Inspection·October 12, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had received complaints from residents about the uncleanliness of their rooms, including the smell of urine. She said this was their homes, who wants to smell that? She stated she brought the concerns to the Unit Manager's (UM) and Social Services Director's (SSD) attention. On 10/11/23 at 11:22 AM, CNA D stated when she noticed a room that needed to cleaned, she did it herself as there were times the housekeeper did not clean the rooms. She explained when she noticed something did not work or needed repair in a resident's room, she notified the nurse. She indicated the nurse entered a work order ticket electronically to alert the Maintenance Director and he took care of the problem quick. She indicated she did not have access to enter work orders electronically. Later on 10/12/23 at 1:20 PM, CNA D stated she had noticed the closet door in room [ROOM NUMBER] resting on the side of the closet and she had told the Maintenance Director a long time ago. On 10/12/23 at 10:32 AM, the Housekeeping Manager stated she had been working at the facility less than a month and walked into a mess. She indicated her responsibilities included oversight of the housekeeping and laundry staff. She explained the housekeepers were expected to clean residents' rooms and bathrooms daily and notify her of any dirty or stained privacy curtains. She indicated the housekeeping staff were to notify her of any items in need of repairs and she, in turn, notified the Maintenance Director. She said they performed a deep cleaning of one room on each wing every day. She indicated they changed privacy curtains when rooms were deep cleaned. She noted the windows, windowsills and mini blinds were cleaned daily. She reported she did not have documentation of audits performed because she was just shown last week how to document the room audits. She said they now have a calendar for deep cleaning. She noted the former Housekeeping Manager did not have a deep cleaning calendar nor room audits. She indicated she did not address deep cleaning or performed any audits since she started because of low staff. She explained they had deep cleaned empty rooms. On 10/12/23 at 10:59 AM, the Maintenance Director stated his responsibilities included the maintenance of the entire building. He explained they used TELS, an electronic system to enter and track work orders for repairs. He indicated when repairs were needed in any resident's room, the staff member entered a work order in TELS. He indicated all clinical staff had access to TELS and were trained on how to use it. He explained he also received verbal notification of repair requests and at times, he did not create a work order because he handled it at the time. He indicated he closed all work orders when repairs were completed. He reviewed work orders since May 2023 for rooms #226 and #230. At 4:51 PM, the Maintenance Director indicated he found a work order for room [ROOM NUMBER] on 5/17/23 when the resident requested a toilet paper holder, but she then agreed to have loose toilet paper instead. He stated he did not find a work order for the closet door in room [ROOM NUMBER]. He explained he checked rooms weekly or monthly based on tasks assigned in TELS. On 10/12/23 at 11:17 AM, during tour of Wing 2 with the Maintenance Director, he validated the closet door in room [ROOM NUMBER] was off again and stated he did not know it needed repair this time. He indicated the nursing staff should have told him when it happened. He then explained he was aware of resident #55's concern but the resident asked for another toilet roll dispenser or to have her own toilet paper outside the dispenser, which they had provided for quite some time. He stated he did not know she was keeping the toilet paper on the bathroom floor for easy access. On 10/12/23 at 11:26 AM, during tour of Wing 2, the Housekeeping Manager acknowledged the privacy curtains in rooms 232, 234 and 238, had multiple stains and stated they needed be changed. She validated all 3 window mini blinds in room [ROOM NUMBER] were broken and stated the housekeeping staff should have let her know or informed the Maintenance Director to change them. She validated the windowsill in room [ROOM NUMBER] was dirty. She stated the housekeeper in this area was new and did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 2 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few receive proper training because of low staff in her department. She stated this was the residents' home and they should have a clean and homelike environment. Review of the job description for the Director of Plants Operations signed on 8/17/23 read, The Director of Plants Operations ensures the facility, equipment, and utilities are maintained in good working order and facility grounds are properly maintained in accordance with facility policies and State and Federal regulations. Review of the Healthcare Services Group, Inc. Housekeeping In-Service form revealed a 5-step Daily Patient Room Cleaning which included horizontal surfaces and read, Table tops, headboards, window sills, chairs - should all be done. Review of the facility policy and procedure titled Facility Standards dated April 2017, read, The facility will monitor each facility's housekeeping program for operational efficiency, quality, effectiveness, and budget control. Provide a clean, safe, pleasant and a functional environment for residents, staff and visitors. Review of the facility policy and procedure titled Physical Environment dated January 1, 2020, read, A safe, clean, comfortable, and home-life environment is provided for each resident/patient . