Inspection·November 8, 2023

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR]. Review of Resident #1 physicians' progress note dated [DATE] read, Code status discussed/request {sic} to remain full code. Review of Resident #1's Hospice admission Orders/Hospice Certification dated [DATE] under the section titled, Resuscitation, the Do Not Resuscitate box was left blank/not checked. Review of the nursing progress note dated [DATE] at 8:06 AM, written by Staff A, LPN reads, At approximately 6:30 AM, this nurse went into room [Resident #1's room] to give medication and observed patient lying in bed on back absent of pulse and respiration. Called [Hospice company name], [Resident #1's primary care physician name], and [Resident #1's daughters name]. Review of the hospice form titled Record of Death for Resident #1 completed on [DATE] read, Relative/Guardian: [Resident #1's Daughter's Name]. Time Notified: 0640 [6:40 AM]. Nurse Notifying: [Staff A's Name]. Date & Time Of Death: [DATE] 0630 [6:30 AM]. Service of Doctor: [Resident #1's physician's Name]. Time MD Notified: 0730 [7:30 AM]. Nursing Notifying: [Staff A's Name]. Pronounced By: [Staff A's Name]. Review of Staff A, LPN's, statement of incident dated [DATE] documented, At approximately 0630 [6:30 AM], I came out of room [Facility Resident's Room Number] after passing out medication when CNA [Staff B's Name] came to me and said she thinks [Resident #1's Room Number] has passed. I went immediately and checked the resident for signs of resp. pulse [respirations and pulse]. I did not find any. I went and got my stethoscope and checked to verify my findings. I immediately went to my desk called [Name of Hospice Company] at 0640 [6:40 AM] concerning the expiration on {sic} [Resident #1's Room Number]. I called family at 0645 [6:45 AM] concerning their family member and I contacted the patients' doctor at 7A [7:00 AM]. Hospice nurse arrived to facility at approximately 0730 [7:30 AM]. Review of Resident #1's physicians orders, date created [DATE] at 7:54 AM, by Staff A, LPN, with an order date of [DATE] at 3:15 PM, read, DNR [Do Not Resuscitate]. During an interview on [DATE] at 10:00 AM, the Administrator stated, The Nurse [Staff A, LPN] assigned to Resident #1 had put a DNR order in Resident #1's chart after Resident #1 was found deceased , without an order from the Primary Physician. During a telephone interview on [DATE] at 10:16 AM, Staff B, CNA stated, Around 5:30 AM, I went into the residents' room [Resident #1's room] and noticed he was cold to touch, his lips were a little blue and his chest was not moving up and down. I notified the nurse [Staff A]. I saw her feel for a pulse, she did not start CPR, and [she] said he had passed. During a telephone interview on [DATE] at 12:17 PM, Staff A, LPN stated, At around 6:30 AM I was passing medications, when CNA [Staff B's Name] came and said she thinks [Resident #1 Name] has passed. I went immediately and checked [Resident #1's Name] for signs of respirations, pulse, I did not find any. I went and got my Stethoscope to verify my findings. The resident had no pulse, no eye movements, he was blue and stiff to the touch, he just had that look. I have been a hospice nurse on and off for over 20 years and knew he had been deceased for a while. During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) stated, The LPN [Staff A] (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 11/08/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety did not start CPR. Irreversible death is someone that is cold, has blueness of lips, mottling, lividity, and stiffness. An RN (Registered Nurse) can assess these symptoms and an LPN can observe and report. An LPN can describe symptoms but cannot pronounce death. A physician can pronounce death. When asked why the LPN created a DNR order she stated, the nurse made a mistake, when she thought the resident [Resident #1] was a DNR. A request was made for documentation of Resident #1 exhibiting mottling, lividity, and stiffness. None was provided. Residents Affected - Some Review of www.crossroadshospice.com/hospice-resouces/end-of-lifesigns/mottled-skin-before-death read, Mottling is blotchy, red-purplish marbling of the skin. Mottling most frequently occurs first on the feet, then travels up the legs. Mottling of skin before death is common and usually occurs during the final week of life, although in some cases it can occur earlier. Mottling is caused by the heart no longer being able to pump blood effectively. Because of this, blood pressure drops, causing extremities to feel cool to the touch. The skin then starts to become discolored. During an interview on [DATE] at 11:30 AM, the Regional Nurse Consultant/ [NAME] President (VP) of Clinical Services stated, The CNA [Staff B] informed the LPN [Staff A] the patient [Resident #1] did not seem to be breathing. The LPN [Staff A] looked at patient [Resident #1], there was no heartbeat, no breathing, cyanotic around the mouth, no signs of life. The LPN [Staff A] knew he was on hospice and later realized he was a full code. During a telephone interview on [DATE] at 11:55 AM, Staff C, CNA stated, I was doing my rounds at approximately 6:30 AM, when I was told by [Staff A's name ] that the resident [Resident #1] had passed. When I went in to see [Resident #1's name], I saw that he [Resident #1] had chocolate around his mouth, and a Three Musketeer's candy wrapper on his chest. I helped with the postmortem care of the resident [Resident #1]. During an interview on [DATE] at 2:44 PM, the Medical Director stated, I expect that when an LPN comes across a resident that is a full code and no signs of life that CPR should be started, and EMS [Emergency Medical Services] should be activated. During an interview on [DATE] at 3:15 PM, with Staff A, LPN, when asked if she could clarify why CPR was not started on [Resident #1's name], Staff A stated, When I went into the residents' room, I could see that he was