Inspection·March 31, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she does not want the shower. She said she had spoken to the Administrator and the nurse on duty several times regarding the concern. On 3/29/23 at 9:36 a.m., Certified Nursing Assistant (CNA) Staff R said the shower list was posted on each unit. Staff R said a resident wanted to change from a day to evening shower or evening to a day shift shower the process was to notify the nurse. The nurse will speak with the resident and change the schedule if that is what the resident wants. The CNA was informed of Resident #4's request to receive her showers on the day shift and said she would notify the nurse. On 3/29/23 at 1:47 p.m., LPN Staff O said if a resident wanted to change the shower schedule from evenings to days, the nurse would have to find another resident who wanted to change their shower time to evening. LPN Staff O said was not aware Resident #4 had requested to change her shower time from evening shift to day shift, and she would take care of it. Review of the CNA documentation for February 2023 documented showers were provided as scheduled for the month on the 3-11 shift. Review of the March CNA documentation showed Resident #4's scheduled shower time was on the 3-11 shift. Resident #4 declined her shower on 3/6/23 and did not receive a shower on 3/23/23. On 3/29/23 at 3:08 p.m., the Assisted Director of Nursing (ADON) said she was not aware Resident #4 wanted her showers on the day shift. The ADON said she would change the shower schedule for Resident #4 today to make sure she receives showers on the morning shift. On 3/31/23 at 9:24 a.m., Resident #4 said she did not remember if the staff had asked her about her shower schedule and said , I don't like to shower at night, I can't see well and they come and get me out of bed and I don't want to go. I know my daughter had asked them to change my time, I don't know why they can't do it. They tell me they can't change the schedule. On 3/31/23 at 10:00 a.m., review of the CNA shower scheduled documented Resident #4 was still scheduled for showers on the 3-11 shift on Monday and Thursday. On 3/31/23 at 10:10 a.m., CNA Staff F said the shower schedule was done according room and bed location, not by resident names. Staff F explained the 7-3 shift provides showers for all residents on the door side of the room and 3-11 provides showers to all residents by the window bed. CNA Staff F said to get the shower list changed if someone wanted a shower on days instead of nights, would require finding another resident to change it with, we would need to find a resident willing to change their shower time to nights. CNA Staff F confirmed resident #4 was still scheduled for showers on the 3-11 shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 2 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on review of the clinical record, review of facility policy and procedures and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1(Resident #96) of 26 residents reviewed for activities of daily living (ADL's). Residents Affected - Few The findings included: The facility policy Activities of Daily Living, (revised 3/18) specified Residents will be provided with care, treatment and services as appropriate to maintain or improve good nutrition, grooming and personal hygiene. Review of the clinical record revealed Resident #96 had an admission date of 3/7/23 with diagnoses muscle weakness, need for assistance with personal care, chronic pain, falls, and atherosclerotic heart disease. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 3/7/23 documented Resident #96 was dependent on staff for bathing. The MDS noted Resident #96's cognitive skills for daily decision making was intact. The plan of care initiated on 3/8/23 identified Resident #96 required assistance with ADL's due to weakness, a recent illness with a hospitalization and instructed staff to assist the resident with tasks including hygiene. On 3/27/23 at 10:47 a.m., Resident #96 said she had not received her showers as scheduled twice a week. The resident said she wanted her showers but in the last few weeks she had received only two showers. Resident #96 said, I asked for my showers but they say there is not enough staff to provide the showers. On 3/29/23 at 12:10 p.m., Licensed Practical Nurse (LPN) Staff D said Resident #96 was on isolation for an infection but was still able to receive showers. LPN Staff D said the resident would need to wear a mask to come out of the room to the shower room. Review of the Certified Nursing Assistant (CNA) documentation showed Resident #96 was scheduled to receive showers on the 7:00 a.m., to 3:00 p.m., shift on Wednesdays and Saturdays. The documentation showed Resident #96 did not receive her scheduled shower on 3/11/23. On 3/22/23 and 3/25/23 the documentation recorded the code NA. On 3/30/23 at 9:29 a.m., in an interview CNA Staff E said N/A recorded on the CNA documentation means the shower was not provided as scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 3 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and resident interviews, the facility failed to ensure 3 (Residents #14, #458 and #459) of 3 dependent residents reviewed for those residents who attend activities, maintained and/or improved their psychosocial well-being and independence. Residents Affected - Few The findings included: On 3/27/23 review of the Director Recreational Therapy job duties stated they were required to plan, direct, and coordinate recreation-based treatment programs to help maintain or improve a patient's physical, social, and emotional well-being. They were required to oversee day-to-day activities of residents, initiate, and promote activities within the facility and stimulate patient interests and well-being, regulate programs in accordance with the patient capabilities, and maintain all activity related records of activity assessment, progress notes, and discharge summary. 