Health inspection·May 2, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the hallway near the spill. Staff C, Dietary Aide, stopped and looked down at the spill, continued pushing the food tray cart over the spill and then continued to walk to the elevators. During an interview on 5/1/2024 at 9:29 AM, Staff C, Dietary Aide, stated, I noticed the spill. I was going to tell someone when I got downstairs. I don't have a mop or anything to clean it. Spills should be addressed immediately so someone doesn't fall, that's why I was going to let someone know downstairs. During an interview on 5/1/2024 at 1:50 PM, the Assistant Administrator stated, It is everyone's responsibility to report safety concerns. The staff member who noticed the spill should have put up a yellow caution sign over the spill immediately and get a mop to clean it or get the housekeeper to help. They should not have left it (the spill) there. The expectation is that staff take care of the issue immediately such as the liquid spill. Or if maintenance is needed, staff need to contact maintenance immediately and put in a work request in the electronic system. Review of CMS Form 802- Matrix for Providers provided by the Administrator on 4/30/2024 showed that there were forty three current residents on the 300 Level (secured unit). The matrix showed thirty seven residents had a diagnosis of Alzheimer's/Dementia and nineteen residents had had a fall (including six with an injury and one with a major injury). During an interview on 5/1/2024 at 2:50 PM, the Administrator stated, We use the Physical Plant Resource Guide for staff recording and reporting work requests and safety issues. Review of the facility's Physical Plant Resource Guide, last reviewed on 1/5/2024, showed it read, II. Daily Guide . 2. Work Orders: Work orders are in duplicate form. Work orders should be available at each nurse station, at the dietary entrance, outside the maintenance shop and at the front desk. After picking up the grounds, conduct a set of rounds through the building, picking up work orders as you go. Work orders should be arranged by priority . If you are unable to complete a work order that day, communicate that to your Administrator . 3. TELS: The Equipment Lifecycle System. TELS is a web-based Senior Living building management system that helps reduce downtime, secure warranty fulfillment, increase compliance, track equipment and maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 2 of 9 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 105512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) was accurate for 2 of 3 residents reviewed for discharge, Residents #174 and #175. Residents Affected - Some Findings include: 1. Review of Resident #174's records showed the resident was discharged on 1/31/2024 to home. Review of Resident #174's Discharge Return Not Anticipated MDS dated [DATE] showed the resident was discharged to short-term general hospital. During an interview on 5/2/2024 at 12:00 PM, the MDS Director stated the documented discharge of Resident #174 to short term general hospital was incorrect and Resident #174's discharge should have been documented as to community. 2. Review of Resident #175's records showed the resident was discharged on 2/9/2024 to home. Review of Resident #175's Discharge Return Not Anticipated MDS dated [DATE] showed an unplanned type of discharge. During an interview on 5/2/2024 at 11:53 AM, the MDS Director stated Resident #175's MDS was incorrect under section A 310 G- type of discharge and should have been documented as a planned discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 3 of 9 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 105512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received appropriate urinary catheter care, and failed to ensure urinary flow into the urinary catheter bag was maintained for 1 of 3 residents reviewed for incontinence care, Resident #165. Findings include: Review of Resident #165's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including urinary tract infection, type 2 diabetes mellitus with unspecified complications, hydronephrosis and neuromuscular dysfunction of bladder. Review of Resident #165's physician order dated 3/18/2024 read, Suprapubic Catheter: Suprapubic catheter to drainage bag for DX [diagnosis] Neurogenic bladder, suprapubic catheter size #18F [French] with 30 cc [cubic centimeters] balloon. Observe Q [every] shift for observation. Review of Resident #165's care plan dated 3/4/2024 read, Focus: Suprapubic Catheter. The resident uses a suprapubic catheter with risk for infection and/or complications related to: Suprapubic #18/30 ml [milliliters], neurogenic bladder . Interventions . Keep catheter tubing free of kinks . keep drainage bag below level of bladder. During an observation on 4/29/2024 at 10:51 AM, Resident #165 was in bed, with the urinary catheter bag resting in a basin that had paper towels in it, and a large wet area on the paper towel. The urinary catheter tubing was looped and resting on the floor with