Health inspection·January 11, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/11/2024 at 10:55 AM the Director of Nursing (DON) stated, All the low blood sugars should have been called to the doctor. I can't find any notification to the doctor in the chart. There are no nurses' notes about this. They should have followed the doctors' orders, and they didn't. During an interview on 1/11/2023 at 2:00 PM Staff G, Registered Nurse, (RN) stated, I remember that her [Resident #47] blood sugar was 48, she was on her cell phone, and I didn't see any concerns. I should have notified the doctor. I can't tell you why I didn't. I was not following the doctors' orders. Review of the policy and procedure titled, Diabetes/hypo/hyperglycemia [low/high blood sugar] with an issue date of 4/1/2022, last approval date of 8/12/2023 read, It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. 5. Staff will provide glucose [sugar] monitoring, medication administration, laboratory testing and diet per physician orders.7. Staff should report signs and symptoms of hypoglycemia to the physician. Many residents receiving insulin or oral hypoglycemics have parameters as to when the physician should be notified. 14. Document pertinent information regarding medication administration, changes in condition, education, or interventions in the clinical record. 2. Review of the admission record for Resident #361 documented diagnoses that include chronic obstructive pulmonary disease, asthma, type II diabetes mellitus, and essential primary hypertension. Review of the admission MDS (Minimum Data Set) for Resident #361 dated 1/5/2024 documented a BIMS (Brief Interview of Mental Status) as a 03, (suggests severe cognitive impairment). Review of the nursing progress note for Resident #361 dated 1/6/2024 at 8:21 AM read, Patient had a fall attempting to get up from his chair. Patient was checked and assessed, he denies any pain. No injuries observed. Vital signs within normal limits, b/p [blood pressure] 116/64, pulse 80, resp [respirations] 18 temp [temperature] 97.5. Review of the medical record for Resident #361 did not provide for documentation of the resident's representative being notified of the resident having suffered a fall. Review of the nursing progress note for Resident #361 dated 1/9/2024 at 1541 (3:41 PM) documented the physician was notified of the resident's fall, but the record did not contain documentation of the resident's representative being notified of the resident's fall. 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 01/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review the facility failed to implement a person-centered comprehensive care plan for respiratory care for 2 of 3 residents, Resident #96 and #7, reviewed for respiratory care services out of a total sample of 37 residents. Findings include: Review of the admission record for Resident #96 documented diagnosis to include chronic obstructive pulmonary disease (COPD), chronic systolic congestive heart failure (CHF), acute respiratory distress, and essential primary hypertension. Review of the physician orders for Resident #96 dated 10/21/2023 read, Continuous O2 [oxygen] at 3 LPM [liters per minute] via nasal cannula as needed for respiratory distress. Review of the written plan of care for Resident #96 read, [Resident #96's name] has a potential for complications of respiratory distress r/t [related to] dx [diagnosis] of COPD and CHF. Interventions: Administer O2 as ordered (3 liters) During an observation on 1/8/2024 at 11:09 AM Resident #96 was observed in bed with oxygen being administered by a concentrator at 4 liters via nasal cannula. During an observation on 1/10/2024 at 12:16 PM Resident #96 was observed in bed with oxygen being administered by a concentrator at 3.5 liters via nasal cannula. During an interview on 1/10/2024 at 12:30 PM Staff H, Licensed Practical Nurse (LPN) stated, The oxygen is running at, I think, 3-3.5 liters. We should follow the orders and the care planned interventions when running oxygen. He is care planned for oxygen at 3 liters. During an interview on 1/11/2023 at 10:52 AM the Director of Nursing (DON) stated, We should administer oxygen at the ordered rates, and we should follow the care plans and the care planned interventions. 