Health inspection·April 7, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few Review of the staff education dated 4/2/25 noted Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility new employee education and in-service training revealed, At the start of the shift, read the [NAME] for updated changes such as interventions in place for bed mobility, transfer status, falls, behaviors. Review of the clinical record revealed Resident #999 was a [AGE] year-old male with an admission date of 2/14/25. Diagnoses included right side hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) related to Cerebral Vascular Accident, Osteoporosis, and a history of falls. The admission Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 2/21/25 documented Resident #999 was dependent for bathing, toileting, personal hygiene and bed mobility (Helper does all of the effort, Resident does none of the effort to complete the activity). The MDS noted Resident #999's cognitive skills for daily decision making were severely impaired. Resident #999 was rarely/never understood. Review of the New admission re-admission Evaluation form dated 2/14/25 revealed Resident #999 required the physical assistance of two persons for bed mobility. Resident #999 scored 18 on the fall risk evaluation upon admission indicating the resident was at high risk for falls. The care plan initiated on 3/21/25 identified Resident #999 had activity of daily living self-care performance deficit due to, Confusion/decreased cognition, musculoskeletal impairment, stroke, and weakness. The interventions noted the resident had an air mattress to his bed and was, dependent with rolling left to right. The care plan did not specify the resident required the physical assistance of two persons for bed mobility as per the admission MDS assessment. The care plan initiated on 3/21/25 noted Resident #999 was at risk for falls related to decreased cognition and decreased mobility. The goal was, The risk for falls will be minimized through the next review. The interventions included to be sure the resident's call light is within reach and encourage the resident to use if for assistance as needed and evaluate the resident's environment to identify factors known to increase risk of falls. On 4/7/25 at 8:40 a.m., in an interview Unit Manager Registered Nurse (RN) Staff B said, I was in [NAME] Garden secured unit when [Resident #999] fell. I applied ice and printed the paperwork to send him to the hospital. He went to the hospital and did not return. He was a two person assist with care. [CNA Staff A] said she did not have another person with her. On 4/7/25 at 8:48 a.m., in an interview RN Staff C said she works the 11:00 p.m. to 7:00 a.m., shift on the North Unit. She said, We regularly keep the [NAME] up to date. The Unit managers and the nurses can do it. If the CNA notices any changes they tell us. If the resident has had any changes we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 2 of 6 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 04/07/2025 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 0600 update the [NAME]. Level of Harm - Actual harm On 4/7/25 at 8:52 a.m., in an interview North Unit Manager Licensed Practical Nurse Staff C said the CNAs and nurses get resident information from the [NAME] and report from the nurse. Unit Managers and MDS nurses mostly update the [NAME]. We received recent education to ensure the [NAME] is updated and reviewed at the beginning of every shift. Residents Affected - Few On 4/7/25 at 11:05 a.m., in a telephone interview CNA Staff A said, I was working the 3:00 p.m., to 11:00 p.m., shift on 4/1/25. I had worked with Resident #999 before. I went to do my last rounds to see if he needed to be changed. I had him positioned in bed to the left side facing the door. I realized he did not have a fitted sheet on the bed, and I went to get one. Before I turned him on his back, flat on his back in bed. He had an air mattress. I did the upper part of the sheet first. I had all the soiled linen and brief rolled up and against him. I went to place the bottom of the fitted sheet on the bed and he began to roll out of the bed. I tried to stop him but I did not make it. He fell out of bed. I saw him and I did not see any blood, so I ran to get the nurse. When we got back to the room, there was blood everywhere. He had a skin tear to his right arm and it was bleeding. What I did wrong was I did not roll him toward me like I should have. I always did him by myself and no one ever told me he was a two person assist. I never knew about the care [NAME]. They told me about the [NAME] after the fact. I know you need to have two people with a mechanical lift, but he was already in bed, I just wanted to change him. They gave education after the fact. If I had known before, I would have had help, but no one ever told me anything about him. It all happened so fast. Review of the Certified Nursing Aide, Competency Checkoff List revealed Staff A completed Review [NAME] on 1/13/25. On 4/7/25 at 11:45 a.m., in an interview the Administrator said Resident #999 was always a two person assist. From the re-enactment with CNA Staff A, using a pillow to demonstrate, she stood at the bed and he was in the center of the bed, she rolled him away from her and he was at the edge of the bed. I educated her the resident needs to be closer to you so when you turn him he is not so close to the edge, do not center the resident. On 4/7/25 at 11:55 a.m., in an interview Occupational Therapist (OT) Staff G said Resident #999 was on caseload when he was first admitted and he required two persons assist with all his care needs. He said Hospice got involved and had their own therapy seeing the resident but the resident was always two persons assist with his care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 3 of 6 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 04/07/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the safety interventions were documented in the care plan and failed to ensure staff used safe repositioning technique to prevent avoidable fall and fall related serious injury for 1 (Resident #999) of 4 dependent residents reviewed. The findings included: Review of the clinical record revealed Resident #999 was a [AGE] year-old male with an admission date of 2/14/25. Diagnoses included right side hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) related to Cerebral Vascular Accident, Osteoporosis, and a history of falls. Review of the New admission Evaluation form dated 2/14/25 revealed Resident #999 required the physical assistance of two persons for bed mobility. The care plan initiated on 3/21/25 identified Resident #999 was at risk for falls related to decreased cognition and decreased mobility. The resident had activity of daily living self-care performance deficit due to, Confusion/decreased cognition, musculoskeletal