amber colored urine going to the top of the tubing, unable to drain into the urinary catheter bag. During an observation on 4/30/2024 at 9:15 AM, Resident #165 was in bed, with the urinary catheter bag attached to the bed and resting in a basin. The catheter bag was sitting in approximately 100 ml of yellow fluid. During an observation on 5/1/2024 at 8:01 AM, Resident #165 was in bed, with his urinary catheter bag in a basin with approximately 100 ml of fluid in the basin. The urinary catheter bag was resting on the bottom of the basin in contact with the fluid. The urinary catheter tubing was looped with amber urine unable to drain into the urinary catheter bag and filled to the top of the tubing. During an interview on 5/1/2024 at 8:02 AM, Staff A, Registered Nurse (RN), confirmed Resident #165's urinary catheter tubing was looped and the urine was unable to drain into the urinary catheter bag and that there was liquid in the basin and the urinary catheter bag was in the liquid. During an observation on 5/1/2024 at 8:02 AM, Staff A, RN, donned personal protective equipment and raised Resident #165's catheter tubing above the level of the resident's bladder to drain the urine into the urinary catheter collection bag. Staff A let go of the tubing to drain additional urine into the catheter bag, again lifting the tubing above the resident's bladder. During an interview on 5/1/2024 at 8:03 AM, Staff A, RN, stated, I should not have lifted the catheter tubing up above his bladder to get it to empty. I should have moved the bag to make sure it wasn't kinked so the urine could flow properly. It was urine in the basin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 4 of 9 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 105512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711 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 During an observation on 5/1/2024 at 8:21 AM, the Director of Nursing (DON) unhooked Resident #165's urinary catheter drainage bag from the bed and lifted the bag above the level of the resident's bladder approximately 1 foot over the bed and the resident's body to visualize the bag and drainage device. During an interview on 5/1/2024 at 8:22 AM, the DON stated, I think that the clamp was not tightened properly and that let the urine leak out of the bag because there doesn't appear to be a leak in the bag itself. I should not have lifted the bag up in the air. During an interview on 5/2/2024 at 8:53 AM, the DON stated, We do not have a policy and procedure for catheter care. It is standard of practice to maintain the catheter and tubing below the level of the resident's bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 5 of 9 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 105512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as per physician order for 2 of 3 residents reviewed for respiratory care, Residents #139, and #154. Residents Affected - Some Findings include: 1. During an observation on 4/29/2024 at 11:01 AM, Resident #139 was in bed, receiving oxygen via nasal canula at 3 liters per minute (LPM). During an observation on 4/30/2024 at 9:53 AM, Resident #139 was in bed, receiving oxygen via nasal canula at 3 LPM. Review of Resident #139's physician orders showed the order dated 4/8/2024 for administration of oxygen at 2 LPM via nasal cannula as needed for shortness of breath. During an interview on 4/30/2024 at 9:55 AM, Resident #139 stated, The nurse turns my oxygen on and off for me. I do not adjust it. During an interview on 4/30/2024 at 10:00 AM, the Director of Nursing (DON) confirmed the oxygen concentrator was set at 3 LPM for Resident #139 and verified the physician order for Resident #139 to receive oxygen at 2 LPM. 2. During an observation on 4/29/2024 at 11:45 AM, Resident #154 was in bed, receiving oxygen via nasal cannula at 4 LPM. During an observation on 4/30/2024 at 9:58 AM, Resident #154 was in bed, receiving oxygen via nasal cannula at 4 LPM. Review of Resident #154's physician orders showed the order dated 4/25/2024 for administration of oxygen at 2 LPM via nasal cannula as needed for shortness of breath. During an interview on 4/30/2024 at 9:58 AM, Resident #154 stated, I don't know what level my oxygen should be on. I let the nurses handle that. I would not know how to change it if I needed to. During an interview on 4/30/2024 at 10:05 AM, the DON confirmed the oxygen concentrator was set at 4 LPM for Resident #154 and verified the physician order for Resident #154 to receive oxygen at 2 LPM. Review of the facility policy and procedure titled Oxygen Therapy with an effective date of November 2023 and a review date of 1/5/24 read, Policy: Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. Procedure: 10 Verify physician order . 