Health inspection·July 20, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Devices) dressings are changed appropriately. It would be a risk for infection if they weren't, but that is a question for nursing, the DON [Director of Nursing]. During an observation of medication administration conducted by Staff D, LPN for Resident #200 on 7/20/2022 at 6:30 AM, Staff D assembled all supplies, performed hand hygiene and donned gloves, removed the end cap from the needleless connector, cleaned the needleless connector for 20 seconds with alcohol, attached the normal saline syringe, and administered 5 milliliters of normal saline without checking for the line patency (verifying for blood return) and administered the medication intravenously. During an interview on 7/20/2022 at 7:10 AM, Staff D, LPN, stated, I asked if I should check for blood return and was told that I didn't need to. There was no order for it. During an interview on 7/20/2022 at 7:30 AM, the Interim Director of Nursing stated, It is not in our policy that we have to verify blood return. Review of the facility policy and procedure titled P & P PICC IV [Peripherally Inserted Central Catheter Intravenous] Line issued on 1/1/2022, reads, Policy: It will be the policy of this facility to adhere to IV/PICC line administration guidelines as set forth by infection control, state and federal regulations. Licensed nurses shall provide care according to state and federal law . Dressing Changes: 1. Sterile dressing change using transparent dressings is performed: * 24 hours post-insertion or upon admission if not dated on admission. * At least weekly. * If the integrity of the dressing has been compromised (wet, loose, or soiled). 2. Dressing changes will be documented in the clinical record. Review of the document titled SASH Technique provided by the facility reads, The Infusion Nurses Society's Infusion Nursing Standards of Practice clearly define three purposes of catheter flushing: to assess catheter function, to maintain catheter patency, and to prevent contact between incompatible medications or fluids that could produce a precipitate. For effective catheter flushing, the nurse must have an understanding of technique and the equipment used within his/her institution as well as the type of catheter in use. S- Saline Flush ensures patency of the line of residual medication . * Aspirate for blood return to ensure line patency before each access. 2. Review of Resident #206's records revealed the resident was admitted to the facility on [DATE] with the diagnoses including other idiopathic peripheral autonomic neuropathy, COVID-19 infection, other chronic osteomyelitis right ankle and foot, and acute kidney failure, unspecified. During an observation on 7/17/2022 at 9:25 AM, Resident #206 had a PICC line dressing with a dressing date of 7/11/2022. During an observation on 7/17/22 at 2:25 PM, Resident #206 had a PICC line dressing dated 7/11/2022. Review of the physician orders for Resident #206 revealed no orders in the computer for dressing changes. Review of the Medication Administration Record (MAR) for Resident #206 revealed no dressing changes documented on the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 - Many Review of the Treatment administration record (TAR) for Resident #206 revealed no dressing changes documented on the TAR. During an interview on 7/17/2022 at 2:25 PM, Staff D, Licensed Practical Nurse (LPN), stated, I don't see any orders for PICC line dressing changes. His PICC line dressing date is 7/11/2022. That was before he was admitted and I think they need to be changed, so we can see the site. I think it is every 7 days. During an observation on 7/20/2022 at 7:00 AM, Resident #206's PICC line dressing was dated 7/17/2022 and there was a 2x2 gauze dressing under the transparent dressing. During an observation of medication administration conducted by Staff D, LPN for Resident #206 on 7/20/2022 at 7:00 AM, Staff D, LPN, donned gloves after performing hand hygiene, assembled all supplies, prepared the IV medication, scrubbed the needleless connector with alcohol for 20 seconds, flushed the PICC line without checking patency of line (checking for blood return), attached the intravenous line to the needleless connector and began infusing the medication. During an interview on 7/20/2022 at 7:10 AM, Staff D, LPN, stated, I asked if I should check for blood return and was told that I didn't need to. There was no order for it. I was not aware that if there was gauze under the transparent dressing that it needed to be changed more frequently. I can't see the site to see if there is any redness or drainage at the insertion site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nutritional