Inspection·March 24, 2022

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall, the nurse completed an incident report which compiled the details of the fall, the predisposing conditions, and notification to the physician and family. The RM indicated the Unit Manager conducted a fall huddle with the resident's assigned nurse and Certified Nursing Assistant (CNA) to get details of the fall. The RM explained if the fall was unwitnessed, the nurse performed an assessment and began neurological checks. The RM indicated all falls were discussed in morning meetings the next business day and interventions updated to the care plan based on the root cause analysis. The RM noted that residents who suffer from Alzheimer's Disease and were ambulatory moved quickly and a caregiver may not get to them timely to assist them. The RM explained the notes regarding resident #40's incident included the resident fall on 3/3/22 at 5 PM. The RM indicated resident #40 did not call for assistance, and the resident reported he lost his balance. The RM reported resident #40 was able to take a few steps inside his room and the resident indicated he forgot to lock the wheelchair brakes. The RM reported therapy screened the resident after the fall and encouraged him to call staff for assistance, lock his wheelchair breaks, and use the walker. She said a review of the fall was conducted on 3/4/22 and determined it was not an adverse incident. The RM conveyed they reminded staff to anticipate resident's needs and said, there is no way to prevent each fall, unfortunately. On 3/24/22 at 1:45 PM, the RM explained the resident was sent to the hospital on 3/5/22 due to wheezing and they were informed by the hospital the resident had a fracture. She explained an additional investigation was not done after learning of the resident's fracture. The RM indicated once the root cause was determined, they did not continue investigating and nothing else was done after resident #40 returned from the hospital. The RM stated the root cause analysis showed the resident refused to ask for help. She did not explain how the resident would request help when he had severe cognitive impairment. The RM noted, we could have done a more thorough investigation after we became aware the resident sustained a fracture. The RM added, I can see where we can make some improvements after learning of the fracture. Review of the facility policy and procedure titled Abuse and Neglect dated 12/28/21 read, The investigation may include interviewing employees, residents or other witnesses to the incident. Interview all involved . individually, not as a group, so that their descriptions of the incident can be compared to determine any inconsistencies. Consider having each person write his or her memory of the event. If possible. Get signed and dated statements from any witnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 2 of 7 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 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Good Samaritan Society-Kissimmee Village 1500 Southgate Drive Kissimmee, FL 34746 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an alleged violation of verbal abuse for 1 of 1 resident reviewed for abuse of a total sample of 48 residents, (#19). Findings: Review of resident #19's medical record revealed he was admitted to the facility on [DATE] with diagnoses of stroke, legal blindness and pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 that indicated he was cognitively intact. Review of the facility brochure in the admission packet titled, We Don't Tolerate Abuse! dated 4/19, read, Verbal Abuse: Any use of oral, written, or gestured communication (including sounds) that willfully includes disparaging and/or derogatory terms to persons or their families within their hearing distance, regardless of age, ability to comprehend or disability On 3/21/22 at 11:40 AM, resident #19 was in his room, lying in bed. He was alert and oriented, talkative, and was listening to a television show. The resident said he had chronic back pain which was very severe at times and he took pain medication every 6 hours. The resident spoke about the nurses at the facility who referred to him as a drug addict, except for the nurse working today. He recalled the most recent time he was called a drug addict was last night. The only nurse he could recall was Licensed Practical Nurse (LPN) A. The resident indicated, this is abuse. The resident noted the last time he reported this allegation was 1 to 2 weeks ago and he had not been able to talk to anyone in administration regarding his concerns. On 3/21/22 at 11:54 AM, the Social Services Director (SSD)/Abuse Coordinator, the Assistant Director of Nursing (ADON), Risk Manager (RM) and Senior Director all indicated they were unaware of the verbal abuse allegation for resident #19. The SSD said she would initiate an investigation. On 3/23/22 at 2:34 PM, the SSD stated she obtained statements from resident #19 and Licensed Practical Nurse (LPN) A. A review of LPN A's phone interview statement from 3/22/22 read, she has not worked with resident since Thursday 3/17/22 .she is resident's regular nurse .since he came to facility he's been on prn [as needed] pain medications .resident asks for his medication every 6 hours and does not appear in pain .she