Health inspection·January 12, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a facility tour on 01/12/23 at 9:10 a.m., an observation was made of room [ROOM NUMBER]. The observation revealed a dead insect on the floor by Bed A's bedside table. Further observation revealed Bed A's privacy curtain was noted stained with brown marks. An observation was made of dark brown matter spattered on the floor by Bed B and on the adjacent wall. The brown matter was splashed on the resident's clothes that were in a bag by the bed. In addition, during this observation Bed B's dresser was noted broken and not closing properly with clothes spilling out. A trash can by the door was noted overflowing with trash and used gloves. The floor was noted with dirt, dust, and papers. (Photographic Evidence Obtained) On 01/12/23 at 10:11 a.m., an interview was conducted with Staff G, Housekeeping / Floor Technician. Staff G reviewed the photographic evidence and said, That looks really bad. I will take care of it now. Staff G stated resident rooms should be cleaned promptly, at least daily and as needed. Staff G stated he did not know why the aide did not at least pick up the mess off the floor and let Housekeeping know. Staff G stated the brown substance on the floor looked like bowel matter. Staff G stated it was unacceptable. Staff G stated he would go to room [ROOM NUMBER] and clean it right away. On 01/12/23 at 1:34 p.m., an interview was conducted with the Director of Maintenance (DOM). The DOM looked at the room appearance and stated the room was not acceptable. It was not clean per their standards. The DOM said, It should have been cleaned right away. The DOM reviewed the photographic evidence and said, It looks like feces, residents should not have feces on the floors and walls. The DOM stated he expected resident rooms to be maintained in a clean and sanitary manner. On 01/12/23 at 1:48 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the resident in room [ROOM NUMBER] Bed B chewed tobacco and spits it on the floor and walls. The NHA reviewed the resident's care plan which had no documented evidence of on-going concerns with spitting tobacco chews or spitting on the floor. The care plan did not show interventions to address the concern. The NHA stated they would put a plan in place, give the resident a spit bottle and/or a trash can to spit in. The NHA stated he would have housekeeping staff go into the room three times a day to maintain a sanitary environment. The NHA reviewed photographic evidence and stated he would have housekeeping take of it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 2 of 14 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 01/12/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure comprehensive assessments were accurately documented for one resident (#84) of 50 sampled residents. Residents Affected - Few Findings included: A review of Resident #84's admission Record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and mixed receptive-expressive language disorder. A review of the facility's Minimum Data Set (MDS) Resident Matrix revealed physical restraints were used for Resident #84. A review of Resident #84's active physician's orders as of 1/12/2023, revealed an order, dated 8/25/2022 for an electronic monitoring device to the left ankle. A review of Resident #84's physician's orders did not reveal an order for use of physical restraints. A review of Resident #84's Quarterly MDS assessment, dated 10/6/2022, revealed under Section P: Physical Restraints, a physical restraint, categorized as other was used while in bed on a less than daily basis for Resident #84. The assessment also revealed a wander/elopement alarm was not used. An observation was conducted on 1/9/23 at 12:32 p.m. of Resident #84 propelling himself in his wheelchair in the hallway outside of his room. Resident #84 was not observed to have any physical restraints in use and was observed to have an electronic monitoring bracelet to his left ankle. An interview was conducted on 1/12/2023 at 8:23 a.m. with Staff A, Registered Nurse (RN). Staff A, RN stated Resident #84 did not have any physical restraints in use and did not have any orders for physical restraints. An interview was conducted on 1/12/2023 at 10:20 a.m. with Staff B, MDS RN and Staff C, MDS Licensed Practical Nurse (LPN). Staff B, MDS RN stated Resident #84 did not have any physical restraints in use but did have an electronic monitoring device in use. Staff B, MDS RN reviewed Resident #84's Quarterly MDS assessment and stated the physical restraint for Resident #84 was documented in error and the assessment should have reflected Resident #84's electronic monitoring device use. Resident #84 should not have been coded as using a physical restraint. An interview was conducted on 1/12/2023 at 11:06 a.m. with the facility's Director of Nursing (DON). The DON stated no residents in the facility have physical restraints in use. A resident would need a physician's order and an assessment completed for any use of physical restraints prior to use. The DON