Health inspection·July 14, 2022

F 0656 and dental care. Level of Harm - Minimal harm or potential for actual harm The care plan initiated on 6/5/22 did not address the resident's dental status or the use of psychotropic medications. Residents Affected - Few On 7/12/22 at 3:17 p.m., MDS coordinator LPN Staff J confirmed the care plan was not updated to include psychotropic medication use or the dental care needs for Resident #81. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 2 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 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 provide the necessary services to maintain the personal hygiene, grooming for 2 residents (Resident #34 and #53) of 4 residents who require assistance with activities of daily living. Daily grooming contributes to the resident's dignity and the failure of maintaining a resident's personal grooming habits has a potential to affect the psychosocial well-being of the resident. Residents Affected - Few The findings included: 1. Review of Resident #53's Quarterly Minimum Data Set (MDS) dated [DATE] severe cognitive impairment. The assessment documented the resident required limited physical assistance of one person for personal hygiene, including combing hair. Resident #53 range of motion was impaired on both upper extremities. The MDS noted Resident #53 did not reject care. Resident #53's care plan showed she was independent to limited assist with dressing, grooming, and bathing related to dementia. The goals were for the resident to have a clean, neat appearance daily. The interventions included to provide hands on assistance with dressing, grooming, bathing as needed. The care plan did not note the presence of behavior such as rejecting care. On 7/11/22 at 10:58 a.m., Resident #53 was observed in the dining room of [NAME] Garden memory care dining room. The resident's hair was not brushed and looked untidy. The hair around the back of her head was standing straight up from around the back of her head in a circle. On 7/12/22 at 9:00 a.m., Resident #53 was observed dressed in a blue sun dress in the [NAME] Garden memory care dining room. Her hair was observed in the same condition as the previous day. The hair around the back of the resident's head was standing straight up in a circle. On 7/13/22 at 11:03 a.m. Resident #53 was observed in the [NAME] Garden memory care dining room. She was sitting in a chair with her hair un-brushed. The back of her head showed the hair was formed as if she had been lying with her head on a pillow. On 7/13/22 at 11:37 a.m., Certified Nursing Assistant (CNA) Staff B said she was assigned to care for Resident #53 on 7/11/22, 7/12/22 and 7/13/22. She verified she did not brush or comb the resident's hair. CNA Staff B said the day before, Resident #53 refused assistance to brush her hair. She said she did not document and did not notify the nurse of the resident's refusal to brush her hair. CNA Staff B said she knew to document, notify the nurse, and reapproach the resident later. On 7/13/22 at 11:57 a.m., observation of the resident's room with CNA Staff B failed to show a hairbrush. CNA Staff B said she would provide a hairbrush to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 3 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 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 Residents Affected - Few 2. The facility policy Activities of Daily Living (ADL), Supporting (revised 3/18) documented, 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 activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. Review of Resident #34's clinical record showed Resident #34's diagnoses included dementia without behavioral disturbance, major depressive disorder, and contracture of the left hand. The record showed a significant change in status minimum data set (MDS) dated [DATE], documented a brief interview for mental status score of 00, indicating the resident had severe cognitive impairment. The MDS documented Resident #34 was dependent on staff for dressing and personal hygiene. Review of the care plan revised 3/4/22 documented Resident #34 had alterations in ADL's and required extensive assistance with dressing and grooming. The goal was for Resident #34 to have his ADL needs met daily by staff, while participating as tolerated. On 7/13/22 at 3:31 p.m., the MDS Coordinator said per the MDS guidelines, hygiene included hair care, nail care, shaving, washing face and hands everything except bathing and showers. On 7/11/22 at 10:42 a.m., Resident #34 was observed lying in bed and appeared unkempt. Resident #34 was unshaven approximately three days growth. The resident was wearing an adult brief and no clothing. Resident #34's fingernails extended approximately 1/2 inch in length, with a brown substance under nail beds. The bed linen was wrinkled, soiled, and stained. Resident #34 did not respond to greeting or