1. Review of Resident #14's medical record revealed his original admission to the facility was 3/26/2019 with a readmission on [DATE]. On 12/8/2022 an significant change activity assessment was completed noting Resident #14 enjoyed all religious services, trivia and word games, TV shows to include sports, law and order and religious shows, sitting outdoors, card games, balloon toss, and social activities. The activity assessment noted Resident #14 program activity preferences are one on one, in room, small groups, large group, outside, independent, and with friends and family. Resident #14's care plan for religion dated 1/7/2020 stated religion was very important to him, and he would like the staff to remind him of Mass, Communion, and other religious services. Resident #14's care plan activity care plan dated 11/21/22 stated he was dependent on staff for emotional, intellectual, physical, and social stimulation related to cognitive deficits. The listed interventions were to assist resident to activity functions as needed, offer 1:1 bedside/in-room visits/activities and thank the resident for attendance at activity functions. On 3/27/23 observed Resident #14 at 10:45 a.m. and 2:30 p.m., wearing a hospital gown in his room in bed without the television (TV) or radio on and/or involved in an activity program. Resident #14 was not interviewable due to cognitive impairment. On 3/28/23 observed Resident #14 at 9:05 a.m. and 12:05 p.m., wearing a hospital gown in his room in bed without the television (TV) or radio on and/or involved in an activity program. On 3/29/22 at 11:30 a.m., the Activity Director said part of her job duties were to do the admission assessment, quarterly assessment, and significant change assessment to determine a resident's likes/interests. She was also to develop an activity program to the resident's well-being, to monitor each resident's day-to-day activity to ensure they are receiving their activity of choice and to assist them in developing and maintaining an individualized activity program for each resident, in order to maintain and/or improve their psychosocial well-being and independence. The Activity Director reviewed Resident #14's medical records and confirmed he was initially admitted to the facility on [DATE]. She further said the significant change activity assessment dated [DATE] stated Resident #14 enjoyed all religious services, trivia and word games, TV shows to include sports, law and order and religious shows, sitting outdoors, card games, balloon toss, and social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 4 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activities. The activity assessment also stated Resident #14's activity preferences were 1:1, in room, small groups, large group, being outside, independent, and with friends and family. The Activity Director said the activity department was only able to review 16 days of each resident's activity tracing log and was unable to go back any further to determine if Resident #14 had attended and/or been engaged in an activity of his choice. Review of Resident #14's activity tracking log from 3/14/22 to 3/26/22 revealed he had attended no religious events and one out of room activity. On 3/29/23 at approximately 11:45 a.m., during an interview with the Activity Director and Activity Assistant, Staff P said confirmed Resident #14's activity tracking log stated he had not attended any religious activities and had attended one out-of-room activity. They said they could not remember the last time Resident #14 was out of bed and dressed for the day so they could take him to a facility scheduled activity even though they have left multiple notes on Resident #14's bedside table asking the nursing staff to please get Resident #14 out of bed and dressed for the day. They both said they were unaware Resident #14 enjoyed religious services and/or gatherings but will now start assisting Resident #14 to religious services as noted in his plan of care. 2. Review of Resident #458's medical record revealed she was admitted to the facility on [DATE]. The initial admission activity assessment dated [DATE] noted the resident liked word puzzles, TV cooking shows, news, and game shows and the resident preferred 1:1 activity with facility staff. On 3/27/23, observed Resident #458 at 11:00 a.m. wearing a hospital gown in his room in bed without the television (TV) or radio on and/or involved in an activity program. Resident #458 said since her admission to the facility they had not offered and/or engaged her in a facility activity. On 3/29/22 at 11:45 a.m., during an interview with the Activity Director, she confirmed Resident #458 was admitted to the facility on [DATE] and the initial admission activity assessment dated [DATE] stated Resident #458 enjoyed word puzzles, TV cooking shows, news, and game shows and the resident preferred 1:1 activity with facility staff. The Activity Director stated after reviewing Resident #458's activity tracking log, they had documented the activity department had conducted two activity programs since Resident #458's admission with an 8-day gap between those activities. She said she was unable to find documentation they had provided a continuous activity program for Resident #458 to ensure they maintained and/or improved her psychosocial well-being and independence. 3. Review of Resident #459's medical record revealed she was admitted to the facility on [DATE]. The initial admission activity assessment dated [DATE] noted the resident liked reading, word puzzles, social clubs, crafts, TV, music, and aromatherapy, and Resident #459 preferred small group activities. On 3/27/23, observed Resident #459 at 11:16 a.m. and 2:38 p.m., wearing a hospital gown in her room in bed without the television (TV) or radio on and/or involved in an activity program. Resident #459 was not interviewable due to cognitive impairment. On 3/28/23 observed Resident #459 at 10:05 a.m. and 12:00 p.m., wearing a hospital gown in her room in bed without the television (TV) or radio on and/or involved in an activity program. On 3/29/22 at 12:15 p.m., an interview with the Activity Director confirmed Resident #459 was admitted to the facility on [DATE]. She confirmed the initial admission activity assessment was dated 3/20/23 and stated Resident #459 enjoyed reading, word puzzles, social clubs, crafts, TV, music, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 5 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0679 Level of Harm - Minimal harm or potential for actual harm aromatherapy, and Resident #459 preferred small group activities. The Activity Director said after reviewing Resident #459's activity tracking log, they