Inspection·April 13, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm A review of the Treatment Administration Record (TAR), dated January 2023, revealed the wanderguard was checked for function and placement daily. A Change in Condition form, with an effective date of 01/22/23, showed the resident was observed outside on the street ambulance entrance on 01/22/23. Residents Affected - Few A review of the Progress Notes, dated 01/22/23 at 1755, revealed the writer was alerted by a Certified Nursing Assistant (CNA) that the resident was not in his room when she went in to serve his dinner tray. The writer immediately went to the dining room as the resident chose to eat there. While exiting the dining room, the writer looked down on the street and saw the resident looking into the window from outside the ambulance entrance. While bringing the resident back inside, he stated he was getting money. The supervisor and the writer assisted him back to his room. Body audit done with no indicators. He proceeded to eat dinner, pleasant mood. Family and doctor notified. Resident was on 15-minute checks. The Elopement Risk Evaluation, dated 09/20/22, revealed Resident #17 was at risk for elopement. The care plan related to elopement, initiated on 11/18/20, revealed interventions that included but were not limited to; distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book, electronic monitoring device, identify patterns of wandering, and provide structured activities. On 04/13/23 starting at 12:50 p.m., the Administrator and Director of Nursing (DON) were interviewed for Quality Assurance (QA). The DON stated they had a reportable incident related to an elopement on 01/23/23. A CNA reported to the assigned nurse that she couldn't find Resident #17 in his room or dining room. The assigned nurse, Staff E, Licensed Practical Nurse (LPN), started to look for him. The nurse went into the resident's room, and he wasn't there. He then checked the dining room, and he wasn't there. Staff E, LPN, observed Resident #17 outside of the building looking into the window of the facility. The resident was outside at the ambulance entrance looking in. When Resident #17 was brought back in, he stated he was trying to get money. The Administration during the time of the incident reenacted what happened. Resident #17 apparently went to the side doors and exited on the side patio door. The resident stated he want out with a female, but they couldn't identify a female. He can read. The sign on the door states push until alarm sounds, door can be open in 15 seconds. He knew how to alert staff to let him back in the building. Prior to the incident, he didn't express interest in leaving the facility. A body audit was completed, and the resident did not have any injuries. Resident #17 was placed on 1 to 1. His wanderguard was working with no issues. He was identified as an elopement risk prior to this incident with a BIMS of 08. The resident was seen shortly before the incident at the nursing station asking for coffee. He went back down to his room. It was at 17:55 when the CNA alerted the nurse. The CNA went into the room to serve the dinner tray and he was not there. They reeducated staff and did missing resident drills. Staff did a count to make sure everyone was accounted for. After the incident, all residents were reviewed for elopement assessments. They had a systemic change in two things. They didn't have a receptionist at that time when Resident #17 got out of the building. They have a receptionist now until 9:00 p.m. The door he went out of is no longer used. Only the Administration has the code now. Prior to the incident, visitors were using that door. They do elopement drills quarterly. The incident was reported to the required agency on 02/03/23 as an adverse incident and has not been investigated by an outside agency, stated the DON. On 04/13/23 at 1:52 p.m., a telephone interview was conducted with Staff E, LPN. He reported he was at the nursing station when the CNA was passing dinner. The CNA came over and said Resident #17 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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 not in his room. He looked in the bathroom and, in his room to make sure he was not in there. Looked in the dining room and didn't see him. As he was walking past E wing on the left side, Resident #17 was at the end of the hallway looking in the window. The resident saw him and pointed at him. Staff E, LPN, got him and brought him back to the facility. He reported this to the supervisors. He performed a skin assessment on the resident with the assistance of the supervisor. The resident did not have an injury. Residents Affected - Few The Nursing Home Adverse Incident Form provided by the facility indicated the elopement incident date was 01/22/23. On 04/13/23 at 1:50 p.m., the DON stated the previous