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 3 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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** 4. Resident #3 was admitted to the facility from acute care hospital on [DATE] with diagnoses that included cerebral atherosclerosis, muscle wasting, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, dementia, and acute kidney failure. Residents Affected - Few A review of the resident payer source showed hospice Medicaid in effect since 11/30/22 to present and the resident representative signed the Medicaid hospice benefit election form on 11/18/22. The hospice physician signed the Initial Certification of Terminal Illness form 12/10/22 attesting, It is my clinical judgment that the above-named patient is terminally ill and has limited life expectancy of six months or less if the terminal illness runs its normal course. The hospice physician had since signed the certification of terminal illness every 3 months as she remained under hospice care. On 10/12/23 at 9:38 AM, the MDS Coordinator acknowledged that section J of the MDS quarterly assessments dated 9/28/23 and 6/28/23 were not accurate regarding life expectancy and should have noted the resident's expectancy was less than 6 months. Review of the Resident Assessment Instrument version 3.0 Manual instructions for completing Section J 1400: Prognosis should be marked [yes] if the medical record includes physician documentation that resident is terminally ill or the resident is receiving hospice services . Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected health conditions regarding falls for 2 of 9 residents reviewed for accidents (#9, #74), and for a hearing device for 1 of 1 resident reviewed for hearing/vision (#94) and failed to accurately assess the prognosis for 1 of 1 resident reviewed for Hospice and end of life care (#3) of a total sample of 49 residents. Findings: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses to include tibia fracture, type 2 diabetes, and anxiety. Review of the medical record noted the resident had an unwitnessed fall on 6/09/23 at 6:20 PM. A nursing progress note dated 6/10/23 at 2:00 AM, read resident #9's left ankle was swollen. An x-ray result indicated a fracture to the left distal tibia. Resident #9 was sent to the hospital for further evaluation and treatment. Review of the Quarterly MDS assessment dated [DATE], Section J indicated resident #9 had two or more falls with no injury since admission. On 10/12/23 at 6:45 PM, the MDS Coordinator acknowledged the MDS assessment dated [DATE] documented the resident had two or more falls with no injury. She stated she did not work here at the time the assessment was completed so she could not comment as to why it was not accurately assessed. She stated she gathered information to complete the assessments by reviewing the Risk Management section electronically, reviewing progress notes and Change in Condition forms, and by speaking to the residents and nurses. She stated the assessment must be accurate in order to gain a comprehensive picture of what the residents' needs are and create an accurate care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 4 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record revealed resident #74 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side, muscle weakness unsteadiness of feet and acquired deformity of head. Review of the resident's medical record revealed two SBAR (Situation, Background, Appearance, Review) completed for falls dated 2/15/23 and 3/15/23. Resident #74's medical record revealed a nurses' progress note dated 3/04/23 which read, Resident had unwitnessed fall in room. No injuries noted. The note indicated resident fell on 3/03/23 at 8:00 PM. Another progress note dated 3/15/23 revealed resident #74 had an unwitnessed fall at 12:00 AM in his room. Review of the Incident by Incident Type log from 1/25/23 to 4/25/23 revealed resident #74 had two fall incidents on 2/15/23 and 3/3/23, and an unwitnessed fall on 3/15/23. Review of the quarterly MDS assessment with assessment reference date (ARD) 4/25/23 revealed Section: J 1800, Health Conditions, Any Falls Since Admission/Entry or Reentry or prior Assessment, resident #74 was assessed as No for falls. On 10/12/23 at 6:45 PM, the MDS Coordinator verified the MDS assessment dated [DATE] did not reflect resident #74's falls on 2/15/23, 3/3/23, and 3/15/23. She stated before submitting the assessment the clinician who completed it signed acknowledging it was accurate. The Centers for Medicare and Medicaid Services Resident Assessment Instrument guidance for J1800 read, Code 1, yes: if the resident has fallen since the last assessment. Continue to Number of Falls Since Admission/Entry or Reentry or Prior Assessment . item (J1900), whichever is more recent. 