Health inspection·April 30, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 4/28/21 at 4:15 p.m. with Staff J, Registered Nurse (RN) revealed that she was assigned to the resident on this day, but that she is a PRN (as needed) nurse, and that the resident was new to her and was unaware as to why the resident's belongings were in a cardboard box. Interview on 4/28/21 at 4:20 p.m. with Staff H, RN, 3:00 p.m.-11:00 p.m. Supervisor, revealed that she was unsure as to when the resident was moved to her current room and was unsure as to why her belongings were being stored in a cardboard box. In an interview on 4/28/21 at 4:23 p.m. with the Social Service Director and the Admissions Director, the Social Service Director reported that the resident was moved to her current room about two weeks ago, and that she was not sure why the resident's belongings were in a cardboard box. She reported that she believes that she may be discharged soon. The Admissions Director reported that when a resident changes rooms all their belongings should go with the resident, and all belongings should be unpacked for the resident. He reported that Resident #77 moved to her current room on 4/14/21, and by now her belongings should have been unpacked. He was unsure as to why her belongings were not unpacked. Review of the facility policy titled, Resident Rights, with a revised date of December 2016, revealed the following: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: ee. retain and use personal possessions to the maximum extent that space and safety permit; Review of the facility policy titled, Quality of Life- Dignity, with a revised date of February 2020, revealed that Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 2 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to implement the care plan for two residents (#49 and #94) out of forty-three residents sampled in regards to ensuring the resident (#49) was not isolated in her room and ensuring the resident (#94) had bilateral floor mats as ordered. Findings included: 1. A review of the admission Record for Resident #49 revealed the resident was admitted to the facility on [DATE] and 9/25/14. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance, unspecified hand contracture, and aphasia following unspecified cerebrovascular disease. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident did not have a Brief Interview of Mental Status score, indicative of severe cognitive impairment. The MDS identified that Resident #49 exhibited physical behavioral symptoms directed toward others, (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 1 to 3 days of the assessment period. The Functional Status indicated that the resident had a range of motion limitation on one side of an upper extremity and both lower extremities. On 4/28/21 at 10:33 a.m., Resident #49's room door was shut. Upon entry the resident was observed alone and sitting in a wheelchair between her bed and the outside wall. The resident's television was not turned on, but the first bed's television was on, playing cartoons and pointed toward Resident #49. The resident's left arm was bent at the elbow with the hand near her neck, the hand was closed with the middle finger crossing over the pointer finger. Both sides of the resident's wheelchair appeared to be in the locked position. An observation at 10:52 a.m. on 4/28/21 indicated that Resident #49 was alone in her room a wheelchair next to the corner of the Packaged Terminal Air Conditioner (PTAC) unit at the end of the bed. The observation revealed a very tight space of maneuverability between the PTAC unit and the footboard of the bed. During an observation at 10:54 a.m. on 4/28/21 Staff W, Certified Nursing Assistant (CNA) was asked why the resident was in her room with the door shut and she stated that she didn't know who had shut the door. The staff member stated the resident could make the corner between the PTAC unit and bed. Staff W demonstrated by pulling the wheelchair (with resident sitting in it) around the corner of the bed, moving the bed slightly. The staff member placed the brakes of the wheelchair in the unlocked position. An observation at 8:55 a.m. on 4/29/21 revealed Resident #49 in her room alone, lying in the bed next to the window. The privacy curtain between the first bed of the room and the resident was pulled to the end of her bed. The first bed's television was playing cartoons and turned toward the resident, the resident's television was not playing. The care plan for Resident #49 indicated that the resident had a communication problem related to (r/t) rarely or never understood or understands r/t cognition/aphasia, dementia and she will reach out and grab at staff and others, usually when she is hungry, thirsty, or needs to rest. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 3 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 - Minimal harm or potential for actual harm Residents Affected - Few interventions regarding the resident's communication problem included, ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position, and wheels locked, Avoid isolation, initiated on 12/6/19. During an interview, on 4/30/21 at 1:40 p.m., with the Director of Nursing (DON), the observation of Resident #49 sitting between the wall and bed was described to her. She stated no that shouldn't happen. She confirmed that the privacy curtain being pulled to the end of the bed with the first bed's television playing was not acceptable. 2. A review of the admission Record revealed that Resident #94 was admitted to the facility on [DATE]. The admission Record included diagnoses not limited to other seizures, unspecified anxiety disorder, and unspecified dementia with behavioral disturbance. The admission Minimum Data Set (MDS), dated [DATE], did not indicate a Brief Interview of Mental Status (BIMS) score as the resident was rarely/never understood. A physician order, dated 3/29/21, identified Floormat to bilateral sides of the bed every shift for fall precaution. An observation on 4/29/21 at 10:25 a.m. of Resident #94 in bed indicated the resident had no floor mats in the room. An observation of Resident #94's room was conducted, at 4/29/21 at 11:05 a.m., with the Activity Director (AD) who also identified herself as a Certified Nursing Assistant (CNA). Resident #94 was in bed at this time. The AD confirmed there were no floor mats in the resident's room. The care plan for Resident #94 identified her as a high risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, vision/hearing problems, and tardive dyskinesia. The interventions related to her high risk of falls included, Floor mats on Floor while on bed, initiated 3/31/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 4 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record revealed that Resident #49 was admitted to the facility on [DATE] and 9/25/14. The admission Record included diagnoses not limited to unspecified hand contracture, and unspecified dementia without behavioral disturbance. On 4/28/21 at 10:33 a.m. Resident #49 was observed sitting in a wheelchair, non-verbal, with a left-hand contracture. The resident's middle finger was crossed over the pointer finger. The resident was not wearing a palm guard on her left hand. An observation on 4/29/21 at 3:24 p.m. revealed that the resident was not wearing a palm guard on her left hand. Review of the