Administrator, who completed the investigation, was contacted via phone and stated they were not required to complete an immediate and a five-day report for an adverse incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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 record review and interviews, the facility failed to ensure one resident (#109) of thirty-one residents sampled, had a complete and accurate Minimum Data Set (MDS) assessment coded for discharge to community. Residents Affected - Few Findings included: A record review of Resident #109's electronic medical record revealed an admission date of 09/26/2022, with primary diagnosis of Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. A discharge progress note showed the resident was discharged to community (home) on 01/13/2023. A record review of the MDS, dated [DATE], read A2100 Discharge Status shows 03 Acute Hospital. The MDS needed to show for Resident #109 01 Community discharge date [DATE]. On 04/12/23 at 02:15 p.m., an interview was conducted with the MDS Coordinator. During the interview the MDS Coordinator confirmed the MDS was coded incorrectly and needed to be changed to reflect Resident #109's discharge to the community, and not to the hospital. The MDS Coordinator further revealed she would fix the record immediately and resubmit it to reflect the correct information. A facility policy titled Resident Assessment Instrument, dated [DATE], under Policy Interpretation and Implementation reads: 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capability. 4. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning an includes as a minimum: r. Discharge Potential 6. All persons who have completed any portion of the MDS 3.0 Resident Assessment Form must electronically sign such document attesting to the accuracy of such information at Z00400. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 4/12/23 at 4:02 p.m. an observation was conducted with Staff E, LPN. Staff E, went to Resident #58's room to look at the resident's sacral wound dressing. The sacral wound dressing was observed to be dated 4/10/23. The dressing was saturated with a visible dark, liquid discoloration, but no discharge was oozing out of the bandage. The LPN confirmed the dressing was in need of changing. The dressing change was not observed per resident's request. Residents Affected - Some A review of the facility policy titled, Dressing, Non-Sterile, dated April 2022, showed: Steps in the Procedure, number 19, Apply the ordered dressing and secure with tape. The section Reporting and Documentation showed the following information may be documented in the resident's electronic medical record: 1. The date and initials of the person that performed the procedure. 2. Type of dressing used and wound care given. 3. If the resident refused the treatment why. A review of the facility policy titled, Physician Orders, dated April 2022, showed Policy Interpretation and Implementation, subsection 4. Medications may not be administered to the resident without the written approval from the attending physician. Based on observations, interviews, and record review the facility failed to 1) provide treatment and care related to pressure related skin conditions and, 2) follow physician orders for a non-pressure related skin condition for one resident (#58) of two residents sampled. Findings included: During an interview on 04/10/2023 at 10:50 a.m., Resident #58 stated he had several skin areas that needed a dressing, his abdomen, groin and backside, and the facility had not placed the dressing on his backside since Friday (04/07/2023), when he was to shower. He had been asking about this, but he still does not have a dressing on it. A review of Resident #58's admission Record revealed diagnoses that included pressure ulcer of unspecified site, stage 4. A review of the Minimum Data Set (MDS), dated [DATE], Section C: Cognitive Patterns showed the resident had a Brief Interview of Mental Status (BIMS) score of 15/15, indicating the resident had no cognitive impairment. Section M: Skin Conditions showed the resident was coded for a stage 4 pressure ulcer. A review of the document titled, [Vendor] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 03/31/2023. The section titled, Plan, showed wound orders as: *Wound #3 Sacrum, Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing Change dressing every day and as needed. A review of the document [Vendor] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 04/07/2023. The section titled, Plan, showed wound orders as: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm * Wound #3 Sacrum, Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with foam dressing Change dressing every day and as needed. A review of Resident #58's active physician orders for April 2023 showed no active orders for the sacral wound. Residents