stated Resident #84 should not have been coded in the MDS assessment as having a physical restraint in use and should have been coded as having an electronic monitoring device in use. A facility policy related to comprehensive assessments was requested on 1/11/2023 at 3:39 PM but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 3 of 14 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 01/12/2023 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 observation, record review, and interview, the facility failed to develop a care plan related to floor mats for one resident (#15) of fifty sampled residents. Findings included: A review of the admission Record revealed Resident #15 was initially admitted into the facility on [DATE] with diagnoses that included but were not limited to dementia, major depressive disorder, and unspecified abnormalities of gait and mobility. Review of Section C Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], indicated the resident was rarely or never understood. On 01/09/23 at 10:50 a.m., Resident #15 was observed sitting on the side of the bed attempting to get out of the bed. The bed frame was observed resting on the floor. A mattress was observed on the floor to the right of the bed and two stacked floor mats were observed on the left side of the bed (Photographic Evidence Obtained). On 01/11/23 at 4:47 p.m., the resident was observed in bed sleeping with the mattress on the right side of the bed on the floor and two stacked floor mats on the left side of the bed on the floor. A review of the Order Summary Report with active orders as of 01/12/2023 did not reveal an order for fall mats. A review of the active care plans revealed Resident #15 did not have a care plan in place related to fall mats. On 01/12/23 at 11:08 a.m., the Director of Nursing (DON) reported Resident #15 had raised floor mats to keep him on a leveled surface. She stated he doesn't necessarily need an order for the floor mats, but it should be on the care plan. On 01/12/23 at 1:00 p.m., the DON reported they did not have a care plan policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 4 of 14 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 01/12/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADLs) related to oral care, were provided for one resident (#91) of five residents sampled. Residents Affected - Few Findings included: During facility tours conducted on 01/09/23 at 12:35 p.m., and 01/10/23 at 12:52 p.m., Resident #91 was observed in her room, laying on her bed. Resident #91's tongue was noted with a white substance all over the surface of her tongue and around her lips. Resident #91's lips were noted dry and chapped on the surface. The resident stated she remains in bed all the time and was dependent on staff for care. On 01/11/23 at 1:43 p.m., an interview was conducted with Resident #91. The resident stated she does not receive oral care every day. Resident #91 said, Some staff will just have me rinse my mouth with water and they do not use a toothbrush or toothpaste. Some of them use a sponge and wipe around the inside of my mouth. Resident #91 stated she did not know if she owned a toothbrush and stated she could she ask her family to bring one, and maybe some have toothpaste. Review of the admission Record for Resident #91 showed the resident was admitted to the facility on [DATE] with the diagnoses to include dysphagia and gastrostomy status. A minimum data set (MDS), dated [DATE], showed under Section C1000 Cognitive Skills for Daily Decision Making that the resident is severely impaired and rarely makes daily decisions. Review of a document titled Point of Care Audit Report showed the Certified Nursing Assistant (CNA) task log for Resident #91's oral care performance. The two-month period reviewed, dates 11/5/22 to 1/5/23 showed Resident #91 was not provided oral care 36 scheduled times. The report showed an expectation to provide oral care once daily per shift /three times daily. A care plan for Resident #91 showed a focus initiated on 9/15/22 related to oral/dental health as a problem related to edentulous. The goal indicated the resident will not have any complications related to oral or dental health problems through the next review date. Interventions included to encourage and assist the resident with oral or dental care as tolerated, to monitor document and report as needed any signs or symptoms of oral/dental problems needing attention, to include lips cracked or bleeding, debris in mouth, tongue coated black, white, inflamed, smooth, and any ulcers/lesions in mouth. An ADL focus initiated 8/24/22 showed a self-care deficit related to chronic medical conditions. Interventions included to encourage and assist with all ADL tasks as indicated, including personal and oral hygiene. On 01/11/23 at 1:52 p.m., an interview was conducted with Staff E ,CNA. Staff E stated they are supposed to complete mouth care for the resident three times a day, typically once per shift. She stated she completes oral care for this resident and uses a toothbrush and toothpaste. Staff E stated she tells the resident not to swallow because she is NPO (nothing by mouth). The CNA sated she is still planning on assisting the resident with oral care today. An immediate tour of Resident #91's room was conducted with Staff E. Staff E could not find the supplies needed to provide oral care for Resident #91. Staff E opened every drawer and said, She should have a toothbrush somewhere. I think she should have the oral brushes too. I don't know why she doesn't have any basin. I will get her some. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 5 of 14 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 01/12/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm On 01/11/23 at 2:30 p.m., an interview was conducted with Staff D, Registered Nurse (RN). Staff D, RN assessed Resident #91's mouth and stated the resident did not have thrush (fungal infection of the mouth). Staff D said, This is a problem with oral care. The CNAs are not cleaning her up. She should not look like this. Staff D stated he would follow -up and make sure oral swabs are provided and care was given as expected. Residents Affected - Few An interview was conducted on 01/11/23 at 2:36 p.m. with Staff F, Licensed Practical Nurse (LPN) Unit Manager. Staff F stated the expectation is for oral care to be provided at least once per shift or as needed. She stated the task is listed on the CNA Task Log to be completed as scheduled. She stated she would evaluate the resident and address the concern. On 01/12/23 at 9:24 a.m. Resident #91 was observed in her room. The resident stated the night before a CNA had cleaned her mouth. The resident stated she felt much better, and she hoped it would continue. Review of a facility policy titled, Activities of Daily Living, ADL's, revised March 2018, showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living, ADL's. Residents who are unable to carry out ADLs independently, will receive the services necessary to maintain good nutrition grooming, personal and oral hygiene. (2.) Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene / oral care. (6.) Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. (7.) The resident's response to interventions will be monitored evaluated and revised as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 6 of 14 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 01/12/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide supervision for smoking and limited access to smoking materials for three residents (#58, #712, and #715) out of ten smokers as evidence by the observation of the three residents smoking unsupervised and the observation of smoking paraphernalia removed from resident rooms. Findings included: 1. An observation was conducted on 1/10/23 at 9:30 a.m., of Resident #58 with Staff H, Registered Nurse (RN). The resident was sitting in the courtyard against the exterior wall of the facility's D-wing. The resident was holding a lit cigarette which had approximately 1 left. An ashtray was not available to the resident in the immediate area. Staff H was the only staff member in the courtyard at the time of the observation and had arrived and then left the courtyard. Staff H did not address the unsupervised smoking with Resident #58. On 1/10/23 at 2:00 p.m. an observation was conducted in the courtyard of three residents (#58, #712, and #715) smoking cigarettes with no staff present in the courtyard. Resident #715 stated the facility kept cigarettes up front. The resident was holding a yellow plastic shopping bag. Resident #58 and #712 were sitting in wheelchairs against the exterior wall of D-wing and not under the covered tables that held metal ashtrays. During the observation, on 1/10/23 at 2:05 p.m., Resident #58 was observed handing an item to Resident #715 and Resident #715 held the item to a cigarette in her mouth. Staff I, Activity Director (AD) arrived to the courtyard with two other residents at 2:05 p.m. on 1/10/23, and she went over and spoke with Resident #58 and #712 then left the area. On 1/10/23 at 2:08 p.m., the AD re-entered the courtyard with a large black box. The AD handed Resident #712 and #715 cigarettes and lit them both with lighter. She was observed passing out cigarettes and lighting them for other residents then handed Resident #58 a cigarette, lit it, and placed cigarettes and lighter into black box. The AD confirmed, on 1/10/23 at 2:47 p.m., that Residents #58, #712, and #715 had been in the courtyard. She stated all smoking material was to be kept with staff, all smoking was supervised, and that no resident was supposed to have smoking material in their rooms. On 1/10/23 at 2:52 p.m., the AD confirmed verbally and visually that she had removed a lighter from Resident #712's room. A moment later, the AD had a yellow plastic bag in her possession and confirmed it contained cigarettes taken from Resident #715's room. The admission Record indicated Resident #58 was initially admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS), dated [DATE], identified the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition. The