had documented the activity department had conducted two activity programs since Resident #459's admission with an 8-day gap between those activities. She said she was unable to find documentation they had provided a continuous activity program for Resident #459 to ensure they maintained and/or improved her psychosocial well-being and independence. Residents Affected - Few 4. On 3/29/22 at 1:00 p.m., during an interview with the Administrator, she said the Activity Director was responsible to conduct the activity program in the facility. The Activity Director was responsible for ensuring the activity program was resident centered, and individualized to each resident to ensure their psychosocial well-being was being met. She said the facility did not have an activity program policy, but they are required follow the State Operational for Long Term Care Facility section 483.24(c)(1) to ensure each resident was attending their activity of choice, in order to maintain and/or improve their psychosocial well-being and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 6 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed ensure 1 (Resident #75) of 2 sampled residents received prompt assistance to repair broken glasses to maintain vision ability. Residents Affected - Few The findings included: Clinical record review revealed Resident #75 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident used corrective lenses. On 3/28/23 at 1:49 p.m., Resident #75 said she uses bifocal corrective lenses. She said, I can't see without them. I need them to look at my phone. The resident explained a while ago, one arm broke after a staff member rolled her to her side. The staff person tried to glue it together. The arm broke again. The resident said she's been using the glasses with one arm. Resident #75 said a Certified Nursing Assistant (CNA) rolled her over yesterday afternoon. She did not take off her glasses quickly enough and the other arm broke completely. The CNA just took the broken glasses and placed them on the bedside table. On 3/28/23 at 4:40 p.m., CNA Staff P said Resident #75 showed her the broken glasses, and she let the Social Services Director (SSD) know. On 3/28/23 at 5:06 p.m., The SSD said she was only made aware on 3/28/23 the resident's glasses needed to be repaired. She said when the first arm broke they should have told her right away. If she cannot get them repaired or replaced within a week she would find a different provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 7 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the policies and procedures, observation, and staff interview, the facility failed to evaluate and modify interventions to prevent avoidable accidents for 1 resident (#358) of 1 resident reviewed who was identified as being at risk for falls and sustained multiple falls while at the facility, including a fall resulting in a transfer to the hospital. The findings included: The policy and procedure for managing falls and fall risk stated the staff would identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and minimize complications from falling. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factors for each resident at risk of falls or with a history of falls. The resident-centered approaches to managing fall and fall risk state if a fall recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the assessment of the nature or category of falling, until falling is reduced or until the reason for the continuation of the falling is identified as unavoidable. Staff will identify and implement relevant interventions (e.g., hip padding, or treatment of osteoporosis, as applicable) to try to minimize the serious consequences of falling. Resident #358 was admitted to the facility on [DATE] after a fall resulting in a lumbar (back) fracture. The 14-day minimum data set (MDS) with an assessment reference date (ARD) of 6/21/22 indicated the resident's brief interview for mental status (BIMS) score was 7. (The BIMS test is used to get a quick snapshot of how well the resident is functioning cognitively at the moment. The total BIMS score ranges from 0-15. A score of 13-15 is indicative of intact cognition. A score of 8-12 indicates moderate impaired cognition. A score of 0-7 indicates severe cognitive impairment.) The MDS indicated resident #358 required one person's physical assistance for transfers. The facility determined Resident #358 was at risk for falls related to a history of falls, cognitive impairment, impulsiveness, impaired balance, and mobility. The care plan was implemented on 6/16/2022. The interventions on 6/16/2022 included anticipating resident needs, assisting with mobility, encouraging the use of proper footwear, i.e., non-skid, well-fitted shoes, maintaining a clutter-free environment, monitoring adverse side effects of medications, placing call bell within reach, placing personal belongings within reach, provide adequate lighting, initiate a psychiatric consult. On 6/25/22, a clinical record review revealed resident #358 was found on the floor at the foot of his bed at 2:15 a.m. He told staff he was trying to use the bathroom. Resident #358 was sent to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 8 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 emergency room for evaluation and admitted for a suspected acute back fracture. Level of Harm - Minimal harm or potential for actual harm On 3/30/23 at 2:24 p.m., during a review of the fall investigation the Administrator said Resident #358 had a suspected lumbar fracture. The Administrator said they did not have studies from the hospital showing a diagnosis of lumbar fracture. Residents Affected - Some Review of the progress notes revealed on 6/29/22, Resident #358 was observed on the floor after an unwitnessed fall. The Certified Nursing Assistant (CNA) documented in the initial report the resident stated he was going to the bathroom. A new skin tear on the left elbow was noted. Nurse assessment documented resident denied pain. New therapy interventions were added to the care plan. Resident #358 needs mod-min assistance with a four-wheel walker device, balance training, endurance training, gait training, positive reinforcement, therapeutic exercise, gait training, and verbal cues for safety sequencing and pacing. On 6/30/22 