dead, rigor mortis had set in. When asked why she did not chart these observations she stated, That is how I always chart it, just without pulse and respirations. Review of the policy and procedure titled Code Blue & CPR, last reviewed on [DATE], reads, Policy: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of cardiopulmonary resuscitation (CPR). Review of the policy and procedures titled Advance Directives, last reviewed on [DATE], reads, Policy: It will be the policy of this facility that the resident has the right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive and participate in advanced care planning. Advanced directives/advanced care planning designations will be respected in accordance with state law and facility policy. Review of the policy and procedure titled Determination of Code Status, last reviewed on [DATE], reads, Policy: The residents code status will be determined by a physician's order and/or validly executed State of Florida DNR Order Form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and/or documented evidence of resident wishes being in place. 12. Any resident without a signed (continued on next page) 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 11/08/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some State of Florida DNR Order form, or without a Physician's DNR order, or without documented verbal wishes of desire for withholding of resuscitation measures, will be a Full Code. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated [DATE] documented the facility has initiated the following: On [DATE] identified staff member A, LPN and Staff B, CNA have been removed from the schedule. 1. On [DATE] the facility director of nursing/designee initiated a house wide full chart review of residence records and systems reviews to include: cross checking DNR/advanced directives with social service list, ensure DNR orders with the EHR [electronic health record] reflect resident current status, DNR books updated appropriately and reflect physician orders, accuracy of physician orders as it pertains to code status/advanced directives, yellow DNRO [Do Not Resuscitate Order] form scanned into residents records and appropriately signed by the resident or resident representative, DNR book and advanced directive list is accurate and validated, care plan and advanced directive care plan tracking form accurate, validated residents on Hospice to validate code orders, residents on Hospice services to validate code status was residents' choice. 2. On [DATE] the director of nursing conducted an audit of residents currently residing in the facility to ensure accuracy of code status within the facility's electronic health record. 3. Residents on Hospice were interviewed by a licensed nurse to validate code status. 4. On [DATE] the facilities executive director and risk manager was {sic} educated by the regional nurse consultant on components of F678 cardiopulmonary resuscitation (CPR) with an emphasis on the provision of CPR in accordance with physician orders to include monitoring of facility systems during administrative/clinical stand up and stand down to ensure residents receive the necessary care and services. Areas of focus to include: Residents Rights, Advance Directives, Following Physicians Orders, Process of code status determination, performing a Code Blue, Paging overhead during a code, Crash Cart process, Identification and response to a resident found to be unresponsive-assessment/evaluation, eInteract SBAR [Situation, Background, Assessment, Recommendation] and Stop-and-Watch to identify and document change and condition, staff to notify the facility Director of Nursing in person and or phone call as soon as possible in the event of an expired resident to review code status - if the DNS [Director of Nursing Services] is unable to be reached, the Executive Director is to be notified. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. 5. As of [DATE], 20 out of 23 licensed nurses, that includes (Registered Nurses, Licensed practical Nurses) were educated. ***(the 3 licensed nurses that were not educated are PRN [as needed] only, were unable to be contacted and will not work until receiving this education in person) ***(Staff will not work without receiving this education) Numbers [20 out of 23] of employees obtained from current active employee roster. Residents' Rights education to include but not limited to the following: 1. The residents Code Status will be determined by a physician's order and or validly {sic} executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced Directives education to include but not limited to the following: 1. In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced directives the resident will be considered a full code until validation of the resident/representative wishes otherwise. 2. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. Following Physicians Orders. Facility policy regarding code status determination. Completing verbal order if required. Location of DNR order within the EHR. Location of DNR binders (to be used when EHR is inaccessible). Paging overhead during a code. Crash Cart process. (continued on next page) 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 11/08/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Identification and response to a resident found to be unresponsive assessment/evaluation. Timely response to a resident needing assistance. Performing a code blue mock drill documented on code checklist. P&P [policy and procedure] Determination of Code Status. P&P Mock Code. P&P Advanced Directives. P&P Residents Rights. Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. P&P Death of resident with emphasis of a resident may be declared dead by a licensed physician, emergency medical services, or the registered nurse with the physician authorization in accordance with state law. ***(Newly hired employees will receive education on the above in orientation). 