simply reports that she has talked to resident about drug addition and that resident mentioned to her that other staff call him a drug addict The SSD and RM acknowledged the nurse should have immediately reported that staff called the resident a drug addict. The SSD did not know when LPN A became aware only that she last worked on 3/17/22 and she should have reported this to the Unit Manager, DON, Administrator, or the SSD. On 3/23/22 at 5:45 PM, during a telephone interview, LPN A denied calling resident #19 a drug addict and said he told her other staff had called him a drug addict. LPN A could not remember the date, only that he reported this to her within the past month. LPN A stated, I did not feel he meant that was verbal abuse. The LPN acknowledged she should have immediately reported to the SSD and should not have made the determination that it was not verbal abuse on her own. Review of the Clinical Psychologist progress note dated 2/14/22 read, Resident #19 indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 3 of 7 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 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Good Samaritan Society-Kissimmee Village 1500 Southgate Drive Kissimmee, FL 34746 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he is often in pain and the staff will not give him medication to address his pain he reported that he is often classified as a drug addict On 3/24/22 at 10:18 AM, during a telephone interview, the Clinical Psychologist acknowledged she saw resident #19 at the facility on 2/14/22, 2/28/22 and 3/14/22. She said on 2/14/22, the resident told her the staff referred to him as a drug addict. She said she did not report this as she thought he was being cynical and did not link a specific staff or specify name. She stated, for the staff to say that would be appalling. Review of the facility policy and procedure for Abuse and Neglect revised 12/28/21, read, the purpose is to ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated Procedure: If an employee received an allegation of abuse, neglect .the employee will take measure to protect the resident .The employee will then report the allegation to a supervisor .Notification procedures: Alleged or suspected violations involving any mistreatment .will be reported immediately to the administrator Ensure that someone is assigned to complete the investigations and that the care plan has been updated with any new interventions put into place. The investigation team will determine whether further investigation is needed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 4 of 7 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 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Good Samaritan Society-Kissimmee Village 1500 Southgate Drive Kissimmee, FL 34746 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of resident #127's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, and heart failure. Review of the discharge Minimum Data Set assessment dated [DATE] showed the resident was transferred to an acute care hospital and his return was anticipated. A progress note dated 2/21/22 noted the resident was short of breath with low oxygen level. The progress note read inhaler administered, physician ordered 6 liters of oxygen via nasal canula and to transfer resident to the hospital. On 3/24/22 at 3:57 PM, the Social Services Director (SSD) indicated she was responsible for residents who were discharged to the community, not transferred to the hospital. The SSD stated she was not sure if a bed hold form was completed and given to the resident or resident's representative. The SSD explained she was responsible for sending the Agency for Healthcare Administration Nursing Home Transfer and Discharge Notice to the resident/resident's representative and the Ombudsman. The SSD reported the notification to the Ombudsman has not been done consistently. She noted she had some forms from October 2021 but nothing after that date. The SSD indicated she was aware this was a requirement and had mentioned the issue to the previous 2 administrators but not the current one. The facility's policy and procedure for Discharge And Transfer - Rehab/Skilled, Therapy & Rehab revised 12/28/21 read, Before a location transfers or discharges a resident, the location must: 1. Notify the resident and the resident's representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. The Notification of Transfer or Discharge (GSS #233 A), or other state-required form, will serve as the written notice to be given to the resident and/or resident's representative. Note: When a resident is temporarily transferred on an emergency basis to an acute care center, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable; 2. With a facility-initiated transfer or discharge, the location must send a copy of the GSS #233 A or other state-required form to a representative of the Office of the State Long-Term Care Ombudsman. Based on interview and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents/representative nor the Ombudsman for 3 of 3 residents reviewed for hospitalizations out of a total sample of 48 residents, (#5, #73 and #127). Findings: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease, end stage renal disease, cirrhosis of liver, dependence on renal dialysis, and type 