active physician's orders (as of 4/29/21) indicated a physician's order, dated 4/20/21, for staff to apply palm guard to left hand daily. On in AM (morning), Off in PM (evening). The Certified Nursing Assistant (CNA) Task documentation did not identify whether or not staff had donned or doffed Resident #49's palm guard. The task report indicated staff to apply palm guard to both hands daily, on in a.m., off in p.m. and was completed on the following: - 4/20/21 at 10:08 p.m. - 4/21/21 at 2:59 p.m. and 9:47 p.m. - 4/22/21 at 2:59 p.m. and 10:30 p.m. - 4/23/21 at 10:59 p.m. - 4/24/21 at 1:37 p.m. and 8:57 p.m. - 4/25/21 at 2:59 p.m. and 9:03 p.m. - 4/26/21 at 2:39 p.m. and 8:33 p.m. - 4/27/21 at 2:45 p.m. and 10:59 p.m. - 4/28/21 at 10:20 p.m. -4/29/21 at 2:18 p.m. The Restorative Task Documentation, April 2021, indicated Restorative staff to apply left palm guards daily as tolerated (as tolerated) on in AM, off in PM. Restorative staff to provide hand hygiene before and after palm guards are applied. Restorative staff to provide range of motion to left hand before donn off and off of palm guard. The task indicated that staff had documented the palm guard on 4/1, 4/2, 4/6, 4/7, 4/11, 4/12, 4/14, 4/15, 4/18, and 4/20/21. The documentation indicated that restorative did not apply Resident #49's palm guard daily, 10 out of 20 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 5 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Staff V, Certified Nursing Assistant (CNA) stated, on 4/29/21 at 3:27 p.m., that she thinks Resident #49 has a splint, and that restorative puts it on her. She stated they usually put the guard in the drawer. The staff member was unable to locate the palm guard in the bedside dresser then looked in the clothes dresser at the end of the resident's bed, and in the top drawer the palm guard was observed. She pulled the guard out of the drawer and it appeared to be stained and dirty looking. Residents Affected - Few The care plan for Resident #49 identified she had an Activities of Daily Living (ADL) Self-care performance deficit related to (r/t) confusion, dementia, limited mobility, limited range of motion (ROM), stroke. The interventions for the resident's ADL deficit included: - Floor CNA to apply palm guard daily on in a.m., off in p.m., initiated 4/20/21. - Restorative staff to apply palm guard to left hand daily to prevent skin impairment due to contraction, initiated 11/23/20. The interventions related to Resident #49's care plan focus for alteration in musculoskeletal status r/t contracture of left hand, decreased ROM to extremities did not address the application of the resident's palm guard. On 4/29/21 at 12:02 p.m., Staff E, Restorative CNA, stated the restorative aides have been back and forth on the floor so she hadn't been working restorative the full five days. This week had only been twice. She reported being pulled to the floor almost daily, four to five times tops we have done restorative this month. During an interview on 4/29/21 at 3:55 p.m., Staff N, Restorative Registered Nurse (RN) stated it was the restorative department's responsibility for putting on splints and/or palm guards until last week; then the responsibility of splints/palm guards was switched to floor nursing, specifically the CNAs. She confirmed Resident #49 was one of three or four residents requiring a palm guard. The staff member stated that the resident did wear her palm guard when restorative was doing it. She confirmed the resident wore one palm guard. The Quarterly Minimum Data Set (MDS) dated [DATE], indicated that Resident #49 had a functional limitation of Range in Motion on one side of her upper extremity and both sides of the lower extremities. The Director of Nursing stated, on 4/30/21 at 1:31 p.m., that she was unaware Resident #49 was ordered a palm guard. She stated she believed that was now the responsibility of the floor aides to put it on, and when the observations of the resident not wearing the palm guard was discussed, she stated that it was a communication problem. The policy titled, Restorative Nursing Services, revised July 2017, indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. The Interpretation and Implementation of the policy indicated, Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Based on observations, record reviews, and interviews, the facility failed to provide restorative services per physician's orders for two residents (#30 and #49) out of the sampled forty-three residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 6 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Findings included: Level of Harm - Minimal harm or potential for actual harm 1. On 04/27/21 at 12:00 p.m., Resident #30 stated that he wanted to get out of bed to keep his legs strong. He stated that he only had therapy for 30 days and was not doing restorative. Resident #30 stated restorative staff are always doing other duties on the floor. He stated this was not fair to him because he was not ready to give up. Residents Affected - Few On 04/28/21 at 11:03 a.m., Resident #30 reported that he had only seen restorative twice since he had been admitted into the facility. He stated that he wanted to stand to help keep his legs strong. Resident #30 stated he had probably been out of bed four times in the last three weeks, and he use to get up every day. He reported he had a stroke on the left side and does not want to get weaker. A review of the admission Record for Resident #30 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of unspecified sequelae of cerebral infarction and other diagnoses that included but were not limited to morbid obesity, left hand contracture, and muscle weakness. A review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15; indicating he was cognitively intact. Section G Functional Status indicated that the resident was totally dependent for bed mobility and dressing with one-person physical assistance, extensive assistance was needed for transfers with two plus persons physical assistance, and extensive assistance was needed for toilet use and personal hygiene with one-person physical assistance. A physician's note dated 03/25/21 revealed that Resident #30 was discharged from therapy to restorative therapy. The resident had the following active physician's order dated 03/23/21: begin restorative nursing functional maintenance program to maintain current level of function 5 times a week as tolerated. The Medication Administration Record for March and April 2021 did not reflect any documentation related to restorative. The Treatment Administration Record for March and April 2021 did not reflect any documentation related to restorative. The POC (Point of Care) Response History report for Resident #30 revealed that restorative was provided for a total of seven days from 3/31/21 to 4/28/21. On 04/29/21 at 4:15 p.m., Staff N, Registered Nurse (RN), reported that she was in charge of the restorative program. She reported that they had three restorative CNAs (Certified Nursing Assistants), but they do not work every day as restorative aides. She stated, Restorative aides have been working the floor a lot. Staff N stated that staff had been pulled to the floor, so the restorative aides had not been functioning as restorative aides. On 04/30/21 at 1:40 p.m., the Director of Nursing (DON) reported that because of staffing; they had been using the restorative