Admission/re-admission Nursing Packet, dated 9/5/22, indicated Resident #58 did not use smoking/tobacco/nicotine products. The instructions identified that if the score was 10 or greater, the resident should be considered at RISK, needs supervision when smoking, and The smoking protocol should be initiated immediately and documented on the care plan. A review of this section identified that it had not been completed because the first question regarding if the resident used tobacco/nicotine products was answered no and the staff were instructed to STOP HERE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 7 of 14 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 01/12/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Smoking/Nicotine Device evaluation, dated 1/9/23, for Resident #58 identified that Resident #58 used cigarettes, was aware of the Smoking Safety Procedure, and was determined not to need supervision as the additional comments read as: All residents are supervised while smoking. 2. The admission Record identified Resident #712 was admitted on [DATE] with diagnoses not limited to epileptic seizures related to external causes not intractable with status epilepticus and unspecified altered mental status. The Admission/re-admission Nursing Evaluation, dated 12/27/22 indicated that Resident #712 did not smoke. The Cognitive Patterns section of the resident's comprehensive assessment identified a BIMS score of 15 out of 15, indicating an intact cognition. Resident #712's care plan, dated 1/11/23, identified the resident as a smoker and indicated that staff were to provide physical assistance for smoking functions such as lighting, holding, and extinguishing the cigarette/cigar as needed, and to Re-educate resident and/or family on designated smoking times and the designated smoking location. The Smoking/Nicotine Devices evaluation for Resident #712, dated 1/9/23, identified the resident did use cigarettes and the additional comments read as: All residents are supervised while smoking. 3. The admission Record identified Resident #715 was originally admitted on [DATE] and most recently admitted on [DATE]. The record included diagnoses not limited to unspecified sequelae of cerebral infarction, and unspecified intractable epilepsy without status epilepticus. Resident #715's active care plan identified that the resident was at risk for complications related to chronic tobacco use of cigarettes and instructed staff to Educate and remind family/visitors not to give smoking materials directly to the resident and not to leave these materials in resident rooms, to Encourage/remind resident to maintain smoking materials including lighters, matches, etc. at the designated facility location, and Provide physical assistance for smoking functions such as lighting, holding, and extinguishing the cigarette/cigar as needed. The Smoking/Nicotine Devices evaluation, dated 1/9/23, indicated that Resident #715 did use cigarettes and the additional comments read as: All residents are supervised while smoking. A record review of the facility's Smoking Contract Acknowledgement, revealed Resident #58 signed it on 11/15/22 , #712 signed it on 1/9/23, and #715 signed it on 1/9/23. The contract's purpose was To provide residents the privilege of smoking while maintaining their safety and the safety of others. The contract included the following facility policies: -2. All smokers will be assessed upon admission or start of smoking and as their cognitive and/or physical status mandates. -7. Tobacco products will be dispensed one at a time per resident request, with a limit of two cigarettes per supervised break. -8. Absolutely no tobacco paraphernalia and/or tobacco products are to be kept in resident rooms. -13. Smoking paraphernalia for all residents will be secured by staff and labeled with individual resident names. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 8 of 14 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 01/12/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The policy titled, Tobacco Restrictive Policy Acknowledgement, undated Attachment D2, indicated It is the policy of the Facility to discourage any smoking in the facility. However we are also understanding of the fact that as a skilled nursing and rehabilitation facility, some of our residents may choose to smoke. Therefore, the facility will designate an outside smoking area to accommodate the request of those individuals. The purpose of restricting the smoking in the facility is to reduce the effect of smoking to residents who do not smoke, including possible adverse effects on treatment, to reduce the risk of passive smoke, and to, reduce the risk of fire. The policy identified the following: - Staff will dispense the resident's cigarettes, light the cigarette, and stay with the resident until the cigarette is properly extinguished. - All residents smoke with supervision and will do so only in the designated area. - All cigarettes, lighters and any other smoking materials will be kept at the nurses' station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 