2. As of [DATE], 146 out of 160 staff have been educated. ***(the 14 staff members that were not educated due to PRN and/or out of {sic} LOA (Leave of Absence)). ***(Staff will not work without receiving this education) Number of employees [146 out of 160] obtained from current active employee roster. Resident rights education to include but not limited to the following: 1. The residents code status will be determined by a physician's order and or validly executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced directives education to include but not limited to the following: 1. In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced 2. {sic} directives the resident will be considered a full code until validation of the resident/representative wishes otherwise. 3. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. 4. Where to locate physician order for code status in the EHR. 5. eInteract Stop and Watch to identify and document change in condition. ***(Newly hired employees will receive education in orientation). 1. On [DATE] Systemic Change: the licensed nurse and one other staff member to verify codes status prior to initiating CPR or withholding CPR. 2. On [DATE] Systemic Change: the facility initiated an advanced directives compliance tracking tool to be used daily during morning clinical meetings to validate advanced directives for new admissions or readmissions and to validate or confirm code status log is being carried out and remains effective. This tool will be utilized to validate any changes in code status as well as tracking new admissions. 3. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meeting to validate that if there is a code that the licensed nurse and one other staff member are to verify code status prior to initiating CPR or withholding CPR. 4. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meetings to validate that licensed physician, a registered nurse, or emergency medical services with physician authorization in accordance with the state law has pronounced death. 5. On [DATE], [DATE], [DATE] Ad-Hoc Quality Assurance Performance Improvement meetings were carried out as it relates to resident rights to formulate advanced directives, provision of CPR, competent staffing, and neglect to include a root cause analysis using 5 why's QAPI CMS [Centers for Medicare and Medicaid Services] tool and audits to be carried out with progress presented to monthly QAA [Quality Assurance and Accreditation] to ensure compliance/recommendations. Review of the Notice of Disciplinary Action for Staff A, LPN, and Staff B, CNA related to employment suspension was documented as completed on [DATE]. Review of the house wide full chart review of resident records including cross checking DNR/advanced directives with social service list, ensure DNR orders with the EHR reflect resident current status, DNR books updated appropriately and reflect physician orders, accuracy of physician orders as it pertains to code status/advanced directives, yellow DNRO form scanned into residents records and appropriately signed by the resident or resident representative, DNR book (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 11/08/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety and advanced directive list is accurate and validated, care plan and advanced directive care plan tracking form accurate, validated residents on Hospice to validate code orders, residents on Hospice services to validate code status was residence choice were documented as completed on [DATE]. Review of the audit to ensure code status within the electronic health record was documented as completed on [DATE] by the Director of Nursing. Residents Affected - Some Review of education conducted by the Regional Nurse Consultant on the components of F678 Cardiopulmonary Resuscitation with an emphasis on the provisions of CPR in accordance with physician orders including monitoring of facility systems for the facility's Executive Director and the Risk Manager were documented as completed on [DATE] and for the Director of Nursing was documented as completed on [DATE]. Review of the facility's education on Resident's Rights, Advanced Directives, following Physicians Orders, facility policy regarding code status determination, completing verbal order if required, location of DNR Order with the EHR, location of DNR binders, paging overhead during a code, crash cart process, identifications and responses to a resident found to be unresponsive, assessment/evaluation, timely response to a resident needing assistance, performing a code blue (mock codes) documented on code check list, Policy and Procedure on Determination of Code Status, Policy and Procedure on Mock Code, Policy and Procedure on Advanced Directives, Policy and Procedure on Code Blue and CPR, Policy and Procedure on Resident Rights, Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record, Policy and Procedure on Death of a Resident with emphasis of a resident may be declared dead by a Licensed Physician, Emergency Medical Services, or the Registered Nurse with physician authorization for 20 out of 23 licensed nurses were documented as completed on [DATE]. Review of the facility's education on Resident's Rights, Advanced Directives, following Physicians Orders, facility policy regarding code status determination, completing verbal order if required, location of DNR Order with the EHR, location of DNR binders, where to locate physician order for code status in the EHR, einteract Stop and Watch to identify change in condition for 146 out of 160 staff was documented as completed on [DATE]. Review of the Advanced Directives Compliance Tracking Tool initiated on [DATE] was documented and up to date as of [DATE]. Review of the Supervisor Tool initiated on [DATE] was documented and up to date as of [DATE]. A review of the Ad-Hoc QAPI meetings held on [DATE], and [DATE] were carried out as it relates to Resident Rights to formulate Advanced Directives, Provisions of CPR, Competent Staffing, and Neglect. Those in attendance included The facility administrator, Director of Nursing, Clinical Educator/Risk Manager, Unit Manager, MDS, Admissions, Rehab, Staffing, Dietary, Social Services Director, Activities, Medical Records, Environmental Services, Maintenance, and the Medical Director. During staff interviews completed on [DATE], 5 RN's, 12 LPN's, and 14 CNA's verified having received education and verbalized understanding of advanced directives, facility policy regarding code status, where to find the code status in the EHR residents rights, identifying and responding to a resident found to be unresponsive, and when to initiate/withhold CPR. 