aides on the floor. Nurses should contact the doctor to let them know that the restorative aides were being used on the floor and to see if they could lower the order from 5 days to 3 days. The DON confirmed that restorative services were not being provided as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 7 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure weekly weights were obtained following weight loss for two residents (#94 and #27) out of four residents sampled for nutrition. Residents Affected - Few Findings included: 1. Review of the admission Record revealed that Resident #94 was admitted to the facility on [DATE]. The admission Record included diagnoses not limited to gastrostomy status, other seizures, and unspecified dementia with behavioral disturbance. The admission Minimum Data Set (MDS), dated [DATE], identified that the resident had a nasogastric or abdominal feeding tube (percutaneous endoscopic gastrostomy (PEG)) and received more than 51% of her total calories through a tube feeding. The Malnutrition, At Risk of Malnutrition, Morbid Obesity Screening Assessment, effective 3/31/21, indicated that Resident #94 was at risk for malnutrition. The Malnutrition Assessment identified that the most recent weight was 122.4 pounds (#) as of 3/30/21 and a Body Mass Index (BMI) of 20. The initial Nutrition Assessment, dated 4/1/21, indicated the resident weighed 122.4# and had a BMI of 20.4. The Dietitian documented that the resident's current weight was within normal limits (wnl) but low for her age. She noted that the resident was NPO (nothing by mouth) and received all nutrition from tube feed of Jevity 1.5. The assessment noted that staff were requesting the tube feed to continue for 20 hours a day instead of the current bolus. The goals of the Nutrition Assessment were to have no complications related to enteral nutrition, will tolerate enteral nutrition, will not pull on enteral nutrition tubing, have no significant weight changes, and have no skin breakdown. The Dietitian prescribed an intervention for weekly weights (wts) x 4 and to monitor enteral infusion tolerance related to the resident being at risk for inadequate enteral infusion related to bolus interruption as evidence by Registered Nurse stating resident becomes combative when nursing staff tries to administer bolus. A review of the active physician orders, as of 4/29/21, indicated an order, dated 4/13/21, for Weekly weights, nursing to schedule day and time every evening shift every Tuesday (Tue) for weight loss monitoring for 21 days, weekly weights, nursing schedule day and time. A review of the electronic Weight Summary indicated the following weights: - 3/30/21: 122.4# - 4/5/21: 117.6# The difference in the two weights for Resident #94's was -4.8# loss, or a loss of 3.92% body weight in 6 days while obtaining nutrition via a PEG tube. During an interview on 4/30/21 at 11:46 a.m., the Registered Dietitian (RD) stated she completes a monthly assessment of residents who receive tube feedings and then monthly weights unless there was an issue with the tube feed. The RD reported that new admissions are to be weighed weekly. She stated she had noted her concern with Resident #94's bolus when it was changed to continuous feeding and that she had calculated to ensure there would not be a weight loss when changing from bolus to continuous and had noted her concern. If an order was received to weigh weekly her expectation was for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 8 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm the residents to be weighed weekly. When asked if it would be prudent to get weekly weights when changing from bolus to continuous (feeding) she stated absolutely. On 4/30/21 at 12:21 p.m., the RD provided a weight of 124.2# for Resident #94, that staff had obtained, per her previous request, on 4/30/21 but had not given to her. Residents Affected - Few The care plan for Resident #94, initiated on 3/30/21, indicated the resident required tube feeding related to dysphagia and dementia. The plan instructed staff to monitor weight as recommended. 2. A review of the admission Record revealed Resident #27 was admitted to the facility on [DATE] and 9/2/18. The admission Record included diagnoses not limited to dementia in other disease classified elsewhere with behavioral disturbance, and unspecified obstructive and reflux uropathy. Resident #27's Nutrition Assessment, dated 4/19/21, indicated that the resident weighed 164.2# on 4/5/21 with a BMI of 21.0. The assessment identified that the resident had a gradual weight loss of 9.6%/ 9.8# in 6 months. The Dietary Manager suggested weekly weights x 4 weeks. A review of Resident #27's physician orders indicated an order, dated 4/23/21, for weekly weights. A review of the Weight Summary did not indicate any weights were obtained after 4/5/21. On 4/30/21 at 12:21 p.m., the RD provided a weight for Resident #27 of 163.4# that had been obtained by staff on 4/30/21. The weight indicated Resident #27 continued with a gradual weight loss. During an interview, on 4/30/21 at 12:21 p.m., the RD stated that the previous Certified Dietary Manager (CDM) had done a quarterly assessment of Resident #27, recognized a 9% gradual weight loss over 6 months, and wanted to trend weights. She stated her expectation would be that if the order was written on 4/23/21, a weight would have been obtained at that time and that at this time the facility failed to obtain weekly weights for two opportunities. On 4/30/21 at 10:52 a.m., Staff O, Unit Manager (UM) stated that Certified Nursing Assistants (CNAs) do not chart weights, that they give them to the nurses, and the nurses give them to the RD who inputs the weights in the computer. She reported that to prevent discrepancies, restoratives obtained weights but because of restorative aides having to take floor assignments due to staffing issues, all aides were responsible for obtaining weights. Staff O stated that after the weights are obtained the aides give them to the nurse or to her to put in the computer and then she gives a note to the RD that the weight was already in the computer. She stated that when restorative was getting weights, they were done on Sundays but now when a weight is needed the aides are informed, there was no schedule for getting weights. The residents are weighed at least monthly, and the RD would notify that a weight was needed when they are tracking a resident for weight loss. The RD stated, on 4/30/21 at 12:21 p.m., that if a resident had an order to weigh weekly her expectation was to weigh weekly. She stated she gives a list of residents needing weekly weights to the Director of Nursing and she highlights a census to indicate which residents need weekly weights to restorative. She stated her expectation is that the restorative team gets weights and then gives her the list, which she would input them. She has seen other people putting weights in, but her belief was that only the RD should be putting in weights. She stated when the list was given to the restorative department she doesn't really know if they get it done until she reviews them. The RD stated the staff doesn't really have any way to communicate with her except for the morning meeting. She acknowledged that she was aware of the staff not getting weights, had talked to the Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 