3. Resident #94 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included chronic kidney disease, hypertension and anxiety disorder. Review of the Agency for Healthcare Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/22/23 revealed resident #94 was alert and oriented but had impaired sight and used hearing aids for his hearing. Review of the Admission/readmit: Data Collection and Baseline Care Plan dated 8/25/23 revealed under the Sensory section his ability to hear was not assessed, but left and right hearing aids were indicated for devices that were used or needed. The Minimum Data Set (MDS) admission assessment with assessment reference date 8/31/23 section B: Hearing, Speech and Vision indicated resident #64's ability to hear was adequate and did not indicate he used a hearing aid or other hearing appliance. On 10/12/23 at 6:45 PM, the MDS coordinator confirmed resident #94's admission MDS assessment dated [DATE], section B was inaccurate for hearing aids. She was unable to say why it was marked as no hearing aids used, as she said did not work at the facility at the time. Review of the Resident Assessment Instrument version 3.0 Manual revealed instructions for completing section B0300: Hearing Aid instructed the nurse to code 1, yes if the resident did use a hearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 5 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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 Level of Harm - Minimal harm or potential for actual harm aid for the hearing assessment . The item rationale described problems with hearing can contribute to social isolation and mood and behavior disorders. Further, knowing if a hearing aid was used when determining hearing ability allows better identification of evaluation and management needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 6 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a plan of care for hearing aid devices for 1 of 1 resident reviewed for hearing and vision of a total sample of 49 residents, (#94). Findings: Resident #94 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included chronic kidney disease, hypertension and anxiety disorder. Review of the Agency for Healthcare Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/22/23 revealed resident #94 was alert and oriented but had impaired sight and used hearing aids. Review of the Admission/readmit: Data Collection and Baseline Care Plan dated 8/25/23 revealed under the Sensory section his ability to hear was not assessed, but left and right hearing aids were indicated for devices that were used or needed. Review of the admission Minimum Data Set (MDS) assessment Section B dated 8/31/23 revealed he had adequate hearing, but the assessment inaccurately showed resident #94 did not have or use hearing aids. On 10/09/23 at 12:03 PM, resident #94 was in bed with his eyes closed. On his bedside table was an empty case and on the wall above his bed were instructions directing staff to put the resident's hearing aids in his ears. On 10/09/23 at 4:53 PM, and on 10/12/23 at 8:50 AM, resident #94 was observed in his room wearing his left hearing aid and was able to hear and converse with the surveyor. In a telephone interview on 10/09/23 at 3:52 PM, resident #64's granddaughter stated she put the sign about the hearing aids on the wall so staff would remember to put his hearing aids in his ears so he could hear. She explained her grandfather had his right hand amputated in the past and he required help from the staff for much of his care. The granddaughter described her frustration as the hearing aids would sometimes be lost, not in his ears or not working because the batteries needed to be replaced and she would have to ask the staff to do it. On 10/11/23 at 1:55 PM, assigned Licensed Practical Nurse (LPN) A stated resident #94 was very hard of hearing if he wasn't wearing his hearing aids, and explained he currently only had one hearing aid since the other was lost. She described if a resident had hearing aids, the Certified Nursing Assistants (CNAs) or the nurses would apply the hearing aids or take them out. She said staff knew how to care for the hearing aids usually from a care plan, especially if they were unfamiliar with a resident or their needs. LPN A explained most hearing aids made a whistling type noise when the batteries were low, but they would not be changed on a regular basis. Review of resident #94's medical record on 10/11/23 revealed no care plan for hearing or use of hearing aids for resident #94. Further review of the medical record revealed no CNA documentation or task for application or removal of resident #94's hearing aids, or any other care of the hearing aids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 7 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/12/23 at 9:10 AM, the 100 Unit Manager (UM) explained CNAs usually put in or took out resident's hearing aids and they utilized the Kardex to ascertain the care the resident needed. She described the CNA Kardex came directly from the care plan. She stated usually hearing aids would be part of a communication care plan that was initiated by the admitting nurse and reviewed again by the Inter-disciplinary (IDT) clinical team after admission. She explained, after the IDT review, the UMs would again review the chart and add care plans as needed. The 100 UM stated resident #94 had hearing aids at admission and after review of his medical record she confirmed he did not have a care plan for his hearing aids. She also confirmed the importance of resident #94's hearing aids because she said he did not hear well without them and it was important for resident's wellbeing to be able to hear. On 10/11/23 at 10:37 PM, the Director of Nursing (DON) explained that up until the past week or so the facility had a travel nurse in the role of Minimum Data Set (MDS) coordinator. She described the admitting nurse initiated the baseline care plan, then the IDT team reviewed the chart after admission, the next business day. She stated the IDT team looked at diagnosis codes and anything else that needed a care plan and put them in immediately. The DON indicated the care plans were also reviewed when any event was reviewed by the risk management team, and any interventions or care plans were entered there. On 10/12/23 at 6:45 PM, the MDS coordinator explained she was new to her role at the facility but explained assessment of the resident was important to know what the resident's accurate, comprehensive care needs were, to get the comprehensive picture to develop the plan of action. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 manual helps facility staff to gather definitive information about resident's needs which must be addressed in an individualized care plan (retrieved from www.cms.gov on 10/13/2023). The CMS RAI Version 3.0 Manual Section B: Hearing, Speech and Vision describes the rationale for assessment of hearing aids being problems with hearing can contribute to social isolation and mood and behavior disorders. The document described resident care plans should include use and maintenance of the hearing aids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 8 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate care and services related to the use of splints for 1 of 2 residents reviewed for position and mobility of a total sample of 49 residents, (#48). Findings: Review of resident #48's medical record revealed she was readmitted to the facility on [DATE]. Her diagnoses included lack of coordination, stroke, contractures of left hand, left elbow, right elbow and abnormal posture. Review of the Minimum Data Set (MDS) annual assessment with Assessment Reference Date of 9/20/23 revealed the Brief Interview for Mental Status was not conducted because resident #48 was rarely or never understood. The MDS assessment showed resident #48's cognitive skills for daily decision making were severely impaired. The assessment showed resident #48 was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for her health and well-being. Observations on 10/09/23 at 11:36 AM, 10/10/23 at 11:04 AM and 10/12/23 at 1:24 PM, showed resident #48 lying in bed with her hands placed on her chest and contractures noted on her left hand and elbows. She was not wearing any splints. Review of the comprehensive care plan for resident #48 revealed a focus for activities of daily living (ADL) revised on 8/30/18 and read, cannot complete ADL tasks independently and requires individualized interventions to maintain because . risk of contracture. Interventions directed staff to apply bilateral hand splints and left upper elbow splint as resident allowed and tolerated. On 10/12/23 at 1:11 PM, Licensed Practical Nurse (LPN) E stated had seen resident #48 wearing splint on her left arm once in a while. She indicated she assumed the Certified Nursing Assistant (CNA) was responsible for putting them on and she had seen the therapists doing this sometimes. She explained this task was not included in the Treatment Administration Record where she would document it. She stated the splints were used to prevent or slow the progression of contractures. On 10/12/23 at 1:31 PM, CNA F stated resident #48 required total care and she had an arm splint which therapy or the CNA was responsible to apply. CNA F searched for the splints in resident #48's dresser drawer and her closet. She pulled various splints out of resident #48's closet, and stated these were splints for her elbow, arm and hand. She then placed the splints back in the resident's closet. CNA F confirmed she was regularly assigned to this resident and had worked with her on Monday, 10/9/23, Tuesday, 10/10/23 and today (Thursday, 10/12/23). She stated she did not remember placing the splints on any of these days because she was going to ask therapy what exactly she needed to wear as she had a whole bunch of them. She recalled therapy worked with resident #48 but it had been a while back. She recalled therapy notified and showed her when her assigned residents required splints to be applied. She stated she did not think CNAs should be responsible for this and said, I did not go to school to be a therapist. She indicated resident #48 needed to wear a splint because her arm was contracted but stated she was not sure what could happen if the resident did not wear it daily as indicated. CNA F stated she was familiar with how to access the resident's plan of care (POC). She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 9 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed resident #48's POC under the mobility section and read, Apply bilateral hand splint or left elbow when hand splint is not on as resident tolerates for up to 3 hours. She reflected she had not looked at the POC in a while. She stated she documented the splints inaccurately as she selected resident not available, but was not sure. She then reviewed the Resident Splint Binder 200 Unit in the nurses' station and acknowledged resident #48 was included in the Splint List Updated 10/2/23. She mentioned she was busy, and restated she had been very busy, and she did not know what she was supposed to do with the splints. On 10/12/23 at 1:58 PM, the 200-wing Unit Manager (UM) stated his responsibilities included the oversight of the safety and care of the residents, the timely execution of interventions and physicians' orders and ensured adequate staffing was in place to take care of each resident's needs. He stated he rounded residents' rooms approximately every 2 hours and observed for safety and comfort among other things. He stated he knew resident #48 was supposed to wear splints as tolerable but had not noticed she was not wearing the