Inspection·June 16, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observed or suspected abuse or neglect with a resident, she was supposed to handle it and inform the Director of Nursing (DON) or Administrator. LPN A said reporting abuse would depend on the person making the allegation. LPN A stated if the resident had visible physical marks or anything like that, but she (resident #50) did not have any when she assessed her, and it sounded like she just did not want those CNAs to change her. LPN A stated when the CNAs went in to resident #50's room, the resident did not want them to change her, but the CNAs did it anyway because they could not leave her 8 hours without changing her. LPN A indicated resident #50 told her she had reported the incident to her assigned nurse during the shift the incident occurred. LPN A stated she could not believe how CNAs who had been working years in the facility would do something like that, but she had to give her the grievance form for the resident to fill it out. LPN A stated she assessed the resident's wrist and there were no visible marks. LPN A reiterated the alleged incident had happened days before the report and she did not see anything, hence why she gave the grievance form, that's why I did it that way. LPN A stated she would only handle reporting if it happened during her shift. LPN A stated she did not know if resident #50 turned the grievance form in. LPN A stated she did not report what resident #50 told her to her manager, and she only gave the grievance form to the resident. LPN A stated she received abuse and neglect training quite often, with most recent time within the previous week. LPN A explained whenever someone filed a grievance about abuse, management went around and in-serviced them about abuse and neglect. LPN A stated she should had called her supervisor at home as they did not have a supervisor in the facility that day. LPN A stated in the 12 years she had been working in the facility, this was the first time this resident mentioned something like that to her. On 6/15/22 at 4:49 PM, the Administrator indicated she was made aware of an incident for resident #50 the previous Monday, 6/13/22. The Administrator explained LPN A had reported the incident with the 2 CNAs to the Director of Nursing (DON), and the DON spoke and assessed resident #50. The Administrator stated the DON found no bruises, scratches, or skin discoloration during her assessment. The Administrator stated that Monday, 6/13/22, they spoke with resident #50 and the resident did not think the CNAs did anything intentionally. The Administrator indicated resident #50 mentioned she did not want CNA B to be assigned to her care. The Administrator did not file a report and they did not obtain written statements because the resident told them she did not think it was deliberate. On 6/15/22 at 5:13 PM, the DON explained when she came in to work the previous Monday a therapist, who had been working with the resident that morning, came to her and informed her what resident #50 had told her. The DON stated resident #50 told the therapist she had reported an incident with 2 CNAs to LPN A and LPN A left a grievance form with her. The DON indicated the occupational therapist (OT) wanted her to know that resident #50 said the girls were turning her, one of the CNAs was holding her right wrist and she was sore. The DON stated she immediately went to the unit and spoke with LPN A. The DON visited resident #50 by herself and resident #50 told her while getting care from the 2 CNAs, it caused pain in her wrist. The DON stated resident #50 told her she was unable to complete the grievance form LPN A left her and no one offered to assist her with completing the grievance form. The DON explained resident #50 told her she did not like CNA B and she wanted to only have the assistance of CNA C but CNA C told her she needed assistance to turn her and asked CNA B to help her. The DON stated the resident indicated CNA B was behind her, while CNA C was positioned in front of her when she hurt her wrist. The DON stated she assessed resident #50 and there were no negative findings. The DON reported resident #50 did not say CNAs B and C were rough. The DON stated neither the Administrator nor her received a call that weekend from LPN A with a report of alleged abuse. The DON stated she returned to resident #50 with LPN A and together they assessed the resident's arm. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105448 If continuation sheet Page 2 of 4 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 105448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Rehabilitation & Nursing Center 1705 Jess Parrish CT Titusville, FL 32796 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 0609 Level of Harm - Minimal harm or potential for actual harm stated LPN A mentioned the arm did not look any different than before resident reported soreness, and no bruises or redness was noted. The DON stated she did not feel there was abuse or neglect and that was why they did not file an immediate report with the State Agency. The Administrator agreed if LPN A had reported what resident #50 told her timely, an investigation could have been started sooner. The Administrator stated the staff was not responsible to determine if a report from a resident was abuse or not. Residents Affected - Few Review of in-service objectives from staff education on 5/02/22 included, All reported, suspected or alleged form of resident abuse, neglect and misappropriation should be reported immediately to the administrator/DON. All staff is responsible reporters of abuse, neglect, misappropriation. On 3/02/22, an abuse and neglect in-service attended by LPN A revealed the objectives were, How to identify abuse, when to report abuse and whom you report abuse to. Review of sign-in sheets revealed LPN A attended abuse and neglect in-services provided by the facility. Review of the facility policy and procedure Abuse Prevention Program, reviewed in March 2022 read, Staff are instructed to report concerns, incidents and grievances without fear of retaliation . The Administrator, DON, and/or designated individual are responsible for the investigation and reporting of suspected, or alleged abuse, neglect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105448 If continuation sheet Page 3 of 4 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 105448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Titusville Rehabilitation & Nursing Center 1705 Jess Parrish CT Titusville, FL 32796 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility failed to maintain kitchen equipment, cookware and refrigerators, in a clean, sanitary, and functional condition. The kitchen staff also failed to ensure milk was returned to the vendor or discarded after the expiration date. Findings: During the initial kitchen inspection on 6/13/22 at 10:37 AM: 1. The 3-compartment sink was observed with pots and pans sticking out of the sanitizer solution in the third sink compartment. The Certified Dietary Manager (CDM) used a 10-second test strip to determine the sanitizer solution's strength/parts per million (ppm). After submerging the test strip in the sanitizer mixture for 10 seconds, the CDM referred to the test strip and said, it was barley readable, that indicated the sanitizer strength could not be determined. Review of the sanitizer solution manufacturer's instructions noted it was effective against commonly identified sources of food contamination such as Escherichia Coli, Staphylococcus Aureas, Campylobactor Jejuni, Listeria Monocytogenes, Salmonella and Shigella, when the sanitizer solution was mixed with water and had strength between 200 ppm to 400 ppm. On 6/16/22 at 1:25 PM, the CDM stated the contractor had been in the kitchen to adjust the sanitizer solution dispenser. The CDM said the contractor found issues with the lines and the right amount of sanitizer was not being pumped. 2. There were 3 frying pans on the bottom of a 2 tier wire shelf in the food preparation area. Two of the frying pans were heavily covered with black carbon stains/scoring. The CDM and the Registered Dietitian (RD) could not explain if the 2 frying pans were non-stick pans that had lost their non-stick coatings or if they were stainless steel pans with heavy carbon scoring. 3. The juice dispenser in the kitchen was observed with the CDM. When the nozzle was removed, a light brown substance on the dispenser gun was noted. The CDM stated that it needed to be cleaned. The walk-in refrigerator had 2 half-pints of lactose free milk and both cartons had an expiration date of 6/11/22. The CDM could not explain why the milk was in the refrigerator past it's expiration date. 4. On 6/16/22 at 12:43 PM, the 200 Wing Pantry Top Freezer Refrigerator was observed. In the freezer section there was a purple like juice stain on the sides and bottom of the freezer. The freezer did not have a thermometer but there was a popsicle and an individual pot in the freezer. In the refrigerator section there was milk and liquid supplements on the door rack. At the bottom of the refrigerator was a crisper that had spilled juice and a brown-like substance on the edges of the crisper. The RD stated she would informed housekeeping staff that the Freezer/Refrigerator needed to be cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105448 If continuation sheet Page 4 of 4