9 of 14 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 01/12/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide enteral nutrition in accordance with professional standards for one resident (#459) of two residents sampled for enteral nutrition needs. Findings included: A review of Resident #459's admission Record revealed Resident #459 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). A review of Resident #459's active physician's orders revealed an enteral feed order, dated 1/6/2023, for Glucerna 1.5 at 50 milliliters per hour (ml/hr) with water flush at 30 ml/hr for 20 hours, up at 2:00 PM - down at 10 AM. An observation was conducted on 1/10/2023 at 9:35 a.m. of Resident #459 in the resident's room. Resident #459 was observed resting in bed with the head of the bed elevated and enteral feeding running. An observation of Resident #459's enteral feeding pump revealed Glucerna 1.5 was being administered to Resident #459 at a rate of 55 ml/hr with water flush at 40 ml/hr. The same rate was also labeled on the Glucerna 1.5 solution bottle hanging on the enteral feeding pump pole. An interview was conducted on 1/12/2023 at 9:23 a.m. with Staff A, Registered Nurse (RN). Staff A, RN verified Resident #459's enteral feeding order for Glucerna 1.5 at 50 ml/hr with water flushes at 30 ml/hr. Staff A, RN stated nurses were responsible for ensuring the enteral feeding pump's rate is the same as what is order for the resident and stated Resident #459's pump should not have been set to administer Glucerna 1.5 at 55 ml/hr with water flushes at 40 ml/hr. An interview was conducted on 1/12/2023 at 11:14 a.m. with the facility's Director of Nursing (DON). The DON stated she was notified Resident #459's enteral feeding rate was set to a different setting than what was ordered and she was not sure who adjusted the rate for the feeding. The DON also stated nursing staff should be verifying the rate that is set on the enteral feeding pump and ensuring it is the same rate as what is ordered by the resident's physician. Photographic Evidence Obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 10 of 14 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 01/12/2023 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 observation, record review, and interview, the facility, 1. failed to ensure blood pressures were monitored adequately for a period of three months for one resident (#40) of five sampled residents, and 2. failed to ensure one resident (#98) receiving antibiotic treatment had a diagnosis listed, to indicate the purpose of the treatment of four residents reviewed for a UTI (urinary tract infection) diagnosis. Residents Affected - Some Findings included: 1. A review of the admission Record revealed Resident #40 was initially admitted into the facility on [DATE] with a diagnosis that included but was not limited to hypertension. A review of the Order Summary Report with active orders as of 11/01/22 indicated the following order: Hydralazine HCL Tablet 25 MG (milligram)- Give 25 mg by mouth four times a day for hypertension, start date 9/25/22. Hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60. A review of the Medication Administration Record (MAR) for November 2022, December 2022, and January 2023 revealed the medication was administered four times a day from 1/1/23 - 1/11/23, 12/1/22 - 12/31/22 and 11/1/22 - 11/30/22. The MARS did not reflect blood pressures were checked per order. A review of the Weights and Vitals Summary, dated 1/11/23, for blood pressures revealed the following blood pressures taken from 11/1/22 to 1/11/23: 01/06/23 - 131/82 01/04/23 - 110/51 12/04/22 - 128/71 11/30/22 - 128/62. The care plan related to hypertension initiated on 09/27/22 included the following intervention: monitor vital signs. On 01/11/23 at 5:15 p.m., the Director of Nursing (DON) confirmed blood pressures were not being checked per orders. She stated the blood pressures should have been checked four times per day. 2. On 01/09/23 at 2:40 p.m., an interview was conducted with Resident #98's Responsible Party. The Responsible Party stated the resident had a UTI infection and he was not well. Review of the admission Record for Resident #98 showed the resident was admitted to the facility on [DATE]. Review of physician orders for Resident #98, dated 1/10/23, showed Resident #98 was prescribed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 11 of 14 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 01/12/2023 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 Residents Affected - Some Bactrim DS tablet 800-160 mg, give 1 tablet by mouth two times a day for infection for 7 days. Orders initiated on 1/5/23 and with an end date of 1/12/23 showed the resident was being treated for an infection but did not indicate the diagnosis reflecting why the resident was receiving the antibiotic treatment. Review of the Medication Administration Record (MAR) for January 2023 for Resident #98 showed the antibiotic [Bactrim DS tablet 800 - 160 MG), was administered two times a day for