supplements were offered as ordered by the physician for 1 of 5 residents reviewed for nutrition, Resident #70, in a total sample of 48 residents. Residents Affected - Few Findings include: Review of Resident #70's records revealed the resident was admitted to the facility on [DATE] with the diagnoses including essential (primary) hypertension, major depressive disorder, other specified arthritis, personal history of COVID-19, and primary insomnia. Review of the physician orders for Resident #70 reads, Order Summary: Magic cup one time a day for wound healing lunch daily. Order Date: 07/10/2022. During an observation on 7/17/2022 at 1:39 PM, no magic cup provided to Resident #70 on her lunch tray. During an observation on 7/18/2022 at 12:34 PM, Resident #70 did not have magic cup delivered on her meal try. During an observation on 7/19/2022 at 12:44 PM, Resident #70 had no magic cup delivered on her lunch tray. During an interview on 7/19/2022 at 12:45 PM, Staff A, Licensed Practical Nurse (LPN), stated, She does have an order for a magic cup with lunch. Isn't it on the tray. I see that it isn't on the meal ticket, so I don't know how they would know to put it on the tray. During an interview on 7/19/22 at 12:56 PM, the Registered Dietician stated, I usually let the staff know that I have orders for supplements. Unfortunately, this did not get conveyed to the dietary staff and we have not provided the magic cups on the trays since the order was written on 7/11/2022. The only way that dietary would know to get the magic cup on the tray is to review the meal ticket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 7/17/2022 at 9:37 AM, Resident #78 was sitting up in a chair with the oxygen concentrator behind the resident. Oxygen was infusing at 4 liters per minute via concentrator, and the tubing was dated 7/4/2022. A passive nebulizer mask was on the resident's bed. Residents Affected - Some Review of Resident #78's records revealed the resident was admitted to the facility on [DATE] with the diagnoses including type 2 diabetes mellitus with diabetic neuropathy, hypertensive heart disease with heart failure, lymphedema, heart failure, unspecified atrial fibrillation (an irregular heartbeat), atherosclerotic heart disease of native coronary artery, and chronic obstructive pulmonary disease. Review of the physician orders for Resident #78 reads, Order Summary: May apply O2 @ 2 LPM via nasal cannula as needed related to Chronic Obstructive Pulmonary Disease . Order Date: 07/08/2022 . Order Summary: Ipratropium- Albuterol Solution 0.5-2.5 (3) mg [milligrams]/3 ml [milliliters], 3 ml inhale orally four times a day related to Chronic Obstructive Pulmonary Disease unspecified . Order Date: 05/19/2022. During an observation on 7/17/2022 at 1:00 PM, Resident #78 was sitting up in a chair with oxygen at 4 liters per minute via concentrator with a passive nebulizer mask on the resident's bed. During an interview on 7/17/2022 at approximately 1:00 PM, Staff B, Registered Nurse (RN), stated, It is running at 4 liters. The resident can't reach it. The tubing was dated 7/4. It needs to be changed. Review of the facility policy and procedure titled P & P Oxygen Administration issued on 4/1/2022, reads, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident . 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident . 6. After completing the oxygen setup, administration or adjustment, it is appropriate to document in the appropriate locations of the medical record such as nurses' notes, MAR [Medication Administration Record]/TAR [Treatment Administration Record], etc. Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care and services consistent with professional standards of practice for 2 of 3 residents, Residents #89 and #78, in a total sample of 48 residents. Findings include: 1. Review of Resident #89's records revealed the resident was admitted to the facility with a diagnosis including chronic obstructive pulmonary disease and congestive heart failure. Review of the physician orders for Resident #89 reads, reads, Order Summary: May apply O2 [oxygen] @ [at] 3 LPM [Liters Per Minute] via nasal cannula as needed for respiratory distress related to Chronic Obstructive Pulmonary Disease . Order Date: 04/13/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 7/18/2022 at 9:30 AM, Resident #89 was resting with head of bed at 30 degrees with oxygen being administered at 1 liter via nasal cannula. During an interview on 7/18/2022 at 9:11 AM, Resident #89 stated, My oxygen is set at 1 and I only use oxygen when needed. I do not change the oxygen setting. I just take the tubing out of my nose at times and put it back on when I need it. During an interview on 7/18/2022 