9 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (DON), Nursing Home Administrator (NHA), and the Regional Dietitian about the issue. She stated she has talked to the staff scheduler to assure someone was scheduled to get weights and that restorative report that weights are not being done due to restorative staff being assigned to the floor. The DON stated, on 4/30/21 at 1:23 p.m., due to restorative being pulled to floor other staff were able to obtain weights. She stated that weights should be on the aide task or the nurse should be able to tell the aides that weights, monthly or weekly, are needed as they are ordered and should be populated on the Medication and/or Treatment Administration Records. The DON reported that after a resident was admitted they should receive weekly weights then monthly or extend weekly weights if necessary. The policy titled, Weight Assessment and Intervention, revised September 2008, reported that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The policy Interpretation and Implementation section indicated the nursing staff will measure resident weights on admission and weekly for 4 weeks and if no weight concerns are noted at that point, weights would be measured monthly thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 10 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy reviews, and interviews the facility failed to ensure respiratory equipment for two residents (#40 and #94) out of thirty residents who received respiratory treatments was stored in a sanitary manner for three of four days. Residents Affected - Few Findings included: During an interview on 4/27/21 at 12:07 p.m., Resident #40 was observed lying in bed with a Continuous Positive Airway Pressure (CPAP) machine sitting on her bedside dresser. On top of the machine was a CPAP uncovered mask. The resident confirmed using the machine nightly. (Photographic Evidence Obtained) On 4/28/21 at 10:20 a.m., Resident #40 was observed sitting in a wheelchair in front of her bedside dresser. On top of the dresser was a CPAP machine with its mask and tubing sitting on top of it. The mask was not in a labeled bag. On 4/29/21 at 10:25 a.m., an observation indicated the Resident #40's CPAP mask was lying uncovered on top of the machine. A review of the admission Record revealed that Resident #40 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated the resident used a BiPAP/CPAP while not a resident and while a resident. Resident #94 was observed lying in bed, on 4/27/21 at 12:23 p.m., with a working oxygen concentrator sitting on the floor in front of the bedside dresser. On the bedside dresser was a suction machine with tubing attached lying uncovered and an oxygen cannula lying against the machine and under a package of peri-care wipes. (Photographic Evidence Obtained) A review of the admission Record revealed that Resident #94 was admitted to the facility on [DATE]. The admission Record included diagnoses not limited to unspecified dementia with behavioral disturbance and unspecified encephalopathy. The active physician orders, as of 4/29/21, included an order for Oxygen (O2) nasal cannula (NC) 2 liters (L) continuously diagnosis (dx) hypoxia, may titrate up to 93% to keep saturation (sat) >93% every shift for hypoxia. This order was started on 4/13/21 and was discontinued on 4/29/21 at 9:29 p.m. On 4/27/21 at 3:18 p.m. Staff U, Licensed Practical Nurse (LPN) confirmed that Resident #94 was supposed to be on continuous oxygen and that she was not wearing the oxygen. The staff member stated she wasn't on oxygen because her family member was here to visit. The oxygen cannula continued to be stored uncovered on top of the bedside dresser and when asked, Staff U stated yes. She then wound up the tubing and stated it was supposed to in a bag. She searched for the storage bag in the bedside dresser and was unable to locate it. When asked if the suction tubing was supposed to be lying on the dresser, she stated she did not suction the resident. On 4/29/21 at 11:05 a.m., an observation was conducted of Resident #94 with the Activity Director (AD), who identified she was also a Certified Nursing Assistant (CNA). Resident #94 was lying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 11 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sideways in the bed with her head against the top of bed and below the knees were off the bed. She confirmed that Resident #94's oxygen tubing was not being worn and was lying on the floor next to the resident's bed. She also confirmed that Resident #40's CPAP mask should be in a bag, which it was not. On 4/30/21 at 8:20 a.m., the Director of Nursing (DON) stated that resident oxygen equipment should be stored in a plastic bag when not in use. She confirmed Resident #94 was to be on continuous oxygen and that the equipment was not stored appropriately in a bag. The DON reviewed photographs taken of Resident #40's CPAP mask and Resident #94's oxygen cannula and she stated they were not stored appropriately. The facility did not provide a policy regarding the storage of the resident's oxygen equipment by the end of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 12 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to monitor side effects of psychotropic medications for two residents (#30 and #25) and failed to monitor behaviors for one resident (#25) out of the sampled five residents reviewed for unnecessary medications. Residents Affected - Few Findings included: 1. A review of the admission Record for Resident #30 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of unspecified sequelae of cerebral infarction. A review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. Section N Medications revealed that the resident received antipsychotics five days a week and antidepressants four days a week. The resident had the following active physician orders: Desvenlafaxine Extended-Release Tablet 24 hour 50 mg (milligram)- Give 1 tablet po (by mouth) one time a day for depression, start date of 1/22/21. Trazodone HCL Tablet- Give 400 mg po at bedtime for sleep for major depressive disorder, start date of 1/25/21. The Medication Administration Record (MAR) for April 2021 indicated that the medications were given daily as ordered. The MAR and Treatment Administration Record (TAR) for April 2021 did not reflect side effect monitoring. The MAR for March 2021 indicated that the medications were given daily as ordered. The MAR and TAR for March 2021 did not reflect side effect monitoring. A review of the progress notes from 03/01/21 to 04/30/21 did not reflect any notes related to side effect monitoring. The care plan for antidepressants initiated on 01/24/21 reflected interventions that included but were not limited to monitor/document side effects and effectiveness. The care plan for psychotropic medications initiated on 01/28/21 reflected interventions that included but were not limited to monitor/document side effects and effectiveness. 