at 3:00 p.m., the nurse documented in a progress note Resident #358 had an unwitnessed fall and was observed lying on the floor. The resident was coming back from the bathroom and lost his balance. A head-to-toe assessment was completed. Resident #358 was encouraged to wear proper footwear and to call for assistance. On 3/30/23 at 2:24 p.m., during a review of the fall investigation the Assistant Director of Nursing (ADON) said the investigation did not state if the resident was using his walker, or had proper footwear at the time of the fall. The care plan was updated on 7/1/2022 with new interventions which included a floor mat on one side of the bed, the bed in the lowest position, and a toileting schedule. On 7/19/22 at 8:57 a.m., a progress note documented Resident #358 was observed on the floor to the left side of his bed. He complained of back pain at that time. On 3/30/23 at 2:24 p.m., during a review of the investigation with the Administrator and the Assistant Director of Nursing, the ADON said the investigation did not specify if the resident had access to his call bell, if he was wearing shoes, if the bed was in the lowest position or if the resident had been assisted to the toilet. No new interventions or revisions were added to the care plan to address the cause of the fall or minimize the risk of further avoidable falls. On 8/18/22 at 7:08 p.m., a progress note documented Resident #358 was observed sitting on the floor. The facility investigation noted Resident #358 spouse had visited and left him sitting in the chair. The resident said he was going to meet his wife. The investigation report noted a head-to-toe assessment was completed, the walker was to be placed within reach, and he would be referred to rehab services for screening. The facility said they educated resident #358's wife not to leave him alone. On 9/4/22 at 8:00 a.m., Resident #358 had an unwitnessed fall. The CNA alerted the nurse she observed Resident #358 on the floor on the right side of the bed. On 3/30/23 at 2:24 p.m., during a review of the investigation, the ADON said the resident's call light was not on, and the resident was wearing slip-resistant socks. The resident stated, I was all over the bed, then on the floor. The resident was assisted back to bed, a head-to-toe assessment was completed, no injuries were found, and a floor mat was in place to the right side of the bed. Neurochecks were to be implemented for 72 hours, and hourly safety checks were started. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 9 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/21/22 at 10:55 a.m., a progress note documented Resident #358 was found on the floor after an unwitnessed fall. The nurse reported resident was found sitting on his buttocks on the floor near his bed. Vital signs were assessed, resident denies hitting his head. He stated he was trying to use the bathroom. No injuries were noted ,and the resident was assisted back to bed. The resident was educated to use the call light as an immediate intervention, and the physician was notified. No new or changed interventions were identified or added to the care plan. On 11/12/22 at 6:33 p.m., Resident #358 was heard yelling from his room after an unwitnessed fall. Resident #358 was assessed for injuries and pain. No new interventions or care plan revisions were noted to ensure the residents' safety. On 12/4/22 at 7:00 p.m., resident #358 had a witnessed fall where she heard the resident calling out for help and sliding off the bed to the floor. The resident was assessed, and no injuries were noted other than mild back pain. He was assisted to his wheelchair. No revised or new interventions were added to the care plan to ensure the resident's safety. On 12/16/2022, the facility reported resident #358's mattress was changed to a scoop mattress, and hourly safety checks were initiated. On 3/29/23 at 2:57 p.m., the Administrator and Corporate [NAME] President stated the fall investigation was internal and could not be shared. The Corporate [NAME] President stated he would ask the Administrator to review the fall history. On 3/29/23 at 4:19 p.m., observation of Resident #358's room with Licensed Practical Nurse (LPN) Staff M failed to reveal the fall mat was in place as per the care plan. She said the resident's room had some flooding, perhaps the fall mats were removed at that time and never replaced. On 3/30/23 at 10:21 a.m., the Regional [NAME] President reviewed the hourly safety check documentation. He confirmed the flow sheets provided did not reflect Resident #358 being checked hourly. On 3/30/23 at 1:05 p.m., observation of Resident #358's bed with LPN Staff O revealed Resident #358 did not have a scoop mattress in place to prevent him from rolling out of bed as per the interventions listed in the care plan . On 3/30/23 at 2:24 p.m., the Administrator stated that most of Resident #358 falls were unwitnessed. After a resident fall, we ask what happened, question the staff, and ask them where the resident was found. Usually, the MDS coordinator will update the care plan. Resident #358 should be reevaluated, and interventions be evaluated after each fall. The ADON and regional vice president both confirmed the care plan had not been updated after each fall to ensure the resident's safety and prevent avoidable falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 10 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 - Some 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, review of facility policy and procedures and staff interviews, the facility failed to maintain an indwelling catheter in a safe and sanitary manner for 1 (Resident #84) of 1 resident sampled with an indwelling catheter. This has the potential to cause injury and urinary tract infection. The findings included: Facility policy Catheter Care Urinary documented The purpose of this policy is to prevent catheter-associated urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident #84's clinical record showed an admission date of 7/11/22 with diagnoses including obstructive and reflux uropathy (urine is unable to pass through the urinary tract). The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/22/23 documented Resident #84 was dependent on staff for toileting needs. The MDS noted Resident #84's cognitive skills for daily