and stated they have had to utilize the Tide and bleach in the past when they had run out of commercial detergent and sanitizer. She was asked to describe the type and capacity of the washers at the laundromat. The manager was unable to provide specific information regarding type, manufacture, or recommendations for detergent and/or hot water temperatures for washers at the laundromat. On 2/1/24 at Approximately 10:29 AM, when the surveyor entered the clean side of the laundry area where the dryers were located, there were 4 bins of wet laundry waiting to be dried. The bins were labeled Soiled Linen. Clean dry linen and clothes were being sorted and folded in the same room where these 4 bins were located. The surveyor asked how long those linens have been waiting to be dried. The Environmental Services Manager said they were left over from yesterday at approximately 6:00 PM that had not yet been dried. Clean resident clothes were folded and sorted on a table that did not have a barrier present. Outside there was a bin marked trash stored next to a cart where clean dry resident clothes were stored outside. Tree leaves were observed to be underneath the linen. (photographic evidence was obtained). On 2/1/24 at about 1:20 PM, the surveyor observed the washed wet bagged laundry in the back of the same pickup truck after return from the laundromat. There was no indication that the bed of the truck had been cleaned after the soiled linen was transported and before the wet washed laundry was loaded. The bed of the truck appeared the same as the prior observation, containing dirt, debris, and empty bleach and detergent containers. The Environmental Services Manager was asked about cleaning the truck bed. She indicated that they are wiping out the truck bed using a a small bottle of Broadside sanitizer spray. The Environmental Services Manager was asked to provide a list of employees that were assisting with processing laundry. She explained that she, Laundry Worker A, Maintenance Worker K, and the Maintenance Supervisor were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 52 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0945 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many assisting with transporting and processing soiled linens at the laundromat. The Environmental Services Manager was asked to provide evidence of training for the employees who were processing laundry for the facility. On 2/1/24 at approximately 4:00 PM, a follow-up interview was conducted with the Environmental Services Supervisor who is also the Housekeeping Supervisor. She provided the latest training regarding handling infectious laundry, dated 4/25/2023. Three employees signed that they completed the training. Laundry Worker A, another employee who was no longer employed and Housekeeping Staff Member P. Maintenance Worker K and the Maintenance Supervisor did not sign that they had received the training. Per the in-service materials, to prevent microbial contamination of laundry equipment staff should: -remove solids such as feces or vomit before the wash/dry cycle. -follow manufacturer recommended temperature, detergent and laundry additive guidelines. -do not leave damp textiles in machines overnight. The inservice advised that a temperature of at least 160 degrees Fahrenheit for a minimum of 25 minutes was commonly recommended for washing laundry. Chlorine bleach becomes activated at water temperatures of 135-145 degrees Fahrenheit. The training materials were based on the Centers for Infection Control and Prevention (CDC) guidance. On 2/1/24 at approximately 2:30 PM, during a second interview with the Maintenance Supervisor, he indicated that he had training regarding processing laundry but could not recall exactly when the training occurred or give details related to the training. On 2/1/24 at approximately 3:00 PM, an interview was completed with the Infection Prevention (IP) Nurse who stated that the Environmental Services Manager was in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. The IP nurse was asked who was responsible for providing education regarding handling laundry. The Infection Control Nurse indicated that she was unsure who did the training, but it was probably the Environmental Services Supervisor. The IP nurse was shown images of bins labeled soiled linen which contained clean wet laundry that had waited all night before being placed in dryers. The Infection Control Nurse indicated that clean linen should never be stored in bins that are labeled soiled linen and that clean linen should be processed in an area that does not contain contaminated laundry. On 2/1/24 at approximately 4:36 PM, an interview was conducted with the Administrator. She was asked who provides the education for laundry serves. The Administrator explained that she would find out who is responsible. The Administrator was asked when she last toured laundry area, and replied that she toured the laundry when she first came on board (in December). She stated that nothing caught her eye that was off. The Administrator was shown photographs of laundry on the ground being sorted out of bags. The Administrator stated that it should not be like that, and that she would find out who is responsible for education. On 2/1/24, a review of the Laundry Services Policy dated 12/8/23 was conducted. The policy stated soiled and clean linen should be separated at all times. The policy directed staff not to place clean linen in contaminated areas or transport clean linen in containers designated for soiled linen. The policy directed staff to wash their hands after handling soiled linen and before handling clean linen. Staff should consider all soiled linen to be potentially infectious and handle it with standard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 53 of 54 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 105435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shores Nursing and Rehab Center 220 Ninth Street Port Saint Joe, FL 32456 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 0945 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many precautions. All soiled linen should be placed directly into covered containers designated for soiled linen. Handle soiled linen as little as possible and prevent agitation. Employees sorting or washing linen must wear a gown and gloves. The policy directed employees to not leave damp linen in laundry machines overnight. The policy recommended that staff follow manufacturer instructions (instructions from equipment, detergent, rinses etc.) for all laundry processing. The policy directed staff to keep soiled and clean linen and their respective hampers and laundry carts separated at all times. Mops are to be washed separately from linens and kept in separate laundry carts. Staff processing clean linen were directed to place a barrier on the sorting folding table before placing any clean linen or clothing items. The laundry services policy did not address any procedures regarding utilizing the local laundromat. On 2/1/24 a review of the job description for laundry services workers, undated, was conducted. The job description stated that laundry workers should participate in an in-service training program prior to performing tasks that involve potential exposure to blood body fluids or hazardous chemicals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105435 If continuation sheet Page 54 of 54