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 11/08/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure nursing staff followed policy/procedure and the nurse practice act related to initiating emergency care for a resident found to be without a pulse or respiration such as initiating cardiopulmonary resuscitation (CPR) or calling emergency medical services. Staff A, a Licensed Practical Nurse, observed Resident #1 on [DATE] at 6:30 AM, unresponsive and absent of life, pronounced Resident #1 as deceased and withheld cardiopulmonary resuscitation despite the resident's full code status. The Licensed Practical Nurse stated the resident was dead and she did not provide cardiopulmonary resuscitation or contact Emergency Medical Services. The resident was not legally pronounced deceased until the Medical Director wrote a clarification statement on [DATE] at 8:27 PM stating that he had acknowledged the resident's death by releasing the remains to a funeral home. The hospice report of death record states that facility staff pronounced the resident deceased and did not document hospice's assessment of the resident's status. Resident #1 was pronounced deceased by Staff A, LPN who is not qualified to pronounce. CPR was not initiated per the resident's wishes due to the determination of being deceased by Staff A. The Administrator was informed of the existence of and provided with the template for Immediate Jeopardy on [DATE] at 1:50 PM. The Immediate Jeopardy began on [DATE] and was removed on site on [DATE]. The scope and severity of the deficiencies were lowered to E, pattern, with no actual harm, with potential for more than minimal harm when the facility provided evidence of the actions taken to remove the immediacy. Findings include: Review of the Licensed Practical Nurse/Registered job description reads, Purpose of your job position: The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by CNA's and other nursing personnel. Such supervision must be in accordance with current federal state and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. Charting and Documentation: Complete and file required record keeping forms or charts upon the resident's admission, transfer and or discharge. Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies. Receive telephone orders from physicians and record on the physician's order form. Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents' response to the care. Maintain established nursing objectives and standards. Ensure that the direct nursing care is provided by a licensed nurse, qualified to perform the procedure. Use an automated external defibrillator as required. Perform Cardiopulmonary Resuscitation (CPR) as necessary. Ensure that personnel providing direct care to residents are providing such care in accordance with the residents' care plan and wishes. Specific Requirements: Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities. (continued on next page) 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 11/08/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the Nurse Practice Act reads, (15) Licensed practical nurse means any person licensed in this state or holding an active multistate license under s. 464.0095 to practice practical nursing. (18) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist; and the teaching of general principles of health and wellness to the public and to students other than nursing students. Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure, morbid obesity due to excess calories, cirrhosis of the liver, hemiplegia and hemiparesis following cerebral infarction, left nondominant side, atherosclerotic heart disease of native coronary artery without angina pectoris, essential (primary) hypertension, major depressive disorder, generalized anxiety, and cognitive communication deficit. Review of Resident #1's resident centered care plan initiated on [DATE] read, [Resident #1's name] expressed the following wishes regarding code status and has the following advanced directives in place: is Full Code. [Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR]. Review of the nursing progress note dated [DATE] at 8:06 AM, written by Staff A, LPN reads, At approximately 6:30 AM, this nurse went into room [Resident #1's room] to give medication and observed patient lying in bed on back absent of pulse and respiration. Called [Hospice company name], [Resident #1's primary care physician name], and [Resident #1's daughters name]. Review of the hospice form titled Record of Death for Resident #1 completed on [DATE] read, Relative/Guardian: [Resident #1's Daughter's Name]. Time Notified: 0640 [6:40 AM]. Nurse Notifying: [Staff A's Name]. Date & Time Of Death: [DATE] 0630 [6:30 AM]. Service of Doctor: [Resident #1's physician's Name]. Time MD Notified: 0730 [7:30 AM]. Nursing Notifying: [Staff A's Name]. Pronounced By: [Staff A's Name]. Review of Resident #1's physicians orders, date created [DATE] at 7:54 AM, by Staff A, LPN, with an order date of [DATE] at 3:15 PM, read, DNR [Do Not Resuscitate]. During an interview on [DATE] at 10:00 AM, the Administrator stated, The Nurse [Staff A, LPN] assigned to Resident #1 had put a DNR order in Resident #1's chart after Resident #1 was found deceased , without an order from the Primary Physician. During a telephone interview on [DATE] at 10:16 AM, Staff B, CNA stated, Around 5:30 AM, I went into the residents' room [Resident #1's room] and noticed he was cold to touch, his lips were a little blue and his chest was not moving up and down. I notified the nurse [Staff A]. I saw her feel for a pulse, she did not start CPR, and [she] said he had passed. During a telephone interview on [DATE] at 12:17 PM, Staff A, LPN stated, At around 6:30 AM I was passing medications, when CNA [Staff B's Name] came and said she thinks [Resident #1 Name] has passed. I went immediately and checked [Resident #1's Name] for signs of respirations, pulse, I did not find any. I went and got my Stethoscope to verify my findings. The resident had no pulse, no eye movements, he was blue and stiff to the touch, he just had that look. I have been a hospice nurse on and (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 11/08/2023 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 0726 off for over 20 years and knew he had been deceased for a while. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) stated, The LPN [Staff A] did not start CPR. Irreversible death is someone that is cold, has blueness of lips, mottling, lividity, and stiffness. An RN (Registered Nurse) can assess these symptoms and an LPN can observe and report. An LPN can describe symptoms but cannot pronounce death. A physician can pronounce death. When asked why the LPN created a DNR order she stated, the nurse made a mistake, when she thought the resident [Resident #1] was a DNR. A request was made for documentation of Resident #1 exhibiting mottling, lividity, and stiffness. None was provided. Residents Affected - Some During an interview on [DATE] at 11:09 AM, the Administrator stated, The nurse [Staff A] pronounced the death. When asked if an LPN can pronounce death, the Administrator stated, Two nurses can pronounce death, a single LPN cannot pronounce death. During an interview on [DATE] at 11:30 AM, the Regional Nurse Consultant/ [NAME] President (VP) of Clinical Services stated, The CNA [Staff B] informed the LPN [Staff A] the patient [Resident #1] did not seem to be breathing. The LPN [Staff A] looked at patient [Resident #1], there was no heartbeat, no breathing, cyanotic around the mouth, no signs of life. The LPN [Staff A] knew he was on hospice and later realized he was a full code. During a telephone interview on [DATE] at 11:55 AM Staff C, CNA stated, I was doing my rounds at approximately 6:30 am, when I was told by [Staff A's name] that [Resident #1] had passed. During an interview on [DATE] at 2:24 PM, the Risk Manager stated, An LPN cannot pronounce death. During an interview on [DATE] at 2:44 PM, the Medical Director stated, I expect that when an LPN comes across a resident that is a full code and no signs of life that CPR should be started, and EMS [Emergency Medical Services] should be activated. An LPN cannot pronounce death. During an interview on [DATE] at 3:15 PM, with Staff A, LPN, when asked if she could clarify why CPR was not started on [Resident #1's Name], Staff A stated, When I went into the residents' room, I could see that he was dead, rigor mortis had set in. When asked why she did not chart these observations she stated, that is how I always chart it, just without pulse and respirations. During an interview on [DATE] at 3:40 PM the Regional Nurse Consultant and VP of Clinical Services stated, An LPN cannot pronounce death, it is out of the scope of practice for an LPN. Review of the Facility Assessment Tool, updated [DATE], documented every staff member has knowledge competency in: abuse, neglect, exploitation and misappropriation, resident rights; identification of condition change; and resident preferences. Additional knowledge competencies for all staff include dementia management, infection transmission and prevention, immunization, QAPI [Quality Assurance Performance Improvement], and OSHA hazard communication. Competencies are based on current standards of practice. Competencies are verified upon orientation, at least annually and as needed. The facility provides education and training. The staff training and education program is designed to ensure knowledge competency for all staff. Review of the policy and procedure titled Code Blue & CPR, last reviewed on [DATE], reads, Policy: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of cardiopulmonary resuscitation (CPR). (continued on next page) 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 11/08/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the policy and procedures titled Advance Directives, last reviewed on [DATE], reads, Policy: It will be the policy of this facility that the resident has the right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive and participate in advanced care planning. Advanced directives/advanced care planning designations will be respected in accordance with state law and facility policy. Review of the policy and procedure titled Determination of Code Status, last reviewed on [DATE], reads, Policy: The residents code status will be determined by a physician's order and/or validly executed State of Florida DNR Order Form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and/or documented evidence of resident wishes being in place. 12. Any resident without a signed State of Florida DNR Order form, or without a Physician's DNR order, or without documented verbal wishes of desire for withholding of resuscitation measures, will be a Full Code. Policy for pronouncement of death was requested on [DATE] at 11:30 AM and at 3:44 PM. No policy was received. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated [DATE] documented the facility has initiated the following: On [DATE] identified staff member A, LPN and staff member B, CNA have been removed from the schedule. 