decision making were severely impaired. The care plan identified Resident #84 was at risk for injury or infection related to the indwelling catheter use and instructed staff to position the catheter bag and tubing so that it promotes dignity and drainage. On 3/27/23 at 12:00 p.m., Resident #84 was observed in a wheelchair sitting in the hallway outside of her room. The resident had an indwelling catheter, and the tubing was on the floor and unsecured. The drainage bag was touching the floor. Registered Nurse Staff B confirmed the catheter tubing and drainage bag were in contact with the floor and said she would take care of it. On 3/28/23 at 8:38 a.m., Resident #84 was in a wheelchair in her room eating her morning meal. The catheter drainage bag and tubing were on the floor. On 3/29/23 at 10:50 a.m., in an interview Certified Nursing Assistant (CNA) Staff F said the urinary catheter drainage bag and tubing were to be hooked to the bed/wheelchair and be in a privacy bag. The CNA said the tubing and the bag were not to be on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 11 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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, record review, resident and staff interview the facility failed to follow physician's orders for oxygen therapy for 3 (Resident #8, #17, and #23) of 4 residents reviewed for oxygen administration. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or an increased risk of side effects and complications. Residents Affected - Few The findings included: 1. Review of the clinical record for Resident #8 revealed an admission date of 2/3/23. The admission Minimum Data Set (MDS) assessment with a target date of 2/7/23 revealed Resident #8 scored a 13 on the Brief Interview for Mental Status, indicative of intact cognition. Resident #8's diagnoses included lung disease, chronic obstructive pulmonary disease, and respiratory failure with hypoxia (low level of oxygen). The physician's orders included Oxygen at 2 liters per minute via nasal cannula every shift. On 3/27/23 at 11:10 a.m., Resident #8 was observed lying in bed, the oxygen (O2) was set at one and half liter (L) per minute via nasal cannula (n/c). Resident #8 stated she uses O2 at home at 2 liters/minute via nasal cannula. On 3/28/23 at 10:25 a.m., Resident #8 was not in the room, O2 was on and set at 1 ½ L per minute. On 3/29/23 at 9:50 a.m., Resident #8 was sitting up in bed. Licensed Practical Nurse (LPN) Staff A verified the oxygen concentrator was set at 1 ½ liter. She verified the physician's order and said the oxygen should have been set at 2 liters. 2. Review of the clinical record for Resident #17 revealed an admission date of 12/10/20. The Quarterly Minimum Data Set (MDS) assessment with a target date of 3/10/23 revealed Resident #17 scored a 15 on the Brief Interview for Mental Status, indicative of intact cognition. Resident #17's diagnoses included congestive heart failure, and chronic obstructive pulmonary disease. The physician's orders included administering oxygen at 2 liters via nasal cannula continuously for shortness of breath. On 3/27/23 at 11:26 a.m., Resident #17 was observed sitting up in a wheelchair in his room. The Oxygen (O2) was set at 3 and half Liters per minute via nasal cannula. On 3/28/23 at 10:30 a.m., Resident #17 was lying in bed with oxygen on at 3 ½ liters per minute via nasal cannula. On 3/29/23 at 9:57 a.m., Resident #17 was lying in bed receiving oxygen at 3 ½ liters via nasal cannula. LPN Staff A verified the oxygen was set at 3 ½ liters. She confirmed the physician's order for the oxygen and said the setting should have been 2 liters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 12 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm 3. Review of the clinical record for Resident #23 revealed an admission date of 11/25/20. The Quarterly Minimum Data Set (MDS) assessment with a target date of 2/17/23 revealed Resident #23's cognition was severely impaired. Resident #23's diagnoses included pneumonia and chronic obstructive pulmonary disease. Residents Affected - Few The physician's orders included administering Oxygen continuously at 1 liter via nasal cannula for shortness of breath. Review of Resident #23 physician orders included Oxygen at 1 liter/per minute via nasal cannula On 3/27/23 at 11:44 a.m., and 3/28/23 at 10:31 a.m., Resident #23 was observed in bed watching television receiving oxygen at 0.75 liter via nasal cannula. On 3/29/23 at 10:00 a.m., Resident #23 was sitting up in bed asleep receiving Oxygen at 0.75 liter via nasal cannula. LPN Staff A verified the physician's orders specified to administer Oxygen at 1 liter via nasal cannula. She verified Resident #23 was not receiving Oxygen in accordance with the physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 13 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy review the facility failed to review the risk and benefits of bed rails, attempt alternative interventions prior to bedrail installation and failed to have a schedule for routine maintenance for 2 (Resident #68 and #308) of 7 residents reviewed for side rails. The findings included: Review of the facility policy titled Proper use of Side rails issued 09/2022 and last revised 09/2022 guidelines read: A side rail evaluation will be completed to determine the resident's need for using side rails; Alternative options may be trialed and documented prior to implementation of side rails; Side rails may be used if assessment and Interdisciplinary team review has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; The resident care plan will address the use of side rails when applicable; Facility will follow manufacturer recommendations and specifications for installing and maintaining side rails. 