2. A record review of the admission Record for Resident #25 revealed that she was admitted into the facility on [DATE] with diagnoses that included but were not limited to dementia without behavioral disturbance, anxiety disorders, altered mental status, and major depressive disorder. A review of Section C Cognitive Patterns of the MDS dated [DATE] revealed that Resident #25 had a BIMS score of 09 out of 15 indicating she was moderately impaired. Section N Medications indicated that the resident received antipsychotics seven days a week and antidepressants seven days a week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 13 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm A review of the Order Summary Report with active physician orders as of 04/01/21 revealed the following orders: Depakote Tablet Delayed Release 125 MG- Give 125 MG po two times a day for mood disorder, start date of 3/23/21. Residents Affected - Few Donepezil HCL Tablet- Give 1 tablet po for Dementia, start date of 3/3/21. Zoloft Tablet 100 MG- Give 1 tablet po one time a day for major depressive disorder, start date of 3/20/21. The MAR for April 2021 indicated that the medications were given daily as ordered. The MAR and TAR for April 2021 did not reflect side effect and behavior monitoring. The MAR for March 2021 indicated that the medications were given daily as ordered. The MAR and TAR for March 2021 did not reflect side effect and behavior monitoring. A review of the progress notes from 03/01/21 to 04/30/21 did not reflect any notes related to side effect and behavior monitoring. The care plan for antidepressants initiated on 01/25/21 reflected interventions that included but were not limited to monitor/document side effects and effectiveness. On 04/30/21 at 10:31 a.m., the Consultant Pharmacist stated that she would expect to see side effect monitoring if a resident was ordered psychotropic medications. On 04/30/21 at 1:42 p.m., the Director of Nursing (DON) stated that side effect monitoring could be documented on the MAR or TAR. The DON confirmed that side effect monitoring was not documented for Resident #30 and side effect and behavior monitoring was not documented for Resident #25. She stated that side effect and behavior monitoring should be done daily. The policy titled, Behavioral Assessment, Intervention, and Monitoring, provided by the facility and revised 12/2016, revealed the following: Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT [interdisciplinary team] will seek and document any improvements or worsening in the individual's behavior, mood, and function. 4. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 14 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty- eight medication administration opportunities were observed, and twenty-three errors were identified for four (#43, #11, #27 and #3) of six residents observed. These errors constituted a 60.53% error rate. Residents Affected - Some Findings included: 1. On 4/28/21 at 11:32 a.m., an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #43. The electronic medication profile for Resident #43 was observed to be red-colored, which the staff member stated was due to the medications were late. Staff F was observed dispensing the following medications: - Acetaminophen[[NAME] 325 milligram (mg) - 2 tablets - Vitamin C 500 mg tablet - Clopidogrel 75 mg tablet - Docusate Sodium 100 mg softgel - Fish Oil 1000 mg softgel The staff member searched the medication cart for the Calcium - D3 tablet that was also due at 9:00 a.m. but was unable to locate so he documented on the Medication Administration Record (MAR) that the facility was awaiting the medication from the pharmacy. The staff member crushed the tablets, placed them in a 4 ounce drinking cup, poured water in the cup (approximately 2 ounces) then added a spoonful of pudding into the cup and stirred to dissolve the medications. When offered a drink of water from the cup located on her over-the-bed table, at 11:45 a.m., the resident refused by not opening her mouth. Staff F stated that since she refused the water she did not want her medications either. The staff member threw away the drinking cup with medications into the trash can and documented on the MAR that the resident had been administered Acetaminophen, Vitamin C, Clopidogrel, Docusate, and Fish Oil. A review of the Medication Administration Record (MAR) for Resident #43 revealed the above medications and a Calcium-D3 tablet were scheduled to be administered at 9:00 a.m. 2. On 4/28/21 at 11:49 a.m., an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #11. The electronic medication profile for Resident #11 was observed to be red-colored, which the staff member had previously stated that the red indicated that the medications were late. Staff F was observed administering the following medication with the nutritional supplement of MedPass: - Multi-Vitamin with Mineral tablet. A review of Resident #11's Medication Administration Record (MAR) indicated that the above medication was due at 9 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 15 of 27 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 105442 B. Wing (X3) DATE SURVEY COMPLETED A. Building 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm 3. On 4/28/21 at 12:00 p.m., an observation of medication administration with Staff F, RN, was conducted with Resident #27. The electronic medication profile for the resident was observed to be red, which the staff member had previously identified as being late. Staff F was observed administering the following medications: Residents Affected - Some - Acidophilus Lactobacilli 500 million capsule - Vitamin C 500 mg tablet - Baclofen 10 mg tablet - Fluoxetine Hcl 40mg capsule - Levetiracetam 500mg tablet - Oxybutynin 10mg ER tablet A review of the Medication Administration Record (MAR) for Resident #27 revealed the following observed and unobserved medications were scheduled to be administered at 9:00 a.m.: - Acidophilus Lactobacilli 500 million capsule orally two times a day - Vitamin C 500 mg tablet orally two times a day - Fluoxetine Hcl 40 mg capsule orally one time a day - Levetiracetam 500 mg tablet orally two times a day - Oxybutynin 10 mg Extended Release orally one time a day - Artificial Tears Solution 1.4% drops - one drop in both eyes two times a day - Renacidin solution - instill 30 milliliters (mL) into suprapubic catheter (cath) on Wednesdays. - Ferosul 325 mg tablet - give 2 tablets orally two times a day - Gavilax Powder ([NAME]) - give 17 grams orally one time a day, mix in 8 ounces of fluid. After searching the medication cart and following the medication administration, Staff F documented that the facility was awaiting delivery of the Renacidin, Ferosul, and Gavilax medications, which were not observed as administered. 