2. Review of the admission record for Resident #7 documented diagnosis to include chronic COPD, chronic respiratory failure with hypoxia, hypertensive heart failure, and heart failure. Review of the physician orders for Resident #7 dated 8/9/2023 read, Ipratropium-Albuterol inhalation solution 0.5-2.5 3 mg/3 ml [3 milligrams per 3 milliliters] inhale orally three times a day for COPD. Review of the written plan of care for Resident #7 read, [Resident #7's name] has a potential for complications of respiratory distress r/t dx of COPD, CHF. Interventions: Administer O2 as ordered. (3 Liters, store respiratory equipment in infection control bag when not in use; change q [every] week and prn [as needed]. During an observation on 1/8/2024 at 10:36 AM Resident #7 was observed at bedside with oxygen being administered via nasal cannula. A passive nebulizer (respiratory equipment), was sitting on the nightstand with unlabeled tubing and no infection control bag to store the nebulizer when not in use. (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 01/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 1/8/2023 at 11:00 AM Staff C, LPN stated, I don't know why the passive nebulizer isn't in a bag, it should be. During an interview on 1/11/2023 at 10:52 AM the Director of Nursing (DON) stated, We should have all respiratory care equipment in a bag, and we should be following our care planned interventions. There is no policy that I know of for this. 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 01/11/2024 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and review of the facility policies and procedures the facility failed to ensure residents who required blood glucose monitoring received treatment in accordance with professional standards of practice by failing to document, assess and treat hypoglycemia (low blood sugar) for 1 of 3 residents, Resident #47, reviewed for insulin administration. Residents Affected - Few Findings include: Review of the admission record for Resident #47 documented diagnosis to include type II diabetes mellitus, chronic pancreatitis, gastroparesis, gastroesophageal reflux disease, essential tremor, and major depressive disorder. Review of the physician orders for Resident #47 dated 7/7/2023 read, For blood sugar less than 60 and resident is able to swallow, administer food or glucose gel per manufacturers instruction and notify MD [Medical Doctor] as needed for hypoglycemia. Review of the physician orders for Resident #47 dated 10/22/2023 read, Humalog injection solution inject as per sliding scale. Inject subcutaneously before meals and at bedtime. If less than 70, notify MD [Medical Doctor], follow hypoglycemia [a low blood sugar result] protocol. Inject as per sliding scale, 201-250 = 2 units, 251-300 = 4 units, 301-360 = 8 units, greater than 400, administer 10 units and notify MD. Review of the January 2024 medication administration record (MAR) for Resident #47 documented a blood sugar of 48 at 6:30 AM on 1/5/2024, a blood sugar of 54 documented on 1/6/2024 at 6:30 AM, and a blood sugar of 64 documented on 1/10/2024 at 6:30 AM. There was no documentation of treatment for the low blood sugar results as ordered by the physician. Review of the December 2023 MAR for Resident #47 documented a blood sugar of 60 on 12/16/2023 at 6:30 AM, a blood sugar of 44 on 12/21/2023 at 6:30 AM, and a blood sugar of 53 documented on 12/27/2023 at 6:30 AM. There was no documentation of treatment for the low blood sugar results as ordered by the physician. Review of the nursing progress notes for Resident #47 for the period of 12/01/2023 through 01/10/2024 did not provide for documentation of the physician being notified of Resident #47's blood sugar results of less than 70 per the MD orders related to the sliding scale and/or notification when the resident's blood sugar results were less than 60. There was no documented notification to the resident's representative of the resident's change in condition. The nursing progress notes did not provide documentation of an assessment of the resident with findings of a low blood sugar, treatment of the blood sugars less than 60, or of a reassessment of the resident's blood sugars. During an interview conducted on 1/11/2024 at 10:55 AM the Director of Nursing stated, All the low blood sugars should have been called to the doctor. I can't find any notification to the doctor in the chart, no nurses' notes about this. They should have followed the doctors' orders, and they didn't. The nurses should have treated the low blood sugars per the orders and rechecked the blood sugars. That is a standard of practice. During an interview conducted on 1/11/2023 at 2:00 PM Staff G Registered Nurse (RN) stated, I remember that her [Resident #47] blood sugar was 48, she was on her cell phone, and I didn't see any (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 01/11/2024 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete concerns. I did not use the hypoglycemia protocol. I did not recheck her blood sugar. She seemed just fine, her usual self. I don't remember if I had told the oncoming nurse about her blood sugar. I should have rechecked her blood sugar and offered her the hypoglycemia protocol. I should have notified the doctor. I can't tell you why I didn't. I was not following the doctor's orders. Review of the policy and procedure titled, Diabetes/hypo/hyperglycemia [low/high blood sugar] issued date of 4/1/2022, with a last approval date of 8/12/2023 reads It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. 