communication. On 7/12/22 at 8:29 a.m., Resident #34 was observed in bed and remained unshaven, unkempt, and wearing a hospital gown. The resident's fingernails were long with brown substances under the nail beds. On 7/13/22 at 12:00 p.m., Resident #34 was observed in bed, his hair was greasy and uncombed, he was not shaved with approximately with 5 days growth. The resident was unkempt with long fingernails and brown and black substances under the nail beds. Resident #34 was not responding appropriately to simple questions. Review of the Certified Nursing Assistant (CNA) documentation from 7/1/22 through 7/13/22 documented personal hygiene was provided to Resident #34 on each shift. The document showed Resident #34 had received a bath on 7/11/22 at 2:59 p.m. On 7/13/22 at 12:33 p.m., the Director of Nursing (DON) said Resident #34 never really did his own ADL's, was combative and was scratching staff when they tried to provide care. She said when the resident became agitated, they must stop, wait, and then restart the process. She confirmed there was no documentation of behaviors or refusal of care in Resident #34's clinical record. On 7/13/22 at 1:00 p.m., agency CNA Staff M said she was assigned to Resident #34 for the day and knew him briefly from her time at the facility. CNA Staff M said Resident #34 would resist care, refuse care, pull the covers over his head, say leave me alone, cover me up but did not hit anyone. CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 4 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Staff M said it takes an hour and a half to get the resident up and ready to be in the wheelchair and she requires assistance from the other staff members. On 7/13/22 at 1:31 p.m., Resident #34 was observed propelling himself in a wheelchair in the hallways. The resident was dressed in his own clothing, shaved, his hair was combed, and his nails were trimmed. Resident #34 was pleasant, smiling and answering simple questions. Event ID: Facility ID: 105462 If continuation sheet Page 5 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, resident and staff interview, the facility failed provide an ongoing program of activities designed to meet the physical, mental and psychosocial needs of 2 (Resident #12 and #56) of 26 sampled residents. The failure to provide a structured person-centered activities program has the potential to contribute to the decline of the resident's psychosocial wellbeing. Residents Affected - Few The findings included: 1. On 7/11/22 at 10:18 a.m., Resident #56 said, I don't think they have any word puzzles. I watch TV a lot. The activities they have do not interest me. An activity calendar was observed hanging near the bed in the resident's room. No times were noted for the activities being provided by the facility. On Friday the activity calendar listed Road Trip as an activity. Resident #56 said they do not take the residents on trips at this time. She said the facility used to take the resident's shopping at Walmart. Review of the Minimum Data Set (MDS) showed Resident #56's activity preferences were last assessed on 9/3/21. The MDS showed the resident scored a 12 on the brief interview for mental status (BIMS) indicative of mild cognitive impairment. Resident #56 was able to make her needs known. Review of the activity care plan showed Resident #53 was at risk for decreased social interaction/ activity participation related to dementia. Due to pandemic, all activities require social distancing. She enjoys fresh air, games, cards, reading, movies, arts & crafts, music, reminiscing, Jazz, dancing and watching television shows. She also enjoys shopping, and she is a smoker. The things that are important to her are clothes, belongings, showers, snacks, bedtime, family involvement, phone use, keeping things safe, music, pets and fresh air. The care plan goal was for Resident #53 to continue to participate in activities of choice. The interventions included to determine which individual activities the resident prefers and provide any related materials as needed. Provide assist with television programs of choice as needed. Provide monthly activity calendar in room. Invite to daily group programs; provide assist to group location as needed. On 7/12/22 at 4:38 p.m., the Activities Assistant said she has been the activities assistant at the facility for two years. She said the facility currently did not provide outings for the resident, the road trip listed on the activities calendar was staff asking questions about things that occurred on a road trip. The Activity Assistant said Resident #53 did not like to come out of the room, and liked to watch her soaps. She said all Resident #53 ever says is she wants to get out of here. On 7/14/22 at 11:43 a.m., Resident #53 said it had been about two months since the facility took them out and she would just like to go shopping occasionally. Resident #53 said she felt she did not have any say in the planned activities. The resident said would like to go to dinner and go shopping. Resident #53 said she has mentioned it to staff and they did not respond. 