4. On 4/29/21 at 11:37 a.m., an observation of medication administration with Staff G, RN, was conducted with Resident #3. Staff G was observed administering the following medications: - Bumetanide 1 mg tablet - Carvedilol 25 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 16 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - Ursodiol 300 mg capsule Level of Harm - Minimal harm or potential for actual harm - Reglan 5 mg tablet - Lisinopril 10 mg tablet Residents Affected - Some - Levetiracetam 100 mg/mL- 5 mL - Potassium Chloride 10% - 15 mL The observation revealed that Staff G had poured 7.5 milliliters (mL) of Levetiracetam and when asked how much was poured she identified as 7.5 mL then poured 2.5 mL back into the medication bottle, leaving 5 mL to be administered. A review of Resident #3's MAR indicated that the above medications were to be administered at 9:00 a.m. The electronic medication profile for the resident was observed to be red-colored. Staff G stated the medications are late due to her having to administer medications to 30 residents. At 12:07 p.m. on 4/29/21, a continued observation indicated Staff G administering the resident's insulin after obtaining a blood glucose level of 240. - Admelog SoloStar injectable pen 100 units/mL. - 4 units The staff member removed the insulin pen from the medication cart and reviewed the resident's insulin order to be administered according to a sliding scale. The staff member gathered the pen and needle then re-entered Resident #3's room. She applied the needle to the pen, dialed the pen to 4 units, (which was confirmed), cleaned the right upper quadrant with an alcohol pad, then injected 4 units of Admelog insulin. A review of the resident's MAR indicated the insulin ordered was for Humalog 100 unit/mL which the staff member documented a blood glucose of 240 with the administration of 4 units that was due at 11:00 a.m., one hour and seven minutes prior to the observed administration. On 4/29/21 at 12:16 p.m., Staff G was asked if she had primed the insulin pen. A scenario was given to Staff G as expelling the air from the insulin syringe when drawing from vial, similar to expelling the air from the insulin pen. She voiced understanding and stated, Oh with the 2 units, no I did not, I nervous. During an interview on 4/28/21 at 12:32 p.m., the Director of Nursing (DON) stated Ferosul, Gavilax, and Calcium-D3 were available in the medication cart or the med room. On 4/30/21 at 10:09 a.m., the DON stated if medications are late, staff were to call the doctor and notify the doctor that the medications were late. She stated the staff should notify the physician as soon as they see the medication profile turn red and ask if it was okay to give the medication late. She confirmed that the physicians were not notified prior to the late administration of medications on 4/28/21. At 1:20 p.m., the DON stated that regarding late medications, they should have staggered medication times and staff had one hour before and one hour after the scheduled time to administer and re-confirmed that staff were to contact the physician prior to administration. The DON stated they have work to do. On 4/30/21 at 10:32 a.m., the Consultant Pharmacist was interviewed. When asked if her expectation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 17 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was that medications be administered according to the professional standard of one hour before and one hour after the scheduled time, she stated she would have to check the policy. The policy titled, Administering Medications, revised April 2019, identified, Medications are administered in a safe and timely manner, and as prescribed. The Interpretation and Implementation of the policy indicated that medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) and if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The pharmacy policy titled, Preparation and General Guidelines, 2006 American Society of Consultant Pharmacists and Med-Pass (Revised January 2018), indicated Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. According to the prescribing information for the Admelog Solostar insulin pen (https://products.sanofi.us/admelog/admelog.pdf) instructed users to Do a safety test. The instructions identified users should always do a safety test before each injection to: check the pen and the needle to make sure they are working properly and to make sure that you get the correct insulin dose. The steps to do a safety test was to select 2 units by turning the dose selector until the dose pointer was at the 2 mark, press the injection button all the way in and make sure insulin comes out of the needle tip, if no insulin appears users may need to repeat the process up to three times. The information indicated users were not to use the pen after testing and changing the needle if no insulin comes from the tip. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 18 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 observations, record reviews, and interviews the facility failed to ensure that drugs and biologicals were stored in a safe, secure, and orderly manner related to not ensuring medications were inaccessible to residents, unauthorized personnel and/or visitors during two of six observations of medication administration and failed to permanently affix two of two refrigerated narcotic boxes. Findings included: During the task of medication administration on 4/28/21 at 11:32 a.m., after dispensing medications for Resident #43, Staff F, Registered Nurse (RN), walked away from the medication cart to the nursing station, leaving a bottle of Fish Oil, Docusate Sodium, Tylenol (Acetaminophen), Vitamin C, and the blister card of Clopidogrel on top of the cart while it was unattended. On 4/28/21 at 11:49 a.m., Staff F retrieved Resident #11 from near the nursing station and assisted the resident into his room then administered medication to the resident. Staff F left the bottle of Multi-Vitamin with mineral tablets on the medication cart during the administration. After the administration, on 4/28/21 at 12:00 p.m., of Resident #27's medication, two fluid-filled softgels were observed sitting in a medication cup inside of the open trash can attached to the side of the medication cart, which was parked in a resident room hallway. Staff F stated he would normally put the capsules in cellophane and put it somewhere safe. He confirmed the softgels were accessible to others. During an interview on 4/28/21 at 12:32 p.m., with the Director of Nursing (DON), she confirmed that the softgels were accessible. An observation on 4/29/21 at 5:58 p.m., was conducted with Staff H, Registered Nurse / Nursing Supervisor (RN) of Station One Medication Room. A khaki-colored metal box was observed sitting on a grated shelf in the medication refrigerator. The box was easily removed and placed alongside of the room's sink while Staff H unlocked it and exposed the contents. The box contained one brown plastic bag which contained 5 vials of 2 milligram/milliliter (mg/mL) of Lorazepam and one brown plastic bag containing one vial of 2 mg/mL vial of Lorazepam. Staff H confirmed the box was not permanently affixed to the locked refrigerator. On 4/29/21 at 6:25 p.m., the DON and the Interim Nursing Home Administrator confirmed that the refrigerated narcotic box within the Station One Medication room was not permanently affixed to the refrigerator. The DON stated someone could take the box and walk out with it. When asked to see the Station 2 Medication Room's refrigerator, they both reported that the refrigerator was broken so the contents were in the DON's refrigerator. The DON stated she knew that the narcotic box was not permanently affixed to the refrigerator. An observation of the narcotic box from Station 2 indicated that the box was in the refrigerator inside of the DON's office and not permanently affixed and could be easily removed. During an interview, on 4/30/21 at 10:32 a.m., the Consultant Pharmacist stated she could arrange for the narcotic boxes to be permanently affixed to the refrigerators. She stated she was unaware of any statute that required narcotic boxes to be permanently affixed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 19 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 The policy titled, Storage of Medications, revised April 2007, indicated