Affected - Some A review of the Treatment Administration Record (TAR) for March 2023 and April 2023 revealed treatment was provided for the sacral wound daily from 03/11/2023 to 03/28/2023. No further documentation for the sacral wound until 04/12/2023. A review of the document titled, [Vendor] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 03/31/2023. The section titled, Plan, showed wound orders as: *Wound #5 Left umbilical Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing. Change dressing every other day and as needed. A review of the Treatment Administration Record (TAR) for March 2023 and April 2023 revealed treatment was provided to the wound on 03/27/2023, 03/29/2023, 03/31/2023, 04/03/2023 and 04/05/2023. A review of the document [Vendor] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 04/07/2023. The section titled, Plan, showed wound orders as: *Wound #5 Left umbilical Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing - ABD pad Change dressing every day and as needed. A review of the Treatment Administration Record (TAR) for March 2023 and April 2023 revealed treatment was provided to the wound on 04/08/2023, 04/09/2023 and 04/10/2023. A review of the document titled, [Vendor] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 03/31/2023. The section titled, Plan, showed wound orders as: *Wound #8 Left Groin Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing ABD pad. Change dressing twice a day and as needed. A review of the Treatment Administration Record (TAR) for March 2023 and April 2023 revealed treatment was provided to the wound three times per day, 03/24/2023 to 04/07/2023. A review of the document [Vendor Name] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 04/07/2023. The section titled, Plan, showed wound orders as: *Wound #8 Left Groin Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing - ABD pad. Change dressing twice a day and as A review of the TAR for April 2023 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some *Start date 04/08/2023 cleanse left and right groin and mid abdominal fold with dakins, apply silver alginate, cover with ABD pad. Every day and evening shift for cleanse left groin with dakins, apply silver alginate cover with ABD pad every other day. Treatments were signed as completed. Order discharge date on 4/12/2023. *Start date 04/08/2023 cleanse left and right groin and mid abdominal fold with Dakins, apply silver alginate, cover with ABD pad every day and night shift for medicate resident for pain prior to dressing changes cleanse left groin with Dakins, apply silver alginate, cover with ABD pad. Treatments were signed as completed. Order discharge on [DATE]. A review of the document titled, [Vendor] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 03/31/2023. The section titled, Plan, showed wound orders as: *Wound #9 Abdomen Mid Fold Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing - ABD pad. Change dressing twice a day and as needed. A review of the Treatment Administration Record (TAR) for March 2023 and April 2023 revealed treatment was provided to the wound three times per day from 03/24/2023 to 04/07/2023. A review of the document [Vendor Name] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 04/07/2023. The section titled, Plan, showed wound orders as Wound #9 Abdomen Mid Fold Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing - ABD pad. Change dressing twice a day and as needed. A review of the TAR for April 2023 revealed: *Start date 04/08/2023 cleanse left and right groin and mid abdominal fold with Dakins, apply silver alginate, cover with ABD pad. Every day and evening shift for cleanse left groin with Dakins, apply silver alginate cover with ABD pad every other day. Treatments were signed as completed. Order discharge date on 4/12/2023. *Start date 04/08/2023 cleanse left and right groin and mid abdominal fold with Dakins, apply silver alginate, cover with ABD pad every day and night shift for medicate resident for pain prior to dressing changes cleanse left groin with Dakins, apply silver alginate, cover with ABD pad. Treatments were signed as completed. Order discharge on [DATE]. A review of the document titled, [Vendor] Surgical and Wound Care Progress Note Details showed Resident #58 was seen by the wound care physician on 03/31/2023. The section titled, Plan, showed wound orders as: *Wound #10 Right Groin Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing - ABD pad. Change dressing twice a day and as needed. A review of the Treatment Administration Record (TAR) for March 2023 and April 2023 revealed treatment was provided to the wound three times per day from 03/24/2023 to 04/07/2023. A review of the document [Vendor Name] Surgical and Wound Care Progress Note Details showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Resident #58 was seen by the wound care physician on 