at 10:02 AM, Staff D, License Practical Nurse (LPN) stated, Nurses check oxygen rate and tubing each shift. During an observation on 7/19/2022 at 10:10 AM, Resident #89 was resting in bed with eyes closed and oxygen being delivered at 1 liter via nasal cannula. During an interview on 7/19/2022 at 10:11 AM, Staff H, LPN, confirmed that oxygen was being administered at 1 liter per minute to Resident #89. Staff H verified the physician orders and stated that the orders were for 3 liters via nasal cannula. Staff H stated that only nurses adjust the oxygen, and she was not aware that the resident was on oxygen and had not reviewed the physician orders. During an interview on 7/19/2022 at 1:51 PM, Staff I, LPN, Unit Manager, stated, I expect our nurses to verify that the oxygen is being administered at the correct rate per physician orders and nurses are to check oxygen rate and tubing every shift. Flow sheet for oxygen administration is to be completed with each PRN [as needed] use of oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 medically-related social services for 1 of 3 residents reviewed, Resident #17, in a total sample of 48 residents. Residents Affected - Few Findings include: Review of Resident #17's admission record revealed the resident was admitted to the facility on [DATE] with the diagnoses including quadriplegia; unspecified, post-polio syndrome; central retinal vein occlusion, left eye, stable; primary open-angle glaucoma, bilateral, stage unspecified; and unspecified vision loss. During an observation on 7/17/2022 at 9:39 AM, Resident #17 was in his room, lying in his bed immobile and nonresponsive to interview attempts. Review of Resident #17's Referral to Therapy form, signed by the Speech Language Pathologist on 4/10/2022, reads, 4/3: Attempted to eval [evaluate] swallow status. Pt [patient] presents as Confused rambling incoherently. Diff [difficulty] communicating needs as he is sev [severely] HOH [hard of hearing], no glasses thus cannot use comm [communication] board to get written message. Referral to Social services requesting: glasses and Hearing device to Facilitate communication to id [identify] wants, needs, somatic c/o [complaints] and assess swallow status. During an interview on 7/19/2022 at 9:14 AM, the Social Services Director confirmed there was no documentation in Resident #17's clinical record to show that the Speech Language Pathologist's recommendation had been followed by the social services department. On 7/19/2022 beginning at 9:18 AM, an observation of Resident #17's room was completed with the Social Services Director. The Social Services Director opened Resident #17's dresser and bedside table drawers and was unable to locate a hearing device or glasses. During an interview on 7/19/2022 at 9:28 AM, Staff E, Speech Language Pathologist, stated she had spoken with the previous Social Services Director related to a referral for Resident #17 to be assessed for a hearing device and glasses to assist him with communication. During an interview on 7/19/2022 at 10:03 AM, Staff F, Licensed Practical Nurse, stated she did not know Resident #17 to have a hearing device or glasses. She added, I have never seen glasses or hearing aids since I've been taking care of him. Review of the facility policy and procedure titled P& P Social Services issued on 4/1/2022 and last reviewed on 4/7/2022, reads, Policy: It will be the policy of this facility to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident to assure that sufficient and appropriate social services are provided to meet the resident's needs. Definitions: . Examples of medically-related social services include, but not limited to the following: . * Making referrals and obtaining needed services from outside entities (e.g. talking books, absentee ballots, community wheelchair transportation). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and included the expiration date when applicable in 4 of 5 medication carts reviewed. Findings include: During an observation of medication cart #1 on 7/17/2022 at 8:50 AM with Staff A, Licensed Practical Nurse (LPN), there were one opened Timolol ophthalmic solution with no resident identifier and no opened date, one opened Latanoprost ophthalmic solution with no opened or expiration dates, one unopened Latanoprost ophthalmic solution with the pharmacy instructions to refrigerate until opened, one opened Erythromycin ophthalmic ointment with no opened date, one Basaglar insulin pen with no opened or expiration dates, one opened Lantus insulin pen with no opened or expiration dates, one unopened Humalog insulin with the pharmacy instructions to refrigerate until opened, one opened Humalog insulin with no opened or expiration