7. Apply device to the resident with appropriate liter flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 6 of 9 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 105512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure foods were stored in a safe and sanitary manner in the main kitchen of the facility. Residents Affected - Few Findings include: During an observation while conducting a tour of the main kitchen on 4/29/2024 at 9:30 AM, with the Certified Dietary Manager (CDM), there were two unlabeled and undated 2.5-gallon buckets of yellowish liquid on the second shelf of the main walk-in cooler, one 4-inch steam pan with a purple jelly like substance on the second shelf of the main walk-in cooler with no label to identify the contents and an expiration date of 4/23/2024, and one opened undated bag of plant-based chicken nugget on the third shelf of the walk-in cooler. During an interview on 4/29/2024 at 9:30 AM, the CDM confirmed the unlabeled and undated food items in the walk-in cooler, and stated, Everything in here should have a label and an expiration date sticker placed on it before storing it. Review of the facility policy and procedure titled Storage with an effective date of January 2023 and a review date of 1/5/2024, showed the policy read, Procedure . 8. Label all leftovers with recipe name, date, (month, day, and year) of storage and use by date. 9. Discard refrigerated leftovers after 72 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 7 of 9 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 105512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration and failed to ensure staff followed infection control standards of practice for administration of subcutaneous medications to help prevent the possible transmission of infection and communicable diseases. Residents Affected - Few Findings include: During an observation on 4/30/2024 at 8:05 AM, Staff B, Registered Nurse (RN), unlocked the medication cart and began preparing medication for Resident #118. Staff B did not perform hand hygiene. Staff B compared the individual medication packet to the physician's orders, poured the medications including Amlodipine 10 mg (milligram) tablet, Escitalopram 10 mg tablet, Buspirone 7.5 mg tablet, Carvedilol 3.125 mg tablet, Aspirin 81 mg Capsule, Iron 325 mg tablet, Vitamin B12 100 mcg (microgram) tablet, Vitamin D 125 mcg capsule, Raw Enzyme tablet, and Losartan 100 mg tablet into a single medication cup for oral administration, and returned each packet to the drawer. Without performing hand hygiene, Staff B locked the medication cart, entered Resident #118's room carrying the medication cup, and administered the oral medications to the resident. During an interview on 4/30/2024 at 8:07 AM, Staff B, RN, stated, I should have performed hand hygiene before administering the medications. I don't know why I didn't. During an observation of medication administration for Resident #106 on 5/1/2024 at 11:13 AM, Staff B, RN, administered an insulin injection into the resident's right abdomen without performing hand hygiene before donning gloves and without cleaning the skin with an alcohol wipe before medication administration. During an interview on 5/1/2024 at 11:14 AM, Staff B, RN, stated, I didn't use the alcohol wipe to clean the skin before I gave the medication. I didn't perform hand hygiene before I gave the medicine either. During an interview on 5/1/2024 at 11:22 AM, the Director of Nursing (DON) stated, Staff should be washing their hands before and after every patient, whether with soap and water or hand sanitizer. The nurses should perform hand hygiene just before and directly after administering the medications to the residents. Review of the facility policy and procedure titled Medication Administration Subcutaneous last reviewed on 1/5/2024 showed the policy read, Policy: To administer a parenteral medication via the subcutaneous route in a safe, accurate and effective manner. Equipment: Medication as ordered, Safety syringe and sterile safety needle of appropriate gauge, Antimicrobial agent for medication product (such as alcohol swab), Antimicrobial agent for resident's skin (such as alcohol swab), Antimicrobial agent for hand hygiene, Gloves. Procedures . 4. Perform hand hygiene . 7. Put on gloves . 9. Cleanse skin with antimicrobial agent, using circular motion from center of chosen site until an area about 3 inches in diameter has been prepared. Allow to dry . 15. Inject medication slowly . 17. Remove needle quickly at the same angle as insertion. 18. Swab the area with antimicrobial agent . 21. Remove gloves. 22. Perform hand hygiene. Review of the facility policy and procedure titled Hand Hygiene last reviewed on 1/5/2024, showed the policy read, Policy: The facility considers hand hygiene the primary means to prevent the spread (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 8 of 9 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 105512 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm of infections. Procedure . 2. Personnel shall follow the handwashing/hand hygiene guidelines to help prevent the spread of infections to other personnel, residents, and visitors . 8. The use of gloves does not replace handwashing/hand hygiene. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105512 If continuation sheet Page 9 of 9