1. On [DATE] the facility Director of Nursing/designee initiated a house - wide full chart review of resident records and systems reviews to include: Cross checking DNR/advanced directives with Social Service List. Ensure DNR orders with the EHR [electronic health record] reflect resident status. DNR books updated appropriately and reflect physician orders. Accuracy of physician orders as it pertains to code status/advanced directives. Yellow DNRO [Do Not Resuscitate Order] form scanned into resident records and appropriately signed by the resident or resident representative. DNR book and Advanced Directive list is accurate and validated. Care Plan and advanced directive care plan tracking form accurate. Validated residents on hospice to validate code orders. Residents on hospice services to validate code status was resident's choice. 2. On [DATE] the Director of Nursing conducted an audit of residents currently residing in the facility to ensure accuracy of code status within the facility's electronic health record. 3. Residents on hospice were interviewed by a licensed nurse to validate code status. 4. On [DATE] the facilities Executive Director and Risk Manager and [DATE] Director of Nursing Services was re-educated by the Regional Nurse Consultant on components of F726 Competent Nursing Staff with an emphasis on the provision of CPR in accordance with physician orders to include monitoring of facility systems during administrative/clinical stand up and stand down to ensure residents receive the necessary care and services and ensuring only qualified individual pronouncement death of a resident in the facility. Areas of focus to include: Residents Rights, Advance Directives, Following Physicians Orders, Process of code status determination, performing a Code Blue, Paging overhead during a code, Crash Cart process, Identification and response to a resident found to be unresponsive-assessment/evaluation, eInteract SBAR [Situation, Background, Assessment, Recommendation] and Stop-and-Watch to identify and document change and condition, staff to notify the facility Director of Nursing in person and or phone call as soon as possible in the event of an expired resident to review code status - if the DNS [Director of Nursing Services] is unable to be reached, the Executive Director is to be notified. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. The facility has initiated a supervisory tool to be used daily during clinical meetings to validate that Licensed Physician, a Registered Nurse, or Emergency Medical Services with physician authorization in accordance with the state law has pronounced death. As of [DATE], 20 out of 23 licensed nurses, that includes (Registered Nurses, Licensed practical Nurses) were educated. ***(the 3 licensed (continued on next page) 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 11/08/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some nurses that were not educated are PRN [as needed] only, were unable to be contacted and will not work until receiving this education in person) ***(Staff will not work without receiving this education) Numbers [20 out of 23] of employees obtained from current active employee roster. Residents' Rights education to include but not limited to the following: 1. The residents Code Status will be determined by a physician's order and or validly executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced Directives education to include but not limited to the following: In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced directives the resident will be considered a 'full code' until validation of the resident/representative wishes otherwise. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. Procedure: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and or respirations. In the absence of pulse and or respirations do the following: 11/2022 Revised: 1. Remain calm. Remain with the resident. 2. Call out for help. 3. Licensed Nurse will assume command of the scene and will direct other personnel in the effort. 4. Direct a staff member to announce the emergency per facility Protocol (i.e., Code Blue & room [ROOM NUMBER] times) and director staff to bring Emergency Equipment Cart to the scene. 5. Two staff members other than the one who is evaluating the resident and preparing to provide emergency care, must promptly check current code status by checking the code status sections of the EHR [Electronic Health Record], eMAR [Electronic Medication Administration Record] or point of care kiosk. At that point provisions or withholding of resuscitation efforts may begin. If a patient is determined to be a full code, CPR will be initiated immediately. 6. (* In the event the EHR is unavailable, code status may be validated using a secondary check of the code binder via presence of physician order and or a signed State of Florida Do Not Resuscitate Order (DH form #1896), and or documented verbal wishes of resident/representative or physician order) CPR will be initiated and will continue until the arrival of EMS or until discovery of a valid DNR. 7. If, after the initiation of resuscitative efforts, a physician order, a valid State of Florida Do Not Resuscitate Order (DH form #1896), and or documented verbal wishes of resident/representative is found, resuscitative efforts may be ceased or withdrawn as long as such efforts have been unsuccessful to that point. 8. If resuscitation efforts have been initiated, and are successful, such efforts should continue until arrival of EMS, even if a valid DNR/Advanced Directive has later been discovered. 9. Once resuscitative efforts are concluded, or resident is transported to the emergency center: a. Call attending/covering provider. b. Call emergency center and give report to the Admitting/Triage nurse as appropriate. c. Call resident family representative. d. Document details of resuscitative efforts in the EHR in a timely manner to include all observation/assessment and care provided. CPR sequence: 1. Check patient for responsiveness. 