dates, and one opened Lantus insulin with no opened or expiration dates. During an interview on 7/17/2022 at 8:57 AM, Staff A, LPN, stated, This is not my usual cart. All insulins should have a date when it was opened. It should not be on the cart until we need to use it. During an observation of medication cart #2 on 7/17/2022 at 8:59 AM with Staff B, Registered Nurse (RN), there were one opened Lantus insulin with no opened or expiration dates, one Victoza insulin with no opened or expiration dates, one opened Levemir insulin with no opened or expiration dates, one Tresiba pen with no opened or expiration dates, one unopened Humalog insulin with the pharmacy instructions to refrigerate until opened, one opened Humalog insulin with no opened or expiration dates, one opened Lantus insulin with no opened or expiration dates, and one bottle of lubricant eye drops with no opened or expiration dates. During an interview on 7/17/2022 at 9:03 AM, Staff B, RN, stated, All insulins should stay in the refrigerator until it is opened, and once we open them, we are supposed to put the date opened on it. During an observation of medication cart #3 on 7/17/2022 at 9:15 AM with Staff C, LPN, there were one opened Latanoprost ophthalmic solution with no opened or expiration dates, one unopened Latanoprost ophthalmic solution with the pharmacy instructions to refrigerate until opened, one opened bottle of Latanoprost ophthalmic solution with no resident identifier and no opened or expiration dates, one opened Humalog insulin with no opened or expiration dates, one unopened Lantus insulin with the pharmacy instructions to refrigerate until opened, one Ozempic pen with no opened or expiration dates and no resident identifier, and one unopened Humalog insulin with the pharmacy instructions to refrigerate until opened. During an interview on 7/17/2022 at 9:25 AM, Staff C, LPN, stated, I should have all of these labeled when they are opened, and insulin should not be on the cart if we aren't ready to use it. During an observation of medication cart #4 on 7/17/2022 at 9:31 AM with Staff D, LPN, there were one unopened Humalog insulin with the pharmacy instructions to refrigerate until opened, one opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0761 Level of Harm - Minimal harm or potential for actual harm Lantus insulin with no opened or expiration dates, one Humalog insulin with no opened or expiration dates, and one Ozempic insulin with no resident identifier and no opened or expiration dates. During an interview on 7/17/2022 at 9:37 AM, Staff D, LPN, stated, All insulins should have a label on them when they get opened or stay in the refrigerator. Residents Affected - Some Review of the facility policy and procedure titled P & P Medication/Biological Storage issued on 4/1/2022 reads, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure: . 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner . 5. Medications requiring specified use by dates related to the date the medication was opened, such as insulin, shall be labeled with the open date . 11. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secure location. Medications must be stored separately from food and must be labeled accordingly. Routine temperature monitoring should take place to ensure proper maintenance of appliance and medication storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain the food production area and equipment in a clean and sanitary manner. Residents Affected - Many Findings include: During the initial tour on 7/17/2022 beginning at 9:07 AM with the Certified Dietary Manager (CDM), observation of the food production area and equipment showed: 1. The oven had a black sticky substance around the control knobs under both the stove top and flat top. The stove front had long black, brown and white drips running down the length of the stove front. The stove door handles had a brown substance on them. 2. The fryer had white drips and splatter on both the front and sides of the fryer. 3. The tile floor between the fryer and convection oven had large amounts of black substances on the floor. The metal strip on the floor to the left of the fryer had large amounts of black debris along its length. 