2. Review of Resident #12's clinical record showed an admission date of 12/4/13. Diagnoses included Alzheimer's, generalized anxiety disorder and dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 6 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the minimum data set (a tool used to gather data) dated 7/12/22 documented Resident #12 had a brief interview for mental status of 00. A score of 00 indicated severe cognitive impairment. Review of the care plan (revised 4/18/22) identified Resident #12 was at risk for decreased social interaction, activity participation related to a diagnosis of Alzheimer's disease and anxiety. The care plan specified Resident #12 participates in outdoor activities at times, listening to church, music, watching television and getting her nails painted. She requires cues and assist during activities. Due to pandemic all activities require social distancing. The interventions included, the resident will continue to participate in activities of choice thru the next review date, invite to daily group programs, provide assist to group location as needed and provide monthly activity calendar in room. Review of the activity, recreation progress note dated 4/20/22 documented Resident #12 had no significant changes in her health or behavior. Her care plan was reviewed and updated to include her current activity preferences which include watching tv, outdoors, and food socials. On 7/11/22 at 11:32 a.m., Resident #12 was observed in her room sitting in her wheelchair facing the hallway and was calling out as staff walked past the room. Resident #12 appeared anxious and restless and was not able to verbally express her needs. There was no television or radio on in the room. The resident's roommate was present and said Resident #12 called out all the time and keeps her up at night. On 7/11/22 at 2:00 p.m., Resident #12 was observed sitting in the hall in front of the nursing station calling out. There was no interaction from the staff observed in the area. On 7/12/22 at 10:27 a.m., Resident #12 was observed in her wheelchair sitting outside of the dining room, not engaged in an activity. Resident #12 was wringing her hands and had a worried facial expression. A July 2022 activity calendar was posted on a board behind Resident #12 with the daily activities listed. The activated listed for 7/12/22 were current events and coffee, board games, music, and popcorn. There were no scheduled times listed for the activities on the calendar. On 7/12/22 at 12:12 p.m., in an interview the Activity Aide Staff A said the facility did not have an Activity Director. Activity Aide Staff A said she provided 1-1 sound spa which plays calming ocean sounds such as water sounds and other calming sounds for residents who are not attending activities and who have dementia. Activity Aide Staff A confirmed she did not put time schedules on the activity calendar and confirmed without the times posted, the residents would not know when the activity begins. Activity Aide Staff A said she had no specific activities planned to meet the needs of residents who have dementia and cognitive impairment. On 7/14/22 at 10:01 a.m., in an interview the Director of Nursing confirmed the activity calendar did not have the scheduled time of the activities and said the residents would not know when the activity was occurring. The DON confirmed the facility did not have an Activity Director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 7 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on administrative and staff interview the facility failed to ensure the activity program was directed by a qualified activities professional who is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body. Residents Affected - Few The findings included: On 7/12/22 at 3:58 p.m., the Administrator said the Activities Director resigned on 5/9/22, and she was in the process of looking for a replacement. She said Certified Nursing Assistant (CNA) Staff A who had been the activity assistant for the past two years has been running the program since 5/9/22. On 7/12/22 at 4:38 p.m. CNA Staff A said she has been assisting the Activity Director for the last two years but had no other training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 8 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, review of the clinical record, review of facility policy and procedures, staff, and resident interviews the facility failed to provide appropriate services and interventions for the management of contractures for 1 (Resident #34) of 2 residents sampled for positioning devices. The findings included: The facility policy Assistive Devices and Equipment (revised 1/20) documented, Our facility maintains and supervises the use of assistive devices and equipment for resident. 