5. Staff will provide glucose monitoring, medication administration, laboratory testing and diet per physician orders.7. Staff should report signs and symptoms of hypoglycemia to the physician. Many residents receiving insulin or oral hypoglycemics have parameters as to when the physician should be notified. 10. Nursing interventions, per physician orders, may vary for residents experiencing hypoglycemia depending on the severity and symptoms of the resident as residents' behavior is different depending on their sensitivity to hypoglycemia. Responsive residents that are able to swallow may receive juice or other rapidly absorbed glucose as an intervention. Responsive residents that are unable to swallow or unresponsive residents may receive oral glucose paste to the buccal mucosa, intramuscular glucagon, or IV 50% dextrose and notify physician for further orders. 14. Document pertinent information regarding medication administration, changes in condition, education, or interventions in the clinical record. 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 01/11/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to provide the necessary care and services for maintaining urine flow and ensuring proper infection control techniques for urinary catheter care for 1 of 3 residents, Resident #361, reviewed for urinary catheters in a total sample of 37 residents. Findings include: Review of the admission record for Resident #361 documented diagnoses to include chronic obstructive pulmonary disease, asthma, type II diabetes mellitus, and essential primary hypertension. Review the physician orders for Resident #361 dated 12/29/2023 read, Catheter Care: Monitor urinary catheter for impairment of drainage flow (kinks). Ensure bag has privacy cover and is below bladder. During an observation on 1/8/2024 at 11:51 AM, Resident #361 was sitting in a wheelchair in the hallway with a urinary catheter drainage bag attached to the wheelchair with the catheter tubing resting on the floor and dragging across the floor when Resident #361 began wheeling himself in the hallway. The tubing had amber colored urine and was not able to drain into the urinary catheter drainage bag. During an observation on 1/9/2024 at 7:51 AM, Resident #361 was sleeping in bed with his urinary catheter drainage bag on the floor with amber colored urine from the top of the tubing, filling the tubing and unable to drain into the urinary catheter drainage bag. During an observation on 1/10/24 at 8:15 AM, Resident#361 was sitting in a wheelchair with a urinary catheter bag attached to the wheelchair. The catheter tubing was looped and was dragging on the floor as the resident wheeled himself in the wheelchair. The tubing was filled with amber colored urine and was unable to drain into the urinary catheter drainage bag. During an interview on 1/9/2023 at 7:55 AM Staff F, Certified Nursing Assistant (CNA) stated, Oh, it [the catheter tubing/drainage bag] should not be that way. The tubing should not be all looped and kinked and it should not be on the floor. The urine needs to drain into the bag, and it can't. During an interview on 1/9/2024 at 8:03 AM, Staff C, Licensed Practical Nurse (LPN) stated, The catheter [drainage bag] should not be on the floor and tubing should not be dragged on the ground. Catheters should be kept so urine is able to flow out and it can't that way. During an interview on 1/11/2023 at 10:40 AM the Director of Nursing (DON) stated, All catheter tubing should be free of loops or kinks that would prevent the urine from freely draining. This could cause a UTI [urinary tract infection]. We should evaluate the resident when we place them in a wheelchair to make sure the tubing is not looping, kinking, or dragging on the ground. Review of the policy and procedure titled, Indwelling Catheters with an issue date of 4/1/2022, and last approval date of 8/12/2023 read, It will be the policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Procedure: 10. Staff should ensure proper placement of the catheter tubing (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 01/11/2024 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 0690 as to ensure that it is not kinked, pulling and allows for gravity drainage . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 01/11/2024 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 review of facility policy and procedure the facility failed to label and store all medications in accordance with professional standards of practice in 3 of 4 medication carts reviewed for medication storage. Findings include: During an observation of medication cart #1 on 1/8/2023 at 8:55 AM with Staff A, Licensed Practical Nurse (LPN) there was one unopened Levemir insulin pen with pharmacy instructions to refrigerate until opened and one unopened Ozempic pen with pharmacy instructions to refrigerate until opened. During an interview on 1/8/2024 at 9:03 AM Staff A, LPN stated, They must have just been put on the cart. I did not put them on the cart. They should be in the refrigerator until we need them, and they are opened. During an observation of medication cart #2 on 1/8/2024 at 9:05 AM with Staff B, LPN there was one unopened bottle of latanoprost ophthalmic solution (eye drops) with pharmacy instructions to refrigerate until opened, and one Loperamide (a medication to treat diarrhea) tablet with no resident identifier and not in the original pharmacy packaging. During an interview on 1/8/2024 at 9:10 AM Staff B, LPN stated, I think the eye drops are labeled to refrigerate until opened, these are not opened. During an observation of medication cart #3 on 1/8/2024 at 9:12 AM with Staff C, LPN there was one opened 10 ml (milliliter) bottle of Lidocaine 1% with no resident identifier, no date opened and not within the original pharmacy packaging, one opened bottle of Lidocaine 1% 10 ml bottle with no date opened, one opened bottle of Dorzol/timolol ophthalmic solution with no date opened, one opened bottle of prednisolone acetate ophthalmic solution with an opened date of 11/2/2023 and one opened bottle of Latanoprost 0.005% ophthalmic solution with an open date of 11/2/23. During an interview on 1/8/2023 at 9:15 AM Staff C, LPN stated, The lidocaine should have the dates opened, what the resident's name is, and it should be in the pharmacy bag with the resident's name. I think all eye drops are good for six months after they are opened, but I don't really know. Review of GoodRx - www.goodrx.com reads, Many manufacturers recommend that you throw away eye drops 28 days after opening the bottle. This is because the preservatives inside can start to break down and allow bacteria to grow. During an interview on 1/11/2024 at 11:10 AM the Director of Nursing (DON) stated, I expect all staff to label medications, remove expired medications from the cart daily, and keep all medications in the refrigerator until they are ready to be used. Review of the policy and procedure titled, Medication/Biological Storage with an issued date of 4/1/2022, and last approval date of 8/12/2023, read, Policy: It will be the policy of this facility to store medications, drugs, and biologicals in a safe, secure, and orderly manner. Procedure: 1. Medications, drugs and biologicals shall be stored in the packaging, containers, or other dispensing (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 01/11/2024 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 systems in which they are received, unless otherwise necessary. 4. The facility shall not use discontinued, outdated up to including (7-days) or deteriorated medications, drugs, or biologicals. 10. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses station or other secure location. Medications must be stored separately from food and must be labeled accordingly . Residents Affected - Some 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 01/11/2024 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 Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and policy and procedure review, the facility failed to ensure food items are dated and/or labeled, expired sanitation test strips are discarded, and food is served in accordance with professional standards for food service and safety. Findings include: During an initial walk through of the kitchen on 1/08/24 at 9:15 AM with the Charge Cook, Staff E, an observation was made of nine bags of various vegetables in the reach-in freezer that had been removed from their original packaging and were not labeled with a food item identifier, receive date, or use-by date. An observation was made of test strips used for dish washing to verify the concentration of the sanitizer to verify it is strong enough