that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 20 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure sufficient staff were available to provide meal assistance for five residents (#20, #52, #54, #55, and #66) during dining services, of 102 residents in the facility, on one of four hallways (the B Hall) for two of two days observed. Findings included: Resident #66 was admitted to the facility with a diagnosis of dementia, according to the face sheet in the admission record. Review of the Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #66 was rarely/never understood, and the Brief Interview for Mental Status (BIMS) could not be conducted, indicating severe cognitive impairment. Section G, Functional Status was reviewed and reflected that Resident #66 required extensive assistance of one staff member for eating. Resident #20 was admitted to the facility with a diagnosis of Alzheimer's disease, according to the face sheet in the admission record. Review of the MDS assessment dated 4/18//21, reflected Resident #20 was rarely/never understood, and the BIMS could not be conducted, indicating severe cognitive impairment. Section G, Functional Status review reflected Resident #20 required extensive assistance of one staff member for eating. Resident #52 was admitted to the facility with a diagnosis of cognitive communication deficit, according to the face sheet in the admission record. Review of the MDS assessment dated [DATE], reflected Resident #52 was rarely/never understood, and the BIMS could not be conducted, indicating severe cognitive impairment. Section G, Functional Status review reflected Resident #52 was totally dependant on staff assistance of one for eating. On 4/28/21 at 12:25 p.m. an observation was conducted during dining services for the lunch meal. Two dining carts were delivered to the B hall. There were four staff members delivering the lunch trays. On 4/28/21 at 12:41 p.m. an observation and interview was conducted on the B hall. Staff C, Certified Nursing Assistant (CNA) was assisting the roommate of Resident #66 with the lunch meal. Staff C, CNA said when she is finished; she will feed Resident #66. Staff C, CNA reported that when she is finished feeding Resident #66 if anyone else hasn't been fed yet, she has to assist them. Further observation on the B hall on 4/28/21 at 12:49 p.m., twenty-four minutes after the dining carts were delivered, revealed Resident #52 did not have a lunch tray. An interview was conducted during the observation, with Staff D, CNA at 12:51 p.m. Staff D, CNA said when she is finished assisting Resident #20 she will assist Resident #52. A review of the face sheet in the admission record for Resident #54 reflected a diagnosis of dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 21 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MDS assessment dated [DATE] revealed that a BIMS could not be completed since Resident #54 was rarely/never understood. Review of Section G, Functional Status, reflected Resident #54 was totally dependent on staff assistance of one person for eating. Resident #55 was admitted to the facility with a diagnoses of cachexia and dementia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] revealed that a BIMS could not be completed since Resident #55 was rarely/never understood. Review of Section G, Functional Status, reflected that Resident #55 required extensive assistance of one person for eating. On 4/29/21 at 12:43 p.m. an observation was conducted on the B hall during dining services for the lunch meal. Two dining carts were on the B hall. On 4/29/21 at 12:59 p.m. an observation revealed a staff member was assisting Resident #52 with the lunch meal. Resident #20, her roommate, had the lunch tray sitting in front of her on the bed side table. On 4/29/21 at 1:01 p.m. an observation was conducted. Residents #54, #55, and #66 did not have their lunch trays. On 4/29/21 at 1:11 p.m. an interview was conducted with the Director of Nursing (DON) during the observation on the B hall. The DON said Residents #54 and #66 need assistance, that's why their trays are still in the cart. The DON confirmed Resident #20 just started getting assistance with her lunch meal. Twenty-eight minutes had passed since the dining carts were delivered. The DON also confirmed Resident #54's lunch tray was still in the dining cart. She said staff can only feed one person at a time, and this hall seems to have more assisted diners. When one resident is being assisted, the other tray is kept on the cart to keep it warm. The DON said that a reasonable wait time would be maybe ten minutes. On 4/30/21 at 11:24 a.m. an interview was conducted with the Registered Dietician (RD) Consultant. The RD consultant said it was her understanding that restorative assists with meals. There should be some way to feed both residents in a room at the same time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 22 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on interviews, record review, observations, menu review, and policy review the facility did not ensure cultural food choices were available for one resident (#61) of 43 residents sampled. Residents Affected - Few Findings included: Resident #61 was admitted with a diagnosis of sepsis according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment, dated 3/1/21, reflected a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #61 was cognitively intact. On 4/27/21 at 12:27 p.m. an interview was conducted with Resident #61. She said the food is always the same. It's green beans or corn every day, and mashed potatoes or pasta. She prefers Latin American food. No one has ever asked her about her preferences. Resident #61 reported that the alternate is a sandwich. A review of the Resident Profile, Company Name, Dietary Management System, dated 12/22/20 reflected no likes or dislikes were indicated for any of the meals. An observation was conducted on 4/27/21 at 12:37 p.m. during the lunch meal. Resident #61's lunch plate had mixed vegetables, mashed potatoes and gravy, roast beef with gravy, a biscuit, a cup of coffee, and fruit cobbler. On 4/28/21 at 12:31 p.m. an observation was conducted during the lunch meal. Resident #61 had scalloped potatoes, a pork chop, lima beans, a roll, a dessert cup, and coffee. A review of the menu for the week of 4/26/21-5/2/21 reflected the following findings: Sunday 4/26/21 lunch included mashed potatoes and gravy Monday 4/27/21 lunch included buttered noodles Tuesday 4/28/21 lunch included mashed potatoes Wednesday 4/29/21 lunch included scalloped potatoes Thursday 4/30/21 lunch included potatoes and carrots Friday 5/1/21 lunch included a baked potato Saturday 5/2/21 lunch included savory noodles Further review of the dinner menu for the week, reflected that on Sunday 4/26/21 the dinner entree was spaghetti sauce with meat balls and spaghetti noodles. The dinner meal on Wednesday 4/29/21 contained macaroni. The dinner meal Thursday 4/30/21 was chicken [NAME] with fettuccini. Further review of the menu for the week of 4/26/21-5/2/21 reflected no Latin American food options or meals were included, and no alternatives were listed as well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 23 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/29/21 at 3:33 p.m. an interview was conducted with the Regional Director of Dietary Services. She said the dietician interviews the