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include but are not limited to splints. 3.5cm for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. Review of Resident #34's clinical record showed a readmission date of 7/3/22. The resident's diagnoses included dementia without behavioral disturbance, major depression, contracture (a permanent tightening of the muscles and joints) of the left hand, and hemiplegia (paralysis on one side of the body). Review of the care plan revised on 3/24/22 documented Resident #34 had contractures on the left hand and fingers (refuses to participate in range of motion (ROM)/splinting program). The interventions included Resident #34 was to wear a hand roll (cone splint) on left hand seven days a week. Review of the CNA task schedule for July 2022, instructed the splint was to be applied to left upper extremity (LUE) 4 hours on daily. The CNA Task Schedule showed no documentation the left-hand splint was applied for Resident #34 on 7/6/22 and 7/10/22. The documentation on the task for 7/11/22 showed the splint was applied at 2:59 p.m. On 7/11/22 at 10:41 a.m., 11:26 a.m., and 4:00 p.m., Resident #34 was in his bed, and he did not have a splint on the left hand. The documentation on the task showed the splint was applied on 7/12/22 at 1:56 p.m. On 7/12/22 at 2:00 p.m., and on 7/13/22 at 11:00 a.m., Resident #34 was observed in bed, and he did not have a splint on the left hand. On 7/13/22 at 12:50 p.m., the Director of Nursing (DON) said Resident #34 had a ROM and splinting program with the Restorative Certified Nursing Assistant (RCNA). The DON said the CNAs are assigned to do the ROM and splints, and We make referrals to therapy if needed. The DON said Resident #34 had the contracture to his left hand since his admission to the facility in 12/2013. On 7/13/22 at 2:21 p.m., the RCNA Staff H said Resident #34 was on restorative services for ROM and splinting to the left hand and arm daily. RCNA Staff H said the resident doesn't like the splint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 9 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 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 and is not able to remove it once it was applied. RCNA Staff H said the splints are applied in the morning then removed by the RCNA in the evening. Review of Resident #34's progress notes from 6/29/22 through 7/13/22 showed no documentation Resident #34 had refused to wear the splint to the left hand. Residents Affected - Few On 7/13/22 at 1:21 p.m., Resident #34 was observed in his wheelchair propelling himself in the hallway. Resident #34 had a blue splint on his left arm extending from his fingertips to approximately two inches below the elbow. Resident #34 said he did not mind wearing the splint, and said it doesn't bother me a bit, I will wear it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 10 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy, clinical record review, staff and resident interviews, the facility failed to have documentation of coordination to ensure effective interventions to address the needs of 1 (Resident #20) of 6 residents reviewed for impaired nutrition and weight loss. Residents Affected - Few The findings included: The facility policy Weight Assessment and Intervention documented The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for out residents. Weights will be recorded in the individual's medical record. Any change of 5% or more since the last weight assessment will be retaken the next day for conformation. If the weight is verified, nursing will immediately notify the Dietician in writing. The Dietician will respond within 24 hours of receipt of written notification. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. On 7/11/22 at 10:00 a.m., Resident #20 was observed in bed with a wash basin on bed at her side. The morning breakfast tray was on the bedside table untouched. The resident said felt nauseated. On 7/12/22 at 9:01 a.m., Resident #20 was observed in bed her with the morning meal on the bedside table, only her milk had been consumed. Resident #20 had a wash basin on her bed said she felt nauseated. Resident #20 said she did not want to lose weight and was not intentionally trying to lose weight. The resident said she was just nauseated and felt like she was going to vomit. Resident #20 said she had been telling the nurse every day and had not received medication for her nausea. On 7/12/22 at 9:13 a.m., in an interview, Certified Nursing Assistant (CNA) Staff F said Resident #20 was able to make choices if she did not like the food and there were always alternatives. The CNA said Resident #20 liked salad at lunch or a hamburger. CNA Staff F said the resident's intake had been declining and she was always saying she was going to vomit. CNA Staff F confirmed