to kill bacteria, viruses, and fungi, or that it is not too strong, had an expiration date of 11/20/23. An interview was conducted with Staff E on 1/08/24 at 9:20 AM. Staff E stated the test strips were expired and should have been discarded on 11/20/23, the vegetables in the reach-in freezer should have had identifying labels as well as use-by dates. An interview was conducted on 1/09/24 at 6:00 AM with the Food Service Director (FSD). The FSD stated all items should be labeled and dated (related to the assorted vegetables identified in the freezer). The FSD confirmed the test strips should have been replaced upon expiration as the expired strips may not reflect the correct readings. An observation was made on 1/08/24 at 11:30 AM of an uncovered baker rack being used to transport lunch meal trays to the west-1 hall with silverware not wrapped or covered. An observation was made on 1/08/24 at 11:43 AM of an uncovered baker rack being used to transport lunch meal trays to the west-2 hall with silverware not wrapped or covered. An observation was made on 1/08/24 at 11:50 AM of an uncovered baker rack being used to transport lunch meal trays to the north-1 hall with silverware not wrapped or covered. An observation was made on 1/08/24 at 11:30 AM of an uncovered baker rack being used to transport lunch meal trays to the north-2 hall with silverware not wrapped or covered. An observation was made on 1/09/24 at 7:30 AM of an uncovered baker rack being used to transport breakfast meal trays to the west-1 hall with juice and silverware not wrapped or covered. An observation was made on 1/09/24 at 7:44 AM of an uncovered baker rack being used to transport breakfast meal trays to the west-2 hall with juice and silverware not wrapped or covered. An observation was made on 1/09/24 at 7:44 AM of an uncovered baker rack being used to transport breakfast meal trays to the north-1 hall with juice and silverware not wrapped or covered. An observation was made on 1/09/24 at 8:03 AM of an uncovered baker rack being used to transport (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 01/11/2024 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 breakfast meal trays to the north-2 hall with juice and silverware not wrapped or covered. Level of Harm - Minimal harm or potential for actual harm An observation was made on 1/09/24 at 11:22 AM of an uncovered baker rack being used to transport lunch meal trays to the west-1 hall with silverware not wrapped or covered. Residents Affected - Few An observation was made on 1/09/24 at 11:30 AM of an uncovered baker rack being used to transport lunch meal trays to the west-2 hall with silverware not wrapped or covered. An observation was made on 1/09/24 at 11:44 AM of an uncovered baker rack being used to transport lunch meal trays to the north-1 hall with silverware not wrapped or covered. An observation was made on 1/09/24 at 11:55 AM of an uncovered baker rack being used to transport lunch meal trays to the north-2 hall with silverware not wrapped or covered. An observation was made on 1/10/24 at 7:25 AM of an uncovered baker rack being used to transport breakfast meal trays to the west-1 hall with juice and silverware not wrapped or covered. An observation was made on 1/10/24 at 7:37 AM of an uncovered baker rack being used to transport breakfast meal trays to the west-2 hall with juice and silverware not wrapped or covered. An interview was conducted on 1/10/24 at 7:35 AM with Staff D, Dietary Aide who stated the baker rack she was delivering down to the west-2 hall did not have a cover and the silverware was not wrapped or covered. An interview was conducted on 1/10/24 at 7:37 AM with the Administrator who confirmed the baker racks being used to deliver meals were not covered and the silverware was exposed. Review of the policy and procedure titled, Dishes and Infection Control Practices dated 4/01/2022 and revised on 10/01/2023 read, 6. Ensure that sanitation strips used to measure PPM [parts per million] are current and not past the expiration date for use for dish machines and three compartment sinks, or as otherwise indicated. 