1. On 3/27/2023 at 12:35 p.m., Resident #308 said she has been at the facility for two days. Resident #308 was able to answer questions appropriately. Her bed has upper ¼ siderails raised bilaterally. She said she asked for the siderails to help her move. The resident said she could not remember staff giving her any instructions related to the siderails or signing a consent for the use of the siderails. Clinical Record review revealed Resident #308 was admitted to the facility on [DATE] and was cognitively intact. had a Brief Interview for Mental Status (BIMS) score of 15 which suggests the resident is cognitively intact. Documentation of a siderail evaluation was completed on 3/25/23 and signed by the resident on 3/26/2023. The siderail evaluation read the resident needs siderails as an enabler to promote independence and no other appropriate alternative exists. The progress notes do not mention side rails or any attempted interventions. The care plan for Resident #308 does not include any interventions for the use of side rails. There was no other documentation in the resident's clinical record regarding side rails. 2. On 3/27/23 at 12:45 p.m. Resident #68 was observed in bed with ¼ side rails raised bilaterally to the upper bed. Resident #68 said he's had the siderails since his admission to the facility approximately five months. He could not remember signing a consent for the use of the siderails. On 3/28/2023 at 1:30 p.m., observed the side rails raised on Resident #68's bed. On 3/29/2023 clinical record review for Resident #68, revealed a side rail evaluation completed on 12/1/2022 and signed by Resident #68 on 12/2/2022. The question regarding resident/representative understands the risk/benefits of the side rail and consents to the use of it was left blank. The evaluation said the resident needed the side rails as an enabler to promote independence and no other appropriate alternative exists. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 14 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 3/29/23 at 12:40 p.m., the Administrator said the only requirements for side rails were an evaluation with signed consent. On 3/29/23 3:30 p.m., the Maintenance Director stated he goes by the manufacturers recommendations when installing siderails to bed. He said he does not keep a log of residents with side rails to check rails periodically for safety. He said he does not have a kit to measure for entrapment and does not check for it. Event ID: Facility ID: 105523 If continuation sheet Page 15 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, policy review and staff interviews, the facility failed to ensure medication irregularities and/or concerns were addressed in a timely manner when the consulting pharmacist identified irregularities and/or medication concerns, for 1 (Resident #14) of 5 resident's medication regimen reviewed. The findings included: On 3/30/23 review of Resident #14's medication regimen revealed he was receiving Gabapentin capsule 100 mg, 2 capsules, by mouth 3 times a day for neuropathy. Gabapentin was used to prevent and control seizures and relieve nerve pain. Some of the common side effects listed with the administration of Gabapentin were drowsiness, dizziness, fatigue, loss of coordination. Review of Resident #14's medical record revealed he had 2 unwitnessed falls on 11/15/22 and 11/17/22 and 1 witness fall on 11/6/22. On 12/12/22 the Consultant Pharmacist identified a potential medication concern stating Resident #14 was currently receiving Gabapentin which had the potential for dizziness and drowsiness and increased the risk of falls. Review of Resident #14's clinical record revealed he had recent falls. The Consultant Pharmacist recommended: Please evaluate possible causal relationship between the falls and the use of the Gabapentin and consider a trial taper to discontinue the use of the Gabapentin, if appropriate. On 12/12/22 Resident #14's ARNP (Advance Registered Nurse Practitioner) checked the disagree tab and wrote control pain - will have pain management evaluate. Further review of Resident #14's medical records revealed no physician order for a pain management review of the Gabapentin, no pain management review as requested by the ARNP and no evaluation of a possible correlation between Resident #14's recent falls and the administration of the Gabapentin medication. On 3/30/23 at 11:30 a.m., during an interview with Resident #14's ARNP, she said she had read the consultant pharmacist recommendation for an evaluation to determine if the recent falls could be related to the use of the Gabapentin and if a possible tapering of the medication would be indicated. She said since she did not order the medication, she determined the pain management physician should do an evaluation to determine if the medication was needed and/or could be tapered as requested by the consultant pharmacist on 12/12/22. The ARNP said after reviewing Resident #14's medical records she was unable to find a physician order requesting a pain management evaluation for the use of the Gabapentin. She further said she was unable to find documentation that a pain management evaluation was completed related to Resident #14's falls and the administration of the Gabapentin medication as requested by the Consultant Pharmacist on 12/12/22. She said she was not aware until today her request for a pain management evaluation, to determine if the use of the Gabapentin medication could have been causing the falls and to determine if the medication could be tapered or be replaced by another medication, had not been completed. On 3/30/23 at 12:01 p.m. in an interview with the Pain Management Physician (PMP) and the Administrator, the PMP said he was not informed on 12/12/22 the ARNP had requested a pain management review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 16 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident #14's Gabapentin medication to determine if the medication could be tapered or discontinued due to the possible correlation of the administration of Gabapentin medication and Resident #14's recent falls identified by the Consultant Pharmacist on 12/12/22. The Administrator told the PMP he had assessed Resident #14 for pain, but the PMP didn't remember doing the assessment. The PMP told the Administrator he did not know the pharmacist consultant had concerns the Gabapentin side effects might be contributing to Resident #14's recent falls and the ARNP had requested on 12/12/22 for a pain management assessment to determine if they could taper the Gabapentin. On 3/30/23 at 1:15 p.m., in an interview with the Assistant Director of Nursing (ADON) said she reviewed Resident #14's medical records and stated the facility had acted upon the pharmacist consultant recommendation for the tapering of the Gabapentin medication and the ARNP request for a pain management