Inspection·August 10, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/22/23 revealed the Brief Interview for Mental status (BIMS) score was 3 out of 15 indicating the resident's cognition was severely impaired. Resident #1 required extensive assistance of one person for bed mobility and extensive assist of two persons for transfers. Review of the resident's annual MDS assessment with ARD of 7/21/23 showed the BIMS was not completed as the resident was rarely or never understood. The resident now required extensive assist of two persons for bed mobility and total assistance of two persons for transfers. Review of resident #1's medical record revealed a care plan dated 7/12/23 for acute pain/discomfort related to a fracture of the left clavicle. A care plan initiated 11/12/18 and revised on 7/11/23 for activities of daily living (ADL) noted the resident required physical assistance of two staff for transfers with total lift with high back medium sling. Review of the Task List Report instructed physical assist of two staff for transfers with total lift with high back medium sling. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 7/11/23 revealed resident #1 was hospitalized for a primary diagnosis of hit by (mechanical) lift. The form indicated she was not ambulatory and required two assistants for transfers. The skin care assessment indicated the resident had a bruise to her left clavicle, bruise to left foot and a laceration to posterior scalp. A Progress Note dated 7/10/23 at 1:32 PM read, resident sent out to ED [emergency department] to get CT [computed tomography] scan for injury on back of head. CNA stated the resident hit her head on one of the bars of the mechanical lift while in the lift. Resident not able to explain what happened. Resident has an open and bleeding laceration to the back of her head, alert and oriented to person, sent to ED for further assessment. On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head. She stated CNA A told her the resident was lying in bed and as she moved the lift bar over to the resident to hook her up to the mechanical lift, the resident moved her head and hit one of the bars on the lift. The Risk Manager said the two CNAs who were present at the time of the injury were asked for statements of how the injury occurred. She said the next day, she reviewed the statements from the CNAs regarding the resident hitting her head and said this did not make sense as the resident had a fractured clavicle. She said leadership wanted to interview both CNAs. She noted CNA A gave the same account of the injury but CNA B's demeanor changed when she attempted to provide the same account of the incident. She explained CNA B came back not long after that interview at 11:30 AM, crying. She recanted her statement and said she observed the resident was lifted out of bed with a mechanical lift by CNA A. She said as the CNA moved the lift, the resident was suspended in midair and fell out of the lift onto the floor. The Risk Manager stated CNA B did a reenactment of the incident using a mannequin and the mannequin fell feet first out of the sling with the head on the lift and her legs were over the lift. CNA B stated at that time, she asked CNA A if they should call the nurse and CNA A told her not to notify the nurse because she wanted to transfer the resident back in bed. The Risk Manager stated CNA B said she helped CNA A get resident #1 back into the sling from the floor and transferred the resident back to bed with the mechanical lift. She stated CNA A told her they had to agree to give the same account of the incident than what actually occurred or they would both get fired. The Risk Manager stated CNA B said that CNA A cleaned up the blood from the floor first and then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 2 of 24 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 08/10/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few proceeded to notify the nurse. The Risk Manager explained CNA B did not assist CNA A to get the resident out of bed with the lift but she did assist in helping CNA A get the resident back into bed after the fall. The Risk Manager indicated CNA B should not have assisted with the resident's transfer back into bed as she was not their employee, she was from a contracted hospice agency and they could not ensure if she had mechanical lift training. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was CNA A did not follow the process to have two staff to transfer a resident with a mechanical lift and the sling was not secured properly. On 8/07/23 at 1:09 PM, during a telephone interview, CNA A asserted resident #1 did not fall. She said she was going to transfer the resident with the mechanical lift but when she pushed the lift toward the bed, the resident turned and hit her head on the lift. It was an accident, I did not mean to hit her. I did not hook the sling to the lift because the lady moved her head when I was bringing the lift to the bed and hit her head. She did not fall, only got hit in the head with the lift. CNA A stated, you need two people when you use the lift. There was another CNA in the hall and I asked her to help me. I did not know if she was a staff of the facility. She reiterated the resident did not fall and that she did not even get the resident out of bed. She insisted the resident remained in bed before and after being hit in the head by the lift. She did not explain how the resident sustained a fractured collar bone but stated she may have applied too much pressure when she tried to stop the bleeding from the head laceration. On 8/07/23 at 4:00 PM, during a telephone interview with CNA B, she stated she worked for a