04/07/2023. The section titled, Plan, showed wound orders as: Wound #10 Right Groin Cleanse/irrigate wound with 0.125% Dakins solution. Apply Calcium Alginate with Silver (Ag), cover with dry dressing - ABD pad. Change dressing twice a day and as needed. Residents Affected - Some A review of the TAR for April 2023 revealed: *Start date 04/08/2023 cleanse left and right groin and mid abdominal fold with Dakins, apply silver alginate, cover with ABD pad. Every day and evening shift for cleanse left groin with Dakins, apply silver alginate cover with ABD pad every other day. Treatments were signed as completed. Order discharge date on 4/12/2023. *Start date 04/08/2023 cleanse left and right groin and mid abdominal fold with Dakins, apply silver alginate, cover with ABD pad every day and night shift for medicate resident for pain prior to dressing changes cleanse left groin with Dakins, apply silver alginate, cover with ABD pad. Treatments were signed as completed. Order discharge on [DATE]. During an interview on 04/12/2023 at 3:43 p.m. Staff E, Licensed Practical Nurse (LPN) stated the resident has physician orders for treatments on his abdominal folds and groin every shift, and sacrum every other day. Staff E confirmed there was no (physician) order for the sacral wound, and he did not change the dressing for the sacral wound on 04/11/2023 when he was assigned to the resident. Staff H, LPN Unit Manager (UM) came over at this time and looked for the (physician) order and could not find the order. She stated, That is interesting. His sacral wound has never closed. There should be an order. During an interview on 04/12/2023 at 4:05 p.m., the Director of Nursing (DON) confirmed there was not an active order for Resident #58's sacral wound. Her expectation is that they follow physician orders as written. During an interview on 04/13/2023 at 9:25 a.m. the DON stated the (physician) order had been inadvertently dropped off of the physician order. The DON stated they reviewed all orders and clarified the TAR was to match the physician orders, one area per order, as this is a best practice for documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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 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. Based on observations, interviews, and record review the facility failed to ensure splints were applied to prevent a decrease in range of motion for one resident (#45) of two sampled resident for range of motion. Residents Affected - Few Findings included: An observation conducted of Resident #45, on 04/10/2023 at 9:58 AM and 04/13/2023 at 10:00 AM, revealed Resident #45 in his bed, without any splints or braces on his hands. Both of his hands were observed each time with closed, fingers bent and touching the palms. A review of Resident #45's admission Record revealed diagnoses that included Hemiplegia (partial paralysis) following cerebral infarction (stroke) affecting left non-dominant side and dementia without behavioral disturbance. A review of Minimum Data Set (MDS) assessment, dated 03/04/2023, Section C: Cognitive Pattern, revealed a Brief Interview for Mental Status (BIMS) score of 0/15, which indicated the resident was severely cognitively impaired. Section G: Functional Status revealed he required extensive to total assistance with mobility and activities of daily living (ADL) performance and had functional limitations in range of motion on one side for upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle foot). In addition the MDS did not have a restorative program marked. A review of the Order Review Report with active physician orders as of 04/13/2023 reflected the following: May have restorative/maintenance programs as indicated, order date 08/20/2022. The care plan for Resident #45 revealed a focus area for complications due to a stroke affecting the left side/Hemiplegia, which included interventions: Monitor/document mobility status. If resident is presenting with any problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat, initiated 04/21/2021. The care plan was silent of any focus areas or interventions related to range of motion or contracture prevention. A review of Resident #45's Occupational Therapy Treatment Encounter, notes dated showed: *10/05/2022, communication was conducted with supervisors regarding the delivery of bilateral upper extremity orthotic's for the resident. *10/07/2022, resident was compliant with adaptations; resident was discharged from case load. *10/14/2022, resident needs to have further assessment of orthotic and wearing ability after initial fitting. Resident had orders for occupational therapy, three times per week to increase tolerance of bilateral upper extremity orthotic's. *11/17/2022, resident was able to tolerate left upper extremity resting hand splint and right upper extremity slim grip orthotic for 6 hours with no pain or redness during doffing. An interview was conducted on 04/13/2023 at 9:05 AM with Staff F, Certified Nursing Assistant (CNA) assigned to Resident #45. She stated she recalled the splints but has not seen them in quite a while. If he (Resident #45) were to have splints, they would be in his room. No splints were located in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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 the resident room. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 04/13/2023 at 09:10 AM with Staff D, Licensed Practical Nurse (LPN). She stated she remembered him with splints, but therapy puts them on and off. She hasn't seen them for a while. Residents Affected - Few An interview was conducted with the Director of Rehabilitation (DOR) on 04/13/2023 at 09:11 AM. She stated therapy screens all residents not on current case load, quarterly, for position/contracture management and other declines. If any change status, then therapy will request orders for evaluation and treatment from the physician. Nursing also can give us a request for therapy to screen based on observation of a problem. In regards to, [Resident #45] the DOR stated he was seen for OT (Occupational Therapy) in November 2022. He is currently in an active restorative program. The DON is acting as our restorative nurse, at this time. We have two CNAs that are assigned to assist with the tasks for the restorative program. Resident #45 was discharged from OT on 11/17/22 with the splint to left upper extremity and right had slim grip. The DOR provided a document titled THERAPY TO RESTORATIVE NURSING COMMUNICATION, for Resident #45. The form revealed PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy) Functional Maintenance Intervention Suggestions:, under Bracing/Splinting was checked for the Type: Left Upper Extremity (LUE) resting hand/right upper extremity (RUE) slim grip; Body Part: LUE/RUE; Wearing Schedule: 6 hours, a day 5 days a week. Under section Adaptive Equipment/Special Instruction given: the therapist documented, Conduct passive range of motion (PROM) on bilateral upper extremities (BUE's) prior to orthotic application, 5 repetitions for 3 sets. Conduct hand hygiene prior to application. Client is to wear orthotic's for 6 hours a day 5 days a week for ongoing duration as tolerated. Perform skin checks before and after application. DOR stated this form was provided to nursing in November 2022. The DOR reviewed her list of residents on the restorative program, and Resident #45 was on the list for current residents to be seen. An interview was conducted with Staff G, Restorative CNA, on 04/13/2023 at 11:45 AM. She stated Resident #45's splint went missing toward the end of last year (2022). I informed the nurse, the Unit Manager, as well as in our weekly restorative meeting. I have been placing hand rolls in his hands so that his fingers were not digging into his hands. An interview was conducted at 04/13/2023 10:37 AM with the DOR and Director of Nursing (DON). The DON stated Resident #45 could not tolerate the splints therapy recommended back in September 2022. The DON stated the expectation would be to have documentation to support that a resident could not tolerate the splint. The DON states the Therapy Intervention was missed, and they don't know why. The DOR stated they are going to have the resident screened for an evaluation for the splint to prevent further decline. Review of the policy and procedure titled, Mobility/Range of Motion, undated, revealed Intent: It is the policy of the facility to ensure that the residents receive range of motion, in accordance with State and Federal Regulations. Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: a. that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; b. a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. C. A resident with limited mobility receives appropriate serves, equipment, and assistance to maintain or improve mobility with the maximum practicable independence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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 unless a reduction in mobility is demonstrated unavoidable. 2. The facility will ensure that the resident reaches and maintains his or her highest level of range of motion and to prevent avoidable decline of range of motion. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and a test tray temperature check the facility failed to provide and serve food at an appetizing temperature to four residents (#260, #22, #3, #87) out of 23 sampled residents. Residents Affected - Some Findings included: During an interview on 04/10/23 at 10:04 a.m., Resident #260 stated the food was cold most of the time. During an interview on 04/10/23 at 11:03 a.m., Resident #22 stated the food was occasionally cold. During an interview on 04/10/23 at 11:47 a.m., Resident #3 stated the food comes out cold. During an interview on 04/10/23 at 1:00 p.m., Resident # 87 stated the food was cold at times. A review of the facility's Grievance Log revealed the following concerns related to cold food temperatures: -March 2023- A concern was addressed about food temperatures. The outcome showed there was monitoring of food temperatures. -November 2022- A concern was addressed about food. The outcome showed food temperature checks were conducted. On 04/10/23 at 12:20 PM, a test tray for food temperatures was conducted with the Dietary Manager on the last tray removed from the food tray cart. The food temperatures were recorded as follows: Ground chicken pot pie with biscuit - 115.7 degrees Fahrenheit Sliced peaches and pears- 56.8 degrees Fahrenheit. Nectar thick milk- 58.3 degrees Fahrenheit Salad- 67.2 degrees Fahrenheit During an immediate interview on 04/10/23 at 12:20 p.m., Staff C Dietary Manager (DM) stated that cold foods should be below 40 degrees Fahrenheit and hot foods should be above 135 degrees Fahrenheit. A review of the facility's policy titled, Food Preparation with revised date 09/2017 showed, All foods will be held at appropriate temperatures, greater than 135 F [Fahrenheit] for hot holding, and less than 41 F [Fahrenheit] for cold food holding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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, interviews, and record review the facility failed to 1) ensure temperatures were checked and documented daily for the walk-in refrigerator, walk in freezer, reach in refrigerator and dishwashing machine, and 2) ensure the walk-in freezer was in good working order. This practice had the potential to effective 104 out of 107 residents residing in the facility. Findings included: An observation on 04/10/23 at 9:10 a.m., showed the April 2023 dish washer temperature document had missing temperatures. The following dates had missing temperatures with photogenic evidence obtained: - 04/06/23- dinner shift - 04/07/23- dinner shift - 04/08/230-dinner shift - 04/09/23- dinner shift - 04/10/23- breakfast shift During an immediate interview on 04/10/23 at 9:10 a.m., Staff A Dietary Aid (DA) stated the dish washer temp log should have been completed before every meal (breakfast, lunch, and dinner) at three times a day. Staff A DA confirmed the April 2023 dishwasher temperature log was missing temperature checks and was incomplete. An observation on 04/10/23 at 9:20 a.m., showed the April 2023 temperature logs for the walk-in refrigerator, walk in freezer and reach in refrigerator logs had missing temperature checks and was incomplete. The following dates had missing temperatures with photogenic evidence obtained: Walk- in Refrigerator - 04/07/23 morning shift - 04/08/23 evening shift - 04/09/23 morning shift Walk-in Freezer - 04/07/23 morning shift - 04/08/23 evening shift - 04/09/23 morning shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 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 105459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nursing & Rehabilitation Center of New Port Richey 8417 Old County Rd 54 New Port Richey, FL 34653 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 Reach- in Refrigerator Level of Harm - Minimal harm or potential for actual harm - 04/07/23 morning shift - 04/08/23 evening shift Residents Affected - Some - 04/09/23 morning shift During an immediate interview on 04/10/23 at 9:20 a.m., Staff B [NAME] confirmed the April 2023 walk-in refrigerator, walk in freezer, and reach in refrigerator logs had missing temperature checks and was incomplete. Staff B [NAME] stated the temperature logs for all refrigerators and freezers should be checked at the start of each morning shift and evening shift to ensure that nothing is wrong. An observation on 04/10/23 at 9:30 a.m., showed ice buildup on the floor of the walk-in freezer. Photographic evidence was obtained. During an immediate interview on 04/10/23 at 9:30 a.m., Staff B, [NAME] stated the ice buildup on the walk-in freezer floor was a common occurrence and then stated, something is going on in there. During an interview on 04/10/23 at 11:00 a.m., Staff C Dietary Manager (DM) stated there was a problem with ice buildup in the walk-in freezer and he thought the problem had been reported to maintenance already. DM stated sometimes the kitchen staff would go in the walk- in freezer and chip the ice away. During an interview on 04/12/23 at 3:30 p.m., the Administrator stated she was unaware of the ice build-up on the freezer floor. The Administrator provided an invoice for review that showed a purchase of a refrigeration door latch on 03/06/23. A review of the facility's policy titled, Food Storage: Cold Foods with revised date 04/2018 showed, An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105459 If continuation sheet Page 14 of 14