consult/evaluation related to the Gabapentin medication could be contributing to Resident #14 falls. She said the PMP had written a progress note with a date of service noted as 12/17/22 upon the Administrator request but confirmed the PMP progress note did not address the possible connection that the Gabapentin medication could be causing Resident #14's recent falls which had been identified by the consultant pharmacist. This progress note was not in the medical record of Resident #14 but was presented for review after the surveyor's interview with the PMP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 17 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review and staff interviews, the facility failed to administer medications according to physician's orders and manufacturer's specification for 4(Residents #9, #18, #41 and #509) of 5 residents observed for medication administration. Three licensed nurses on the morning shift with 26 opportunities were observed. Eleven medication errors were observed resulting in a 42.31% error rate. Residents Affected - Some The findings included: 1. On 3/27/23 at 9:59 a.m., Registered Nurse (RN) Staff B was observed administering an enteric coated aspirin 81 milligrams (mg) to Resident #18. RN Staff B removed the medication from the bottle and placed it in a clear medication pouch and crushed the tablet. RN Staff B placed the crushed tablet in applesauce and administered the medication to Resident #18. Crushing enteric coated tablets may result in the drug being released too early, destroyed by stomach acid or irritating the stomach lining. 2. On 3/27/23 at 10:05 a.m., RN Staff B was observed administering 3 medications to Resident #41 including a tablet of Amantadine HCL 100 mg RN Staff B and Breo Ellipta Aerosol Powder 100-25 Microgram (mcg) inhaler. RN Staff B placed the Amantadine tablet into a clear plastic pouch, crushed the medication and placed it in applesauce. Review of the manufacturer guidelines for Amantadine HCL specified to swallow the tablets whole. (https://www.gocovri.com/pdfs/gocovri-prescribing-information.pdf) Staff B handed the inhaler to Resident #41 who inhaled 1 puff. The nurse finished the medication administration and left the room. She did not instruct the resident to rinse her mouth and spit out the water after the use of the inhaler. Review of the pharmacy label of the Breo Ellipta inhaler revealed specifications to rinse mouth thoroughly after each use. 3. On 3/27/23 at 10:10 a.m., RN Staff B was observed administering 8 medications to Resident #9 including Acetaminophen 325 mg one tablet, Depakote 125 mg 2 capsules, Famotidine 10 mg tablet, Norvasc 5 mg tablet, Gabapentin 100 mg capsule, Norvasc 5 mg tablet and Potassium Chloride 20 milli equivalent (meq) tablet. She placed the medications into a plastic pill cup. RN Staff B counted the medications in the medication cup twice and confirmed there were 8 pills in the cup. Upon reconciliation with the physician's orders, it was revealed an order to administer Tylenol 325 mg administer 2 tablets, Norvasc 5 mg administer 1 tablet. The physician's orders revealed an order to administer Atenolol 25 mg 1 tablet and Glipizide 5 mg 1 tablet that were not administered during observation of the medication administration. On 3/28/23 at 9:25 a.m., RN Staff B did not remember the observed medications errors with Resident #18, #41 and #9. RN Staff B said she was unaware the instructions for the Breo Ellipta inhaler included rinsing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 18 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0759 mouth after use. Level of Harm - Minimal harm or potential for actual harm Photographic evidence obtained. Residents Affected - Some On 3/28/23 at 12:00 p.m., the Regional Nurse Consultant confirmed RN Staff B signed the medication administration record (MAR) on 3/27/23 at 9:01 a.m., for resident #9 indicating all the medications were administered, including the Atenolol 25 mg and the Glipizide 5 mg tablets, before administering the medications. 4. On 3/27/23 at 10:20 a.m., RN Staff C was observed administering eight different medications to resident #509 including, Amlodipine Besylate 1 tablet (medication used to treat hypertension), Magnesium Oxide 400 mg. The RN counted the medications in the medication cup twice and confirmed there were 8 pills in the cup before handing the medication cup to Resident #509. Resident #509 took the medication cup from the nurse and swallowed the medications with water. RN staff C returned to the medication cart and ended the medication observation before moving on to another resident. Upon reconciliation with the physician's order, it was revealed the Amlodipine Besylate was ordered for 10 mg, give 5 mg one time a day. The physician's order for the magnesium oxide specified to administer 250 mg twice a day. The physician's order specified to administer Cholecalciferol 1000 units 2 tablets daily and Lipitor 40 mg that were not administered during the medication observation. Review of the MAR revealed RN Staff C had documented all ordered medications were administered. On 3/28/23 at 9:45 a.m., in an interview RN Staff C she said she had administered 5mg of Amlodipine Besylate to Resident #509. Staff C said the Amlodipine Besylate was in a separate medication card with only pill left and she threw the medication card away after removing the medication. The RN said she gave magnesium oxide 250 mg. She said she gave all the ordered medications, and her initial pill count was not correct. Review of the medication card for Amlodipine Besylate revealed the medication dose was 10 mg. Review of the stock bottle of magnesium oxide revealed the medication dose was 400 mg per tablet. Photographic evidence obtained. On 3/28/23 at 12:00 p.m., the Regional Nurse Consultant confirmed RN Staff C had signed the MAR indicating all ordered medications were administered during the medication observation. On 3/28/23 at 12:20 a.m., in a phone interview the Pharmacist said Resident #509 had a physician order for Amlodipine 10 mg, give 5 mg daily since 12/26/22. The Pharmacist said the physician order was confusing and should have been clarified with the physician. The Pharmacist said the pharmacy had only sent Amlodipine Besylate 10 mg tabs and had never sent 5 mg tablets. The pharmacist said the Amlodipine Besylate 10 mg tablets were not scored and could not be cut in half. The Pharmacist said it was an error and confirmed Resident #509 had not received the amlodipine 5 mg tablets from the pharmacy and had received Amlodipine Besylate 10 mg tablets since 12/26/22. On 3/29/23 at 4:52 p.m., in a phone interview the Medical Director said the facility had not informed him Resident #509 had received Amlodipine Besylate 10 mg daily and not the 5 mg ordered. I was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 19 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0759 not made aware of the error; the facility did not notify me of that one. Level of Harm - Minimal harm or potential for actual harm The Medical Director confirmed the facility had not informed him of the medication errors observed during the medication administration for Resident's #9, #18, #41 and #509. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 20 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and staff and resident interview, the facility failed to ensure 1 (Resident #75) of 1 resident received timely dental treatment to maintain her ability to chew. Residents Affected - Few The findings included: Resident #75 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes, Hypertension, Anemia, Congestive Heart Failure, and dependence on oxygen. Section B of the Quarterly Minimum Data Set, dated [DATE] indicated the resident had no dental problems. The Brief Interview of Mental Status (BIMS) was a level 6, which meant severely impaired cognition. The clinical record review noted Resident #75 had a dental consult ordered for right cheek pain on 3/2/23. She is a Medicaid recipient. On 3/28/23 at 9:21 a.m., Resident #75 stated she does not recall seeing the dentist but has mouth pain when chewing on the right side. She has been chewing on the left side. On 3/29/23 at 11:55 a.m., the Social Services Director (SSD) stated she contacted the dental provider on 3/2/23 but had not heard back from them. On 3/29/23 at 2:54 p.m., the SSD stated she reached the dentist office and was told the resident was last seen by the dentist on January 2023 and needed extractions. She is eligible for services. The SSD stated the dentist would visit Resident #75 on 3/30/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 21 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and family interview the facility failed to implement effective corrective actions to maintain compliance for deficiencies identified during the recertification survey completed on 3/31/23. The findings included: 1. On 5/15/23 at 12:38 p.m., quarter bed rails were observed in the up position for Resident #501, admitted [DATE]. At the time of the observation, Resident #501 said they have been on her bed since admission and said no one discussed the risks vs benefits of side rails with her and she said she did not sign a consent for use of bed rails. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/5/23 that noted rails were not necessary at the time. 2. On 5/15/23 at 1:20 p.m., quarter bed rails were observed in the up position for Resident #502, admitted [DATE]. At the time of the observation, Resident #502's husband said the rails have been on the bed since admission and said no one discussed the risks vs benefits of side rails with him and he said he did not sign a consent for use of bed rails. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/6/23 that noted rails were not necessary at the time. 3. On 5/15/23 at 1:39 p.m., quarter bed rails were observed in the up position for Resident #500, admitted [DATE]. At the time of the observation, Resident #500 was unable to verbally communicate. Record review revealed no evidence of discussion of risks vs benefits or signed consent. There was evidence of a side rail assessment completed on 5/11/23 that noted rails were not necessary at the time. On 5/15/23 at approximately 2:30 p.m., during a tour, the facility Director of Nursing confirmed the quarter rails were in the up position on the beds of Resident #500, #501 and #502 and said they should not be in use. 4. On 5/15/23 at 11:04 a.m., observation revealed the Foley catheter drainage bag for Resident #500 was touching the floor in his room and was not covered with a privacy bag. Photographic evidence obtained 5. On 5/15/23 at 12:57 p.m., observation revealed the Foley catheter drainage bag for Resident #92 laying on the floor in his room and was not covered with a privacy bag. On 5/15/23 at approximately 2:30 p.m., observation revealed the Foley catheter drainage bag for Resident #92 laying on the floor in his room and was not covered with a privacy bag. 6. On 5/15/23 at 1:19 p.m., observation revealed the Foley catheter tubing for Resident #39 laying on the fall mat on the floor in her room. The catheter drainage bag was touching the floor and was not covered with a privacy bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 22 of 23 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 105523 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Port Rehabilitation and Nursing Center 6940 Outreach Way North Port, FL 34287 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 0867 Photographic evidence obtained Level of Harm - Minimal harm or potential for actual harm On 5/15/23 at approximately 2:30 p.m., observation revealed the Foley catheter drainage bag and tubing for Resident #39 was laying on the fall mat on the floor in her room and was not covered with a privacy bag. Residents Affected - Some On 5/15/23 at approximately 2:30 p.m., during a tour, the facility Director of nursing confirmed the Foley catheter drainage bags and or tubing for Resident #92 and #39 were laying on the floor or on the floor mat and the Foley catheter bags were not covered with a privacy bag for Residents #39, #92, and #500. She said the catheter bags and/or tubing for Resident #92 and #39 were laying on the floor or fall mat because the low bed was in the low position. On 5/16 23 at approximately 1:17 p.m., the Administrator and the Director of Nursing said they had been completing weekly audits of bed rails and proper catheter care and they had been in compliance, so they switched to biweekly audits on 5/11/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105523 If continuation sheet Page 23 of 23