4. The convection oven window was brown. When convection oven doors were open, there were black and brown substance along the inside front of the convection oven with yellow drips along the edge. 5. The steamer was located on a stainless steel two-tiered table. The bottom shelf of the table had a yellow liquid pooling in the back right corner. The floor around the steamer had areas of discoloration on the floor. (Photographic evidence obtained) During an interview on 7/17/2022 at 9:25 AM, the CDM confirmed the food production area and equipment observed during the tour were not clean. Review of the facility policy titled Cleaning Guidelines. Floors, Tables, Chairs, undated, reads 1. Kitchen floors will be swept and cleaned after each meal. A thorough cleaning using a disinfectant will be done at least daily. Major appliances will be moved at least once a month (as appropriate) in order to facilitate cleaning behind and underneath them. Review of the facility policy titled Cleaning Guidelines. Ovens, undated, reads, 10. Remove spills and food particles after each oven use as needed (before re-heating the oven). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure medical records were complete and accurately documented for 1 of 6 residents reviewed for unnecessary medications, Resident #80, in a total sample of 48 residents. Findings include: Review of the admission record for Resident #80 documented an admission date of 2/16/2022 with medical diagnoses that included type 1 diabetes mellitus with diabetic peripheral angiopathy (blood vessel disease caused by high blood sugar levels) without gangrene, gastroparesis, other chronic pancreatitis, and long-term use of insulin. Review of the Medication Administration Record (MAR) for the period from 6/1/2022 through 6/30/2022 for Resident #80 reads, Humalog Solution 100 unit/ml [milliliter] (Insulin Lispro (Human)), Inject as per sliding scale: if [Blood sugar levels are] 201-250 = 2 units, under 60 follow hypoglycemia protocol, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401+ administer 10 units and notify MD [Medical Doctor], subcutaneously before meals and at bedtime for diabetes . Insulin Glargine-yfgn [Lantus, long-acting type of insulin that works slowly over 24 hours] 100 unit/ml Solution pen-injector, Inject 20 unit subcutaneously in the morning for DM [Diabetes Mellitus]. The MAR contained no documentation of blood sugar and Humalog administration on 6/11/2022 at 4:30 PM and 9:00 PM, and 6/22/2022 at 6:00 AM. The MAR also contained no documentation of insulin administration on 6/22/2022. Review of the medical record for Resident #80 revealed no documentation that the physician was notified on the following dates where blood sugar was documented greater than 401: 6/13/2022 at 4:30 PM documented blood sugar of 458, 6/19/2022 at 4:30 PM documented blood sugar of 546, 6/20/2022 at 11:30 AM documented blood sugar of 512, and 6/24/2022 at 6:30 AM documented blood sugar of 445. Review of the MAR for the period from 7/1/2022 through 7/31/2022 for Resident #80 reads, Humalog Solution 100 unit/ml (Insulin Lispro (Human)), Inject as per sliding scale: if [Blood sugar levels are] 201-250 = 2 units, under 60 follow hypoglycemia protocol, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401+ administer 10 units and notify MD, subcutaneously before meals and at bedtime for diabetes . Insulin Glargine-yfgn 100 unit/ml Solution pen-injector, Inject 20 unit subcutaneously in the morning for DM. The MAR contained no documentation of blood sugar and Humalog administration on 7/1/2022 at 4:30 PM and 9:00 PM, 7/4/22 at 6:30 AM, 7/7/2022 at 9:00 PM, 7/9/2022 at 6:30 AM, 7/10/2022 at 9:00 PM, and 7/17/2022 at 4:30 PM. The MAR also contained no documentation of insulin administration on 7/4/2022, 7/9/2022 and 7/17/2022 at 6:00 AM. Review of the medical record for Resident #80 revealed no documentation that the physician was notified on the following dates where blood sugar was documented greater than 401: 7/3/2022 at 4:30 PM documented blood sugar of 439, 7/6/2022 at 4:30 PM documented blood sugar of 500, 7/6/2022 at 9:00 PM documented blood sugar of 485, 7/9/2022 at 11:30 AM documented blood sugar of 490, 7/14/2022 at 4:30 PM documented blood sugar of 531, 7/17/2022 at 4:30 PM documented blood sugar of 543. During an interview on 7/19/2022 at 11:15 AM, Staff J, Unit Manager, Licensed Practical Nurse (LPN), stated, There is usually documentation in the progress notes if the blood sugar is over 401 and the doctor is supposed to be called. The call to the doctor is documented when the call was made and if any new orders for insulin. When there are blanks or no documentation on the MAR, it is assumed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0842 that the resident did not get the insulin. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/19/2022 at 11:45 AM, Staff K, LPN, confirmed that the blanks on the MAR meant that the medication was not given. She confirmed the initials on the MAR dated 7/9/22 were hers. She stated, If you didn't chart it, you didn't do it. I called the doctor but did not document it in the medical record. Residents Affected - Few During an interview on 7/19/2022 at 1:10 PM, the Medical Director stated, Personally, I feel the staff has done a good job with [Resident #80's name], but needs to document better when they contact me and the I can see that follow through on record when I come in. He also stated that he received most of his notifications by text message. He was last notified on 7/17/22. Review of the facility policy and procedure titled Charting and Documentation revised in July 2017 and last reviewed on 4/7/2022 reads, Policy Statement. All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . 2. The following information is to be documented in the resident medical record . b. Medications administered . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment provided . f. Notification of family, physician, or other staff, if indicated. Review of the facility policy and procedure titled P & P Medication Administration issued on 1/1/2022 and last reviewed on 4/7/2022 reads, Procedure . 9. The individual administering the medication must initial the resident's MAR on the appropriate line and date for that specific day when administering the next resident's medication. If the facility is utilizing Electronic Health Records (EHR) and eMAR [electronic medication administration record], an electronic signature is appropriate . 14. When medications are administered, the individual administering the medication must record in the resident's medical record/MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure the staff performed hand hygiene during medication administration in 6 of 8 observations of medication administration. Residents Affected - Some Findings include: During an observation of medication administration on 7/19/2022 at 8:30 AM, Staff F, Licensed Practical Nurse (LPN), poured medications for Resident #8 without performing hand hygiene, entered the resident's room without performing hand hygiene, administered medications, and returned to the medication cart. During an observation of medication administration on 7/19/2022 at 8:35 AM, Staff F, LPN, poured medications for Resident #58, entered the resident's room, assisted the resident with repositioning, administered the medications, and returned to the medication cart and began pouring medications for another resident. Staff F did not perform hand hygiene. During an observation of medication administration on 7/19/2022 at 8:41 AM, Staff F, LPN, poured medications for Resident #207, entered the resident's room without performing hand hygiene, administered the medications, returned to the medication cart, and began preparing medications for another resident. During an interview on 7/19/2022 at 8:48 AM, Staff F, LPN, stated, Oh, I should have used the hand sanitizer when I went into the rooms and each time I started pouring the medications. During an observation of medication administration on 7/19/2022 at 8:52 AM, Staff A, LPN, poured medications for Resident #59 without performing hand hygiene, entered the resident's room, administered the medications, returned to the medication cart, and began preparing medications for another resident. During an observation of medication administration on 7/19/2022 at 8:55 AM, Staff A, LPN, poured medications for Resident #56 after performing hand hygiene. Staff A needed to obtain a medication from the emergency drug kit. Staff A locked the medication cart, went to the medication room, obtained the medication from the emergency drug kit, returned to the medication cart, unlocked the cart, and poured the rest of the resident's medications without performing hand hygiene. Staff A entered Resident #56's room without performing hand hygiene and returned to the medication cart. During an observation of medication administration on 7/19/2022 at 9:06 AM, Staff A, LPN, poured medications for Resident #41, entered the resident's room without performing hand hygiene, administered the medications and returned to the medication cart. During an interview on 7/19/2022 at 9:11 AM, Staff A, LPN, stated, I should have washed my hands each time I poured medications. Review of the facility policy and procedure titled P & P Hand Hygiene issued on 4/1/2022 reads, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 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 105467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williston Care Center and Rehab 300 NW 1st Ave Williston, FL 32696 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 0880 Level of Harm - Minimal harm or potential for actual harm spread of infections to other personnel, residents, and visitors . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents; c. Before preparing and handling medications. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 If continuation sheet Page 14 of 14