Inspection·February 3, 2022

F 0676 hallway using R (right) knee unloader brace. (Copy obtained) Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Employee D, Director of Therapy (DOT) on 02/02/22 at 3:45 PM. She explained that Resident #39 was discharged from physical therapy on 01/13/22. She went on to say that therapy wrote recommendations to restorative nurse program for upper body strengthening and ambulation in the hallways. The DOT said, When a resident is put on restorative therapy we send out recommendations to nursing and they will make the orders for restorative therapy. Residents Affected - Few On 02/02/22 at 4:00 PM, an interview was conducted with the resident's Restorative aide, Employee E regarding the restorative plan for Resident #39. He reported that as a restorative aide, he will do exercises, put on splints, and walk residents, depending on orders and needs of resident. Employee E confirmed that resident #39 is on restorative nursing but was not seen today. He stated that the resident was scheduled for restorative nursing on Tuesdays, Thursdays, and Saturday sessions. When he was asked if had assisted Resident #39 with walking in the hallways, he stated that he did not have any orders for walking Resident #39. He explained that the resident's had orders to do upper and lower extremity exercises. On 02/02/22 at 4:19 PM, an interview was conducted with Employee F, Registered Nurse Supervisor who oversees the restorative nursing program. She stated that when a resident is discharged from therapy, the clinical team will decide if they can benefit from restorative nursing program. If a benefit can be achieved, then the therapy department will fill out a communication sheet identifying what programs the resident will need for the restorative program. When Employee F, was asked the current status of #39, she stated, he is on passive/active range of motion with upper and lower exercises which are to be done with the staff. Employee F was asked to provide the communication from therapy to restorative department communication form for recommendations related to Resident #39. Employee F confirmed that the form dated 01/25/22, from therapy to nursing requested that Resident #39 ambulate up to 250 feet x 1 with supervision in hallway using right knee unloader brace. (Copy obtained) Employee F acknowledged that the resident did not ambulate up to 250 feet x 1 with supervision in hallway using right knee unloader brace with restorative aide and confirmed it should be done 3 times a week. She explained that if the restorative aide does not do this activity with the resident, then the certified nursing aides (CNAs) should do it. She went on to say that the agency CNAs might not be doing it. She reported it should have been documented in computer as a restorative duty and proceeded to input it in computer while being interviewed at this time. Employee F was observed adding the restorative exercise into the duties of restorative aides. On 02/02/22 at 4:42 PM, Resident #39 was observed in a wheelchair with his knee brace on. He was asked if he had received his walking exercises in the last week? He stated, No, I have gotten exercises with restorative, but I have not been walked. A review of Resident #39's restorative program record revealed Employee F's recorded an order on 02/02/22 to nursing rehabilitation tasks that stated walking with distance up to 250 feet times 1 with supervision in hallway using Right Knee Loader brace with Front wheeled walker. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105547 If continuation sheet Page 2 of 4 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 105547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, interviews and record review, the facility failed to maintain complete and accurate medical records in accordance with professional standards for one (Resident #7) of one resident sampled for mobility, from a total sample of 36 residents. The findings include: A record review for Resident #7 revealed an admission date of 06/25/18, with diagnoses including dementia without behavioral disturbance, type 2 diabetes mellitus, congestive heart failure, generalized anxiety disorder, major depressive disorder, hypertension, tremor, edema, and anemia. A review of Resident #7's quarterly minimum data set (MDS) assessment, dated 01/22/22 revealed a brief interview for mental status (BIMS) score of 06, indicating severe cognitive impairment. A review of Resident #7's current physician's orders dated October 18, 2021, read: knee immobilizer to left leg every shift with no discontinuation date observed. On 01/31/22 at 10:00 AM, Resident #7 was observed in hallway by her room, self-propelling in a wheelchair. She was observed dressed for day without an immobilizer on her left knee. On 02/01/22 at 4:00 PM, Resident #7 was observed for a second time. She was in her room, sitting in a wheelchair beside her bed, dressed in day clothes. No knee immobilizer was observed on resident's left knee. Resident was asked if she usually wears any type of a brace, splint, or immobilizer on her leg. She stated, I don't think so, no. On 02/02/22 at 10:10 AM, Resident #7 was observed for a third time. She was sitting in her wheelchair in the hallway, dressed in day clothes without a knee immobilizer on her left knee. Resident was asked if she had a brace or immobilizer for her left knee. She stated, No, I think I used to. But I don't anymore. A record review of Resident #7's Treatment Administration Record (TAR) for October 18-31, 2021, November 2021, December 2021, and January 2022 revealed documentation that the resident received the treatment of knee immobilizer to LEFT leg every shift for s/p left hip hemiarthroplasty on each of those days. On 02/02/22 at 10:15 AM, Employee B, Certified Nursing Assistant (CNA) was asked if she had assisted Resident #7 with her morning care, she replied, Yes I did. She was then asked if the resident had a left knee brace/immobilizer, she replied, No, I don't think so, not that I am aware of. On 02/02/22 at 10:20 AM, Employee A, Licensed Practical Nurse (LPN) was asked if she was caring for resident #7 today, she replied, Yes. She was then asked if the resident was using a knee immobilizer, she replied, No, I don't think so, I haven't seen one. During an interview on 02/02/22 at 2:10 PM, Employee D, Director of Physical Therapy confirmed that had worked with Resident #7 and the resident was currently on restorative therapy now. When she was asked if the resident was using a left knee immobilizer, she stated, I know she was using one back in October, when she came back from having her hip surgery. But I think that has been discontinued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105547 If continuation sheet Page 3 of 4 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 105547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 by now. I know she wasn't using it this last time with her physical therapy. Level of Harm - Minimal harm or potential for actual harm On 02/02/22 at 4:25 PM, an interview was conducted with the Director of Nursing (DON). She was asked if she had any knowledge of Resident #7's physician order for a left knee immobilizer. She said, I saw that it was discontinued by her orthopedic doctor in December. The DON provided a Physician Visit Form dated 10/29/21 with a Physician Progress Note that stated, knee immobilizer in place until 12/14/21. When the DON was asked if the resident was still wearing the knee immobilizer, she stated, No. She was then asked if she knew why the nurses were signing off the left knee immobilizer as in place each shift since it was ordered until today in the TAR. She stated, I don't know why they are signing it off, it's not being used. The nurse who took the order just realized she didn't discontinue it in the system, and that's why it still shows up on the TAR. Residents Affected - Few . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105547 If continuation sheet Page 4 of 4