an infection for seven days. The MAR did not show the diagnosis. On 01/10/23 at 12:11 p.m., an interview was conducted with Staff D, Registered Nurse (RN) assigned to Resident #98. Staff D stated Resident #98 was taking antibiotic Bactrim. Staff D reviewed the MAR and said, It says infection, I don't know what infection it is specifically, but the doctor usually prescribes it for UTI. Staff D stated he has administered the antibiotics for two days this week. He stated he did not review what the infection was for. Staff D reviewed the physician orders and the MAR and stated he was not sure exactly what the infection was but, he could look at the labs. Staff D reviewed the labs and stated the resident has a UTI according to labs that were obtained on the 1/3/23 with orders to administer antibiotics for 10 days. Staff D stated the doctor's orders should be specific. Staff D said, It should say for UTI. They need to put in the order clearly. It should state the actual diagnosis not just infection. Staff D stated he would confirm with the physician. On 01/10/23 at 12:27 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nurse who received the orders should have put in the diagnosis. The ADON said, It should not just say infection. It should indicate what the infection is. The nurse put it in wrong. The ADON stated she would follow-up. A follow up was conducted on 01/10/23 at 4:51 p.m., with the Director of Nursing (DON). The DON stated the expectation is for the diagnosis to be listed in the orders, the MAR, and the actual medication label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 12 of 14 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 01/12/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, record review, and interview the facility failed to ensure the physician order for one resident (#17) out of five residents sampled for unnecessary medications was implemented following the recommendation of the consulting pharmacist. Findings included: The admission Record for Resident #17 indicated an admission date of 1/21/21 and included diagnoses not limited to unspecified sequelae of cerebral infarction, ischemic cardiomyopathy, and moderate recurrent major depressive disorder. An observation of Resident #17 lying in bed was conducted, on 1/9/23 at 12:23 p.m. The Medication Regimen Review (MRR) conducted on 10/29/22, identified a recommendation from the Consultant Pharmacist asking the physician to consider a gradual dose reduction, Alprazolam 0.5 milligram (mg) orally (po) every day (qd) for anxiety (anx). The Physician/Prescriber Response section indicated the physician agreed with the recommendation, was signed, and dated on 11/3/22 or 11/7/22 (date showed as a 3 or 7 written over the other number). The physician's progress note, dated 10/27/22 (2 days prior to the recommendation), indicated the plan was to continue Resident #17's current plan of care. The physician's progress note, dated 11/16/22, indicated the physician did not note a change in the resident's Alprazolam. A review of Resident #17's November 2022 Medication Administration Record (MAR) identified the following: - Xanax Tablet 1 milligram (mg) (Alprazolam) - Give 1 tablet by mouth one time a day for anxiety, start date 6/23/22 and discontinued at 5:50 p.m. on 11/9/22. The order was scheduled for bedtime (HS). - Xanax Tablet 1 mg (Alprazolam) - Give 1 tablet by mouth in the evening for anxiety, start date 11/9/22 at 10:45 p.m. The medication was scheduled to be administered at 10:45 p.m. The November 2022 MAR did not identify that the physician order to reduce Resident #17's Alprazolam to 0.5 mg had been implemented and/or changed. A review of Resident #17's December 2022 MAR identified that the resident continued to receive 1 mg of Xanax (Alprazolam) every evening. The review of Resident #17's progress notes did not identify a reason that the physician order had not been followed. The Director of Nursing stated, on 1/11/23 at 4:59 p.m., that she was not here at the time of the (pharmacy)recommendation so it was just a record review for her. She stated her expectation would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 13 of 14 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 01/12/2023 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 0758 that the order should have been changed per the physician order. Level of Harm - Minimal harm or potential for actual harm The policy titled, Medication Utilization and Prescribing, issued 10/2014 and revised 10/22, identified the guideline as: The facility will comply with the requirements specified in accordance with State and Federal regulations as they pertain to Medications Utilization and Prescribing. The Treatment/Management section of the policy indicated, Based on input from the staff and resident, the physician will adjust medications based on their efficacy, indications and the continued presence of clinically significant risks. The monitoring of medications identified that The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105442 If continuation sheet Page 14 of 14