2. If unresponsive, call for help and activate EMS, or direct others to do so. 3. Obtain emergency equipment or direct others to do so. 4. Check for breathing and pulse. 5. If no pulse, and not breathing, begin CPR cycle (30 compressions/2 breaths) ***Compressions depths for ADULT are as follows: at least 2 inches (5cm) but avoid compressions deeper than 2.4 inches (6cm) (See AHA (American Heart Association) flowchart on next page). Clinical signs of irreversible death per AHA include: Decapitation, Transection, Decomposition, Dependent Lividity, Rigor Mortis. Following Physicians Orders. Facility policy regarding code status determination. Completing verbal order if required. Location of DNR order within the EHR. Location of DNR binders (to be used when EHR is inaccessible). Paging overhead during a code. Crash Cart process. Identification and response to a resident found to be (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 11/08/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some unresponsive assessment/evaluation. Timely response to a resident needing assistance. Performing a code blue mock drill documented on code checklist. P&P [policy and procedure] Determination of Code Status. P&P Mock Code. P&P Advanced Directives. P&P Residents Rights. Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record. The licensed nurse and one other staff member to verify code status prior to initiating CPR or withholding CPR. P&P Death of resident with emphasis of a resident may be declared dead by a licensed physician, emergency medical services, or the registered nurse with the physician authorization in accordance with state law. ***(Newly hired employees will receive education on the above in orientation). 2. As of [DATE], 146 out of 160 staff have been educated. ***(the 14 staff members that were not educated due to PRN and/or out of {sic} LOA (Leave of Absence)). ***(Staff will not work without receiving this education) Number of employees [146 out of 160] obtained from current active employee roster. Resident rights education to include but not limited to the following: 1. The residents code status will be determined by a physician's order and or validly executed State of Florida DNR Order form (Florida Department of Health Do Not Resuscitate Form #DH 1896) and or documented evidence of resident wishes being in place. Advanced directives education to include but not limited to the following: 1. In the event that the resident does not have previously developed advanced directives or declines to create and participate in development of advanced 2. {sic} directives the resident will be considered a full code until validation of the resident/representative wishes otherwise. 3. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record readily retrievable by facility staff. 4. Where to locate physician order for code status in the EHR. 5. eInteract Stop and Watch to identify and document change in condition. ***(Newly hired employees will receive education in orientation). 1. On [DATE] Systemic Change: the licensed nurse and one other staff member to verify codes status prior to initiating CPR or withholding CPR. 2. On [DATE] Systemic Change: the facility initiated an advanced directives compliance tracking tool to be used daily during morning clinical meetings to validate advanced directives for new admissions or readmissions and to validate or confirm code status log is being carried out and remains effective. This tool will be utilized to validate any changes in code status as well as tracking new admissions. 3. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meeting to validate that if there is a code that the licensed nurse and one other staff member are to verify code status prior to initiating CPR or withholding CPR. 4. On [DATE] Systemic Change: the facility has initiated a supervisor tool to be used daily during clinical meetings to validate that licensed physician, a registered nurse, or emergency medical services with physician authorization in accordance with the state law has pronounced death. 5. On [DATE], [DATE], [DATE] Ad-Hoc [when necessary or needed] Quality Assurance Performance Improvement meetings were carried out as it relates to resident rights to formulate advanced directives, provision of CPR, competent staffing and neglect to include a root cause analysis using 5 why's QAPI CMS [Centers for Medicare and Medicaid Services] tool and audits to be carried out with progress presented to monthly QAA [Quality Assurance and Accreditation] to ensure compliance/recommendations. Review of Suspension for Staff A, LPN, and staff B, CNA was documented on [DATE]. Review of the house wide full chart review of resident records including cross checking DNR/advanced directives with social service list, ensure DNR orders with the EHR [electronic health record] reflect resident current status, DNR books updated appropriately and reflect physician orders, accuracy of physician orders as it pertains to code status/advanced directives, yellow DNRO [Do Not Resuscitate Order] form scanned into residents records and appropriately signed by the resident or resident representative, DNR book and advanced directive list is accurate and (continued on next page) 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 11/08/2023 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 0726 Level of Harm - Immediate jeopardy to resident health or safety validated, care plan and advanced directive care plan tracking form accurate, validated residents on Hospice to validate code orders, residents on Hospice services to validate code status was residence choice. was documented as completed on [DATE]. Review of the Director of Nursing audit to ensure code status within the electronic health record was documented as completed on [DATE]. Residents Affected - Some Review of Education given by the Regional Nurse Consultant on the components of F678 Cardiopulmonary Resuscitation with an emphasis on