splints. He explained a therapist taught the CNA staff how to place splints correctly. He indicated resident's refusals were to be documented in the medical record. He stated wearing the splints was important to delay the worsening of contractures. On 10/12/23 at 2:36 PM, the Director of Rehab Services explained therapists provided functional maintenance recommendations to the nursing staff and trained floor staff on what tasks they expected them to complete. She indicated therapy documented the instructions and nursing entered a task for the CNA assigned to the resident. She stated the CNAs who received the education were expected to educate the rest. She stated the last episode of care for Occupation Therapy (OT) was 3/29-5/29/23. She explained resident #48 was to wear a left elbow splint and left-hand splint, but they were not to be worn at the same time, either one or the other. She showed evidence of training to CNA F with her signature and dated 5/18/23. She explained the purpose for resident #48 to wear the splints included the risk of further contractures and reduction of pain. Review of the OT - Therapist Progress & Discharge Summary form dated 5/29/23 revealed resident #48's goals according to the POC for contracture management / splinting program were met and the therapist provided caregiver education in splinting program with 75% carryover. Review of the Splinting Program Form for resident #48 read, Schedule wear time: 4-6 hours/day; as tolerated. Patient to wear left UE (upper extremity) elbow extension splint and LUE (left upper extremity) resting hand splint for up to 4-6 hours/day or as tolerated with no s/s (signs or symptoms) of skin breakdown, redness, or pain. Left UE elbow and hand splint not to be worn at the same time. The Splinting Program Form, an In-Service Training Record and Therapy Recommendations for Restorative/Functional Maintenance Program forms were signed by CNA F. Review of resident #48's Task report for October 2023 revealed CNA F signed off the splint task on 10/2, 10/3, 10/4, 10/5, 10/6, 10/10 and 10/12. On 10/12/23 at 3:14 PM, the Director of Nursing (DON) explained the floor maintenance program was not assigned to anyone and the nursing management team oversaw it. She indicated residents discharged from therapy services who required splints were listed in the binder located in the nurses' stations and it was the responsibility of the floor CNAs to carry it out. She indicated splint use was included in the POC and the CNAs documented it in the medical record. She indicated if the CNA was too busy, they needed to inform the nurse, the UM or her. The DON stated it was not a good thing if CNA F documented the task was completed when it was not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 10 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedure titled Restorative Nursing Program revised on October 2017 read, The facility provides Restorative Nursing Program that involve interventions to improve or maintain the optimal physical, mental, and psychological functioning. The programs include: Contracture Management and Prevention - . This program also involves splint/brace assistance to protect joint and skin integrity. The form revealed the programs were based on the person-centered goals of each resident and promoted the highest functional level of each resident as well as enhanced the restorative program. Event ID: Facility ID: 105539 If continuation sheet Page 11 of 12 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 105539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771 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. Based on interview, and record review, the facility failed to implement and monitor the Performance Improvement Plan (PIP) developed by the Quality Assurance Performance Improvement (QAPI) committee to ensure continued accuracy with all resident Minimum Data Set (MDS) assessments and Development/Implementation of Comprehensive Resident Care Plans. Findings: Review of the facility's survey history revealed repeat deficiency concerns for MDS assessment accuracy over the past 2 surveys, and during the current survey. The survey history revealed the facility had inaccurate MDS assessments on 3/2020, and 12/15/21. This is the facility's third deficiency in 4 years for inaccurate MDS assessments. On 10/12/23 at 2:48 PM, an interview was conducted with the facility's Administrator, and Director of Nursing (DON) regarding the facility's QAPI program. The Administrator acknowledged the facility had a PIP for MDS from the last survey. He confirmed there were audits in place through September 2022. The Administrator acknowledged he could not locate current audits for this year for MDS inaccurate assessments. The facility could not show evidence of inaccurate MDS assessments being discussed in QAPI meetings this year or that they had an actual PIP currently in effect for MDS assessment omissions. The Administrator acknowledged the facility did not currently have a QAPI plan in place. The Administrator stated the biggest problem the facility had was MDS staff turnover. He stated the last MDS staff failed to review and assess residents, had inaccurate assessments, and late assessments. He stated the MDS staff was given an action plan to help correct the concerns but she quit a week later. We have had traveling MDS staff until a couple of weeks ago when we hired a new person. She is new and it will take some time to get her trained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105539 If continuation sheet Page 12 of 12