impairment, stroke, and weakness. The interventions noted the resident had an air mattress to his bed and was, dependent with rolling left to right. The care plan did not specify the resident required the physical assistance of two persons for bed mobility as per the admission evaluation. The Significant Change in Status Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 3/5/25 documented Resident #999's cognitive skills for daily decision making were severely impaired. Resident #999 was rarely/never understood. The resident's range of motion was impaired on one side of the upper extremities and both sides of the lower extremities. Resident #999 was dependent on staff for activities of daily living, including bed mobility, rolling left and right (Helper does all of the effort, Resident does none of the effort to complete the activity). Review of the progress notes revealed on 4/1/25 Resident #999 had a fall resulting in a hematoma (collection of blood outside of the blood vessels) to the right cheek and a skin tear to the right hand. Resident #999 was transferred to the local hospital for evaluation. Review of the hospital documentation for 4/1/25 revealed Resident #999 had a CT scan (Computerized Tomography) of the head with findings of acute intra-axial hemorrhage (bleeding) within the left frontal lobe (of the brain) measuring 2.0 by 1.7 by 2.4 cm (centimeters). Review of the fall investigation initiated on 4/1/25 revealed Certified Nursing Assistant (CNA) Staff A was changing Resident #999. She turned the resident to the left side to remove the incontinent brief and change the fitted sheet on the bed. As she was placing the fitted sheet on the bed she went to tuck it under and saw the resident move more off the bed. She placed her hand on his side to hold him, he went off falling off the bed because his weight was too heavy on one side. Once the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 4 of 6 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 04/07/2025 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 0689 resident hit the floor CNA Staff A went into the hallway to get help from a CNA or a nurse. Level of Harm - Actual harm A nurse on duty documented CNA Staff A call to her and said Resident #999 fell. Upon arrival to the resident's room, she observed the resident on the floor on his right side. Resident #999 had a hematoma to the right side of the face. Residents Affected - Few Unit Manager Registered Nurse (RN) Staff B obtained a statement from CNA Staff A who said she always cared for Resident #999 and has not had a problem with caring for him. She was changing the resident and the sheets. She rolled the resident over and saw him begin to move and when she went to hold/grab him, he fell. CNA Staff A said no one ever told her she needed two people to care for the resident. She had taken care of him several times and had no problem. CNA Staff A said it just happened so fast. The facility's investigation noted on 4/2/25 CNA Staff A demonstrated how she had Resident #999 centered and as she turned him, he was more toward the other side, away from her which resulted in him falling as he moved. The facility's investigation noted CNA Staff A was given one to one education on proper positioning and following the [NAME] (System of communication and organization used in nursing that helps long term care facilities document resident care summaries) for transfer status. Review of the [NAME] failed to reveal documentation Resident #999 required two persons assistance for bed mobility. Review of the Education/Training provided to CNA Staff A on 4/2/25 noted, When providing care for patients in the bed and turning patient away from you ensure patient is positioned on the side of the bed closest to you to minimize risk of fall from the bed and maintain safety. Start of shift, review [NAME] for each patient to follow plan of care and transfer status. On 4/7/25 at 8:40 a.m., in an interview Unit Manager Registered Nurse (RN) Staff B said, I was in [NAME] Garden secured unit when [Resident #999] fell. I applied ice and printed the paperwork to send him to the hospital. He went to the hospital and did not return. He was a two person assist with care. [CNA Staff A] said she did not have another person with her. On 4/7/25 at 8:48 a.m., in an interview RN Staff C said she works the 11:00 p.m. to 7:00 a.m., shift on the North Unit. She said, We regularly keep the [NAME] up to date. The Unit managers and the nurses can do it. If the CNA notices any changes they tell us. If the resident has had any changes we update the [NAME]. On 4/7/25 at 11:05 a.m., in a telephone interview CNA Staff A said, I was working the 3:00 p.m., to 11:00 p.m., shift on 4/1/25. I had worked with Resident #999 before. I went to do my last rounds to see if he needed to be changed. I had him positioned in bed to the left side facing the door. I realized he did not have a fitted sheet on the bed, and I went to get one. Before I turned him on his back, flat on his back in bed. He had an air mattress. I did the upper part of the sheet first. I had all the soiled linen and brief rolled up and against him. I went to place the bottom of the fitted sheet on the bed and he began to roll out of the bed. I tried to stop him but I did not make it. He fell out of bed. I saw him and I did not see any blood, so I ran to get the nurse. When we got back to the room, there was blood everywhere. He had a skin tear to his right arm and it was bleeding. What I did wrong was I did not roll him toward me like I should have. I always did him by myself and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 5 of 6 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 04/07/2025 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 0689 Level of Harm - Actual harm no one ever told me he was a two person assist. I never knew about the care [NAME]. They told me about the [NAME] after the fact. I know you need to have two people with a mechanical lift, but he was already in bed, I just wanted to change him. They gave education after the fact. If I had known before, I would have had help, but no one ever told me anything about him. It all happened so fast. Residents Affected - Few On 4/7/25 at 11:45 a.m., in an interview the Administrator said Resident #999 was always a two person assist. From the re-enactment with CNA Staff A, using a pillow to demonstrate, she stood at the bed and he was in the center of the bed, she rolled him away from her and he was at the edge of the bed. I educated her the resident needs to be closer to you so when you turn him he is not so close to the edge, do not center the resident. The Administrator added she thought the placement of the resident in the center of the bed was the root cause of the fall but she had 15 days to determine that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105462 If continuation sheet Page 6 of 6