the provisions of CPR in accordance with physician orders including monitoring of facility systems for the facility's Executive Director and the Risk Manager was documented as completed on [DATE]. Review of the facility's education on Resident's Rights, Advanced Directives, following Physicians Orders, facility policy regarding code status determination, completing verbal order if required, location of DNR Order with the EHR, location of DNR binders, paging overhead during a code, crash cart process, identifications and responses to a resident found to be unresponsive, assessment/evaluation, timely response to a resident needing assistance, performing a code blue (mock codes) documented on code check list, Policy and Procedure on Determination of Code Status, Policy and Procedure on Mock Code, Policy and Procedure on Advanced Directives, Policy and Procedure on Code Blue and CPR, Policy and Procedure on Resident Rights, Nursing Documentation Legal Aspects related to accuracy of documentation in the clinical record, Policy and Procedure on Death of a Resident t with emphasis of a resident may be declared dead by a Licensed Physician, Emergency Medical Services, or the Registered Nurse with physician authorization for 20 out of 23 licensed nurses was documented as completed on [DATE]. Review of mock code drills were documented as conducted and completed for each shift from [DATE] through [DATE]. Review of the Advanced Directives Compliance Tracking Tool initiated on [DATE], was documented and up to date as of [DATE]. Review of the Supervisor Tool initiated on [DATE] was documented and up to date as of [DATE]. A review of the Ad-Hoc QAPI meetings held on [DATE], [DATE], and [DATE], were carried out as it relates to Resident Rights to formulate Advanced Directives, Provisions of CPR, Competent Staffing, and Neglect. Those in attendance included The facility administrator, Director of Nursing, Clinical Educator/Risk Manager, Unit Manager, MDS, Admissions, Rehab, Staffing, Dietary, Social Services Director, Activities, Medical Records, Environmental Services, Maintenance, and the Medical Director. During staff interviews completed on [DATE], 5 RN's, and 12 LPN's verified having received education and verbalized understanding of resident rights, advanced directives, following physicians' orders, process of code status determination, performing a code blue, crash cart process, documentation in point click care, confirmation of code order by 2 licensed nurses, policy and procedure death of a resident with emphasis of who may declare a death in the facility. During staff interviews completed on [DATE], 5 RN's, 12 LPN's, and 14 CNA's verified having received education and verbalized understanding of advanced directives, facility policy regarding code status, where to find the code status in the EHR residents rights, identifying and responding to a resident found to be unresponsive, and when to initiate/withhold CPR. 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 11/08/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a complete and accurately documented medical records for 1 of 3 sampled residents, Resident #1. Findings include: Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure, morbid obesity due to excess calories, cirrhosis of the liver, hemiplegia and hemiparesis following cerebral infarction, left nondominant side, atherosclerotic heart disease of native coronary artery without angina pectoris, essential (primary) hypertension, major depressive disorder, generalized anxiety, and cognitive communication deficit. Review of the nursing progress note dated [DATE] at 8:06 AM, written by Staff A, LPN reads, At approximately 6:30 AM, this nurse went into room [Resident #1's room] to give medication and observed patient lying in bed on back absent of pulse and respiration. Called [Hospice company name], [Resident #1's primary care physician name], and [Resident #1's daughters name]. [close quote] Review of Resident #1's physicians orders, date created [DATE] at 7:54 AM, by Staff A, LPN, with an order date of [DATE] at 3:15 PM, read, DNR [Do Not Resuscitate]. During an Interview on [DATE] at 10:00 AM, the Administrator stated, The Nurse [Staff A, LPN] assigned to Resident #1 had put a DNR order in Resident #1's chart after Resident #1 was found deceased , without an order from the Primary Physician. During a telephone interview on [DATE] at 11:08 AM, Resident #1's primary physician stated, I did not sign a DNR order for [Resident #1's Name]. During an interview on [DATE] at 10:00 AM, the Risk Manager stated, The certified nursing assistant [Staff B] who was assigned to [Resident #1's Name] had checked on the resident at 2:30 AM. The resident was sleeping. At 6:30 AM, she was doing her last rounds and found the resident unresponsive and cool to the touch. [Staff B's name] notified [Staff A's name] who assessed the resident, found no pulse, the resident was cool to the touch, and had pooling on his left side. There was no documentation in the resident's chart. Documentation of the pooling of blood was requested. The facility did not provide the requested documentation. During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) stated, The LPN [Staff A] did not start CPR. Irreversible death is someone that is cold, has blueness of lips, mottling, lividity, and stiffness. A request was made for documentation of Resident #1 exhibiting mottling, lividity, and stiffness. None was provided. During an interview on [DATE] at 3:15 PM, with Staff A, LPN, when asked if she [Staff A] could clarify why CPR was not started on [Resident #1's Name], Staff A stated, When I went into the residents' room [Resident #1's room], I could see that he was dead, rigor mortis had set in. When asked why she did not chart these observations she stated, That is how I always chart it, just without pulse and respirations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 If continuation sheet Page 14 of 14