the resident did not eat her breakfast and said she only drank the milk. Review of Resident #20's clinical record showed a readmission date of 4/9/22. The diet ordered was no added salt, carbohydrate controlled. The clinical record showed a physician ordered dated 6/8/22 for med pass reduced sugar supplement 3 times a day for weight loss with no directions on the amount of the supplement to be administered to the resident. Review of the weight record for Resident #20 documented on 3/31/22 the resident's weight was 247 pounds (lbs.). On 4/29/22 the recorded weight was 243.4 lbs. On 5/11/22 the recorded weight was 231.6 lbs. On 7/1/22 the record documented a weight of 227.6 lbs., with a 19.4 lb., weight loss with the comparison weight on 3/31/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 11 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan documented resident #20 was: at a nutrition and hydration risk related to morbid obesity, therapeutic diet, type 2 diabetes , and schizoaffective disorder. The goal for the resident was to maintain adequate hydration and consume greater than 75% of most meals. The interventions included, administer medications as ordered, Registered Dietician (RD) consult as needed and observe for signs and symptoms of dehydration and other complications and update physician if noted, weigh per facility protocol, and monitor changes. Review of the nursing progress notes documented: On 6/27/22 at 9:32 a.m., resident nauseous after taking medications. Vomiting, contents appear to be medications and food. On 7/5/22 at 12:57 p.m., resident refused medication, said I'm going to throw up. On 7/12/22 at 9:06 a.m., Resident refused breakfast this morning and also refused medications. Resident states she feels nauseous, this nurse educated resident on importance of eating since resident has not been eating or eating much the last few days. This nurse will reach out to Doctor of Nursing Practice (DNR) regarding resident not eating and refusing medications .Resident does have a basin on lap just in case of emesis, but no emesis noted at this time. On 7/12/22 at 10:00 a.m., a review of the medication administration record (MAR) for July 2022 documented Resident #20 received the Med Pass Supplement 3 x's a day but did not document the percentage of the supplement the resident consumed. The MAR showed no medications were ordered for the treatment of nausea or vomiting. Review of the CNA record for meal percentage eaten from 6/29/22 through 7/12/22, documented Resident #20 had refused 22 meals. On 7/12/22 at 3:17 p.m., in an interview the RD confirmed Resident #20 lost 19 lbs. The RD said when I found out about the weight loss, I ordered Med Pass supplement 3 x's a day, 120 milliliters on 7/8/22. The RD said the supplement provided a total calorie of 720 with 30 grams of protein daily. The RD said Resident #20's issues are more of a preference; she asks for burgers and salads. She can tell you what she wants but I have not spoken to her in depth. The RD said there had not been weight meetings in the facility for some time. The RD said when I started here a couple of months ago, I recommended it. The RD said the Assistant Director of Nursing, the Director of Nursing, Social Services, Therapy and the MDS Coordinator attend the monthly weight meetings. The RD confirmed no CNA's attended the weight meetings. The RD said there was a sign in sheet for the meetings, but he had no documentation of the residents reviewed in the meetings. The RD said he had not received a dietary slip for Resident #20 regarding her episodes of nausea or weight loss. The RD said Resident #20 liked soda, hamburgers and fries will ask for a salad. We do have alternatives here and we make sandwiches. The residents do get snacks here. The RD said, he attended the daily clinical management meeting with the interdisciplinary team. On 7/12/22 at 4:04 p.m., in an interview Licensed Practical Nurse (LPN) Staff G said Resident #20 had been reporting nausea since last week and said, I have notified the NP. The LPN said Resident #20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 12 of 13 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 105462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete had not been eating well for several days and makes herself sick. She gets so anxious and when given her medications she gags but I have never seen emesis. Today all Resident #20 had accepted was Med Pass supplement and milk. On 7/12/22 at 4:24 p.m., in an interview the DON said, she was not made aware in the morning clinical meetings, Resident #20 was not eating or had weight loss. The DON said there was no documented behaviors of the resident making herself sick or gagging. The DON confirmed there was no documentation by staff to address the resident's poor intake or her reports of nausea. Event ID: Facility ID: 105462 If continuation sheet Page 13 of 13