residents and asks their likes and dislikes, and it is entered into the system. If they don't like beef for example, they would get chicken. The menus are created through menu management services through Company Name, and sent to us. Then we review them and they are approved. It is a corporate menu. It is reviewed by the RD (registered dietician) and signed off. It is modified by region. For example, Miami has a lot of rice beans and chicken. There is a food committee of residents in every building who look at the menu. If they are on a renal diet they won't get the potatoes they will get noodles. The Regional Director of Dietary Services agreed the potatoes and noodles were not enough variety. On 4/30/21 at 11:24 a.m. an interview was conducted with the RD consultant. She said that she has heard there was a complaint about the variety related to the potatoes and noodles, and no Latino choices. She said she is implementing alternatives that will always be available. She heard the residents want rice and beans. That will always be available. They want salads and fresh produce so we are going to try to implement that ASAP (as soon as possible). We are going to implement a food committee meeting. She has been here about a month and a half, and was not involved in the food committee. The CDM (certified dietary manager) was. As a group they can decide what they want on a particular day. The RD said, I have reached out to my team and asked to review the menu solutions that Company Name provides and see what we can do to increase the happiness of the residents. I was under the impression that the CDM was getting food preferences. The RD consultant said when she sees the residents she will get their likes and dislikes and put them in. She said she would see every resident and document on paper their likes and dislikes. The RD consultant also said the food preferences should be updated at least quarterly. Review of the policy title, Menus, dated 1/15/21, reflected the following: Policy Statement Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Policy Interpretation and Implementation 3. Menu items and available snacks reflect the religious, cultural and ethnic preferences of the residents, whenever reasonable. 4. The dietician reviews and approves all menus. 5. Input from the resident is considered in menu planning. Review of the policy titled, Resident Food Preferences, dated 1/15/21, revealed the following information: Policy Statement Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT). Modifications to diet will only be ordered with the resident's or representative's consent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 24 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 0803 Policy Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm 1. Upon the resident's admission (or within 24 hours after his/her admission) the dietician or nursing staff will identify a resident's food preferences. Residents Affected - Few 2. When possible staff will interview the resident directly to determine current food preferences based on history and life patterns to food and mealtimes. 3. Nursing staff will document the resident's food an eating preferences in the care plan. 8. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. 10. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 11. The facility's Quality Assessment and Performance Improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 25 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 observations, record reviews, and interviews, the facility failed to ensure one of one kitchen was maintained in a clean and sanitary manner, one (Station #2) of two refrigerators in the pantry stations was maintained in a clean and sanitary manner, and temperatures were documented daily for the refrigerators and freezers in two pantry stations (Station #1 and Station #2) of two pantry stations. Findings included: On 04/27/21 starting at 9:50 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The white flap inside of the ice machine was observed with black buildup. The inside of the drink nozzle was observed with white buildup. An excessive amount of black buildup was observed above the food preparation area. An excessive amount of dust was observed on two ceiling vents above the food serving area (Photographic Evidence Obtained). The CDM stated that she spoke to maintenance on Friday (4/23/21), and he stated that he had to order replacement tiles for the ceiling. She then stated she spoke with maintenance about the whole ceiling including the vents. The CDM was asked to provide documentation related to the maintenance request and the document was not provided. Following the tour of the kitchen, observations of Pantry Station #1 and Pantry Station #2 were conducted and revealed: The temperature log for the nourishment refrigerator in Pantry Station #1 was observed to be missing temperatures for April 14th, 16th, 17th, 18th, and 20th-25th. The temperature log for the freezer in Pantry Station #1 was observed to be missing temperatures for April 20th-25th. The CDM stated nursing was responsible for taking the temperatures daily. The temperature log for the nourishment refrigerator in Pantry Station #2 was observed to be missing temperatures for April 2nd, 6th, 18th, and 20th. The temperature log for the freezer in Pantry Station #2 was observed missing temperatures for April 2nd, 6th, and 20th. A brown substance was also observed spilled in the refrigerator. The CDM stated that housekeeping was responsible for cleaning the refrigerators. On 04/29/21 at 12:30 p.m., the Regional Director of Culinary Services stated that the dietary staff was responsible for cleaning the ice machine weekly. She stated that staff should clean the drink nozzles daily. All maintenance requests should be submitted through [Name of the electronic maintenance report system] or verbally to maintenance. The Regional Director of Culinary Services stated, The ceiling should never look like that. A review of the Dietary Cleaning Schedule provided by the facility did not reflect the cleaning of the ice machine and the drink nozzles. On 04/29/21 at 3:47 p.m., the Regional Director of Culinary Services confirmed that the ice machine and drink nozzles were not listed on the cleaning schedule. The policy titled, Refrigeration/Freezer Temperature Log, provided by the facility with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 26 of 27 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 105442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haines City Rehabilitation and Nursing Center 409 S 10th St Haines City, FL 33844 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 effective date of 06/01/04 revealed the following: Level of Harm - Minimal harm or potential for actual harm Policy Residents Affected - Some The Director of Culinary Services will be responsible for implementing and documentation processes on the Refrigerator/Freezer Temperature Log. Process 1. The Director of Culinary Services or designee should ensure that the refrigerator/freezer temperature log is used to record the temperature of all refrigerators and freezers on a daily basis and at routine intervals during all hours of the operation. 4. The Refrigeration/Freezer log should be complete a minimum of twice per day on all refrigeration/freezer equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 27 of 27