2 diabetes. Review of the resident's medical record revealed he was hospitalized on [DATE]. A progress note dated 2/21/22 read, Resident will be transported non-emergency to [the hospital] . because his amputation surgical wound opened up and the bone is visible and is bleeding more than usual. The medical record did not contain a Notification of Transfer form given to the resident/representative nor the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 5 of 7 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 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Good Samaritan Society-Kissimmee Village 1500 Southgate Drive Kissimmee, FL 34746 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 0623 Ombudsman. Level of Harm - Minimal harm or potential for actual harm 2. Resident #73 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Multiple Sclerosis, and benign prostatic hyperplasia with lower urinary tract symptoms. Residents Affected - Some Review of resident #73's medical record revealed he was hospitalized on [DATE], 11/29/21 and 1/06/22. A progress note dated 9/04/21 indicated the resident pulled out his urinary catheter and nursing staff were unable to reinsert the catheter. The nursing staff notified the physician who gave an order to send resident #73 to the hospital. A progress noted dated 11/29/21 indicated resident #73 exhibited verbally and physically aggressive behaviors despite nursing interventions. The resident was sent to the hospital via emergency transport for evaluation and treatment. A progress note dated 1/06/22 indicated resident #73 pulled out his urinary catheter again and possibly still retained a section of the dislodged tubing. The physician gave a verbal order to send the resident to the emergency room for evaluation and treatment. The medical record did not contain Notification of Transfer or Discharge forms for the hospitalizations on 9/04/21, 11/29/21 and 1/06/22. On 3/24/22 at 2:43 PM, the Social Services Director (SSD) stated she completed the Notice of Transfer or Discharge forms for residents who were discharged to the community, but not for residents who were transferred or discharged to the hospital. She acknowledged residents who went to the hospital were also considered discharged from the facility if they did not return to the facility. The SSD was not aware of the staff responsible for completing the notice if residents were transferred to the hospital. On 3/24/22 at 2:59 PM, the 400 Wing Unit Manger stated nursing staff did not complete Notification of Transfer or Discharge forms. She clarified the SSD was responsible for completing the form and notifying the Ombudsman of the transfer or discharge. On 3/24/22 at 3:02 PM, the Licensed Practical Nurse Risk Manager verified the SSD was responsible for completion of the Notification of Transfer or Discharge forms and sending notification to the Ombudsman. On 3/24/22 at 3:18 PM, the SSD confirmed she was responsible for completing all Notice of Transfer or Discharge forms. She stated she was aware the form needed to be completed, provided to the resident or resident's representative and a copy sent to the Ombudsman. The SSD explained she had not been able to complete all Notice of Transfer or Discharge forms nor send copies to the Ombudsman in the 10 months since she assumed her position due to workload. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 6 of 7 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 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Good Samaritan Society-Kissimmee Village 1500 Southgate Drive Kissimmee, FL 34746 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Residents Affected - Many Findings: On 3/21/22 at 11:23 AM, 3/22/22 at 9:57 AM, 3/22/22 at 4:30 PM and 3/23/22 at 9:08 AM, the nurse staffing information form was posted in the front lobby next to the receptionist's desk. The form did not include the total number and actual hours worked by licensed nurses and unlicensed staff (Certified Nursing Assistants/and Personal Care Attendant) who were directly responsible for resident care per shift. On 3/23/22 at 4:26 PM, the Staffing Coordinator stated she was responsible for posting the nursing staffing information daily. She confirmed the total number and actual hours worked were not on the posted form. She explained she was not aware of the federal requirement and had never noted the total number and actual hours worked on any of the postings since she assumed her position in December 2021. On 3/23/22 at 4:45 PM, the Administrator reviewed the nursing staffing information forms for the last 30 days. He acknowledged the forms did not contain the total number and actual hours worked for that period. Review of the facility policy for Nurse Staff Daily Posting Requirements revised 1/25/22, read The location will post the following information on a daily basis: . Total number and the actual hours worked by the following categories of licensed and unlicensed staff member directly responsible for resident care per shift . Licensed and unlicensed nursing staff members includes the following: Registered nurses, Licensed practical nurses or licensed vocation nurses, Certified nursing assistants/restorative nursing assistants, Certified medication assistants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 7 of 7