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 01/11/2024 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 resident record review and interview the facility failed to ensure accurate and complete record documentation of insulin administration for 1 of 3 residents, Resident #47, reviewed for insulin administration. Findings include: Review of the admission record for Resident #47 documented diagnosis that include type II diabetes mellitus, chronic pancreatitis, gastroparesis, gastroesophageal reflux disease, essential tremor, and major depressive disorder. Review of the physician orders for Resident #47 dated 10/22/2023 read, Humalog injection solution inject as per sliding scale. Inject subcutaneously before meals and at bedtime. If less than 70, notify MD [Medical Doctor], follow hypoglycemia [a low blood sugar result] protocol. Inject as per sliding scale, 201-250 = 2 units, 251-300 = 4 units, 301-360 = 8 units, greater than 400, administer 10 units and notify MD. Review of the physician orders for Resident #47 dated 12/14/2023 read, Lantus subcutaneous solution inject 34 units every 12 hours related to Type 2 Diabetes Mellitus. Review of January 2024 medication administration record (MAR) for Resident #47 did not provide for documentation of medication administration on 1/5/2024 at 1800 (6:00 PM), it was blank for Lantus 34 units subcutaneously. Review of the January MAR for Resident #47 Humalog injection solution inject as per sliding scale. Inject subcutaneously before meals and at bedtime, did not provide for documentation, the MAR was left blank, on 1/1/2024 at 1130, on 1/2/2024 at 1130, on 1/5/2024 at 1630 (:30 PM). Review of the December 2023 MAR for Resident #47 did not provide for documentation of medication administration on 12/31/2023 at 1800 (6:00 PM), it was blank, for Lantus 34 units subcutaneously. Review of the December 2023 MAR for Resident #47 did not provide for documentation of blood sugar or medication administration on 12/10/2023 at 11:30 AM, 12/12/2023 at 2100 (9:00 PM), 12/18/2023 at 6:30 AM, 12/18/2023 at 2100, 12/21/2023 at 2100, 12/23/2023 at 11:30 AM, 12/30/2023 at 11:30 AM, 12/31/2023 at 11:30 AM, 1630 (4:30 PM) and 2100, all areas for documentation were left blank. During an interview on 1/11/2023 at 11:07 AM the Director of Nursing (DON) stated, The nurses should be documenting all blood sugars or that the resident is out of the building. This resident has frequent leaves and goes with her medications. We should still be documenting that she is not in the building. 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 01/11/2024 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 review of facility policies and procedures the facility failed to ensure infection control practice standards were maintained for 1 of 5 observations during medication administration. Residents Affected - Few Findings include: During an observation of medication administration conducted on 1/10/2024 at 7:05 AM, for Resident #4, Staff I, Registered Nurse (RN) did not perform hand hygiene when returning to the medication cart and began to prepare medications for Resident #4. Staff I, RN did not perform hand hygiene when entering Resident #4's room, touched the overbed table and moved it out of the way, and administered oral medications. Staff I, RN exited the room without performing hand hygiene, returned to the medication cart, retrieved eye drops and returned to Resident #4's room, donned gloves without performing hand hygiene, administered one eye drop into Resident #4's left eye, removed the gloves and went to the trash can to dispose of the gloves. One glove dropped on the floor beside the trash can and Staff I, RN leaned down placing her left ungloved hand on the trash can for support with her fingers on the inside rim of the trash can, she then picked up the glove with her right hand and disposed of it in the trash can. Staff I, RN returned to Resident #4's bedside, donned gloves without performing hand hygiene and administered an eye drop to Resident #4's right eye. Staff I, RN removed her gloves and wiped the excess eyedrop from Resident #4's cheek with her ungloved hand. Staff I, RN then exited the room without performing hand hygiene and began giving report to the oncoming nurse. During an interview on 1/11/2024 at 10:47 AM Staff I, RN stated, I should not have placed my hand on the trash can. I should have washed my hands or used hand sanitizer when I poured the medications, entered the room, before I put on gloves, after I removed my gloves. I just didn't think when I bent over to pick up the glove. I should not have wiped her eye drops off of her face. I didn't have any tissues and there weren't any in the room. Review of the policy and procedure titled, Hand Hygiene with an issue date of 4/1/2022, and last approval date of 8/12/2023 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 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: c. Before preparing or handling medications, i. After contact with a residents intact skin, m. after removing gloves. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105467 If continuation sheet Page 14 of 14