contracted Hospice service and was in the hall when CNA A asked her to help transfer resident #1. She explained she was not aware if she could assist another CNA with mechanical lift transfers. She stated CNA A lifted the resident out of bed with the mechanical lift, and the resident fell out of the sling, and hit her head. She said the resident's head was bleeding and CNA A asked her to assist to get the resident back to bed. She conveyed CNA A did not want to tell the staff the resident fell but wanted to give a different account of the incident. She said CNA A told her to write that resident #1 accidentally hit the pole of the lift and if their explanations did not match, they would both lose their jobs. CNA B said when she first spoke to Administration, she told them the same explanation as CNA A. She said, my conscience was bothering me so bad that I couldn't stand it. I went and talked to the Hospice nurse and told her what really happened. She asked me what I was going to do, and I told her I want to tell them [the facility] the truth. The Hospice nurse went with me when I talked to them. I went to them and told them the truth. CNA B stated she told the administration team that resident #1 fell out of the lift. She said she saw one of the hooks was not fastened to the lift and she fell out. She said, the resident was moaning when she fell. There was blood on the floor and the other CNA cleaned it up before she called the nurse. On 8/07/23 at 3:20 PM, CNA C stated 2 staff were needed to transfer a resident with a mechanical lift. She said they cannot allow contracted hospice staff to help with that mechanical lift transfers because they would not know if staff were trained. She noted the facility educator trained their staff on the use of mechanical lifts and informed the staff they were not allowed to have non-staff members, such as contracted staff to help with mechanical lift transfers. CNA C stated this was not new information, it has always been the standard. On 8/08/23 at 2:57 PM, the Regional Director of Clinical Operations stated the incident was discussed and decided that it was not neglect because CNA A was in the act of providing care to the resident to stop the bleeding. It did not seem like a willful act and she did not leave the resident unattended. He said, She tried to provide care even if she did it in the wrong way. When asked if they considered neglect after identifying the resident was moved post fall with an obvious head injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 3 of 24 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 08/10/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few before being assessed by a nurse and the blood cleaned from the floor, the Director of Clinical Operations did not provide an answer. On 8/09/23 at 11 :50 AM, during an interview with the Administrator and Director of Nursing (DON), the DON explained, neglect is when you have orders and do not fulfill the orders, if you know that something is going on with a resident, like a change in condition and you don't report it, or if the resident is asking for something and you refuse to help. That is highest level of neglect. The Administrator said, When you fail to give care to the resident or the right kind of care. The Administrator stated their mechanical lift policy instructs there must be two employees to operate the lift. A hospice contracted staff is not an employee of the facility. He said he didn't think to report the incident when they discovered one of the employees involved in the lift transfer incident was not their employee, but was contracted staff, because it was imperative to fully investigate what happened and fix it to ensure it did not happen again. The Administrator stated CNA A was terminated and was reported to the state certification board. He added the Hospice contractor was notified that CNA B could not return to the facility. He explained the incident was discussed with their Corporate office and the decision was made to report it as a State reportable incident rather than neglect which required federal reporting. On 8/09/23 at approximately 12:15 PM, the Administrator, Risk Manager and Assistant Director of Nursing (ADON) demonstrated a reenactment of CNA B's demonstration of the lift incident that involved resident #1. The ADON placed a sling on the bed under the mannequin. When she moved the lift to the bed, the hanger bar was located over the midsection of the mannequin, not close to the head. The ADON and Risk Manager attached the upper 4 loops from the sling to the hooks on the hanger bar. Then they hooked the left leg loop to the right-side hook on the hanger bar in a crisscross fashion, leaving the right leg strap lying on the mannequin. When they lifted the sling above the mattress the mannequin remained in the sling. When they moved the mechanical lift away from the bed, the mannequin began sliding feet first out of the sling but was held in the sling by the left leg strap of the sling. The upper half of the mannequin remained in the sling. It was discussed at that time that the leg straps could not possibly have been attached properly. The mannequin was placed back in the bed, the leg straps were attached by the loops to the hanger bar not being crisscrossed and as the mechanical lift was moved away from the bed the mannequin slid feetfirst out of the sling to the floor. The reenactment identified that not only was a loop left off the hook of the hanger bar, but the leg straps were not placed on the resident properly. The administrative team acknowledged they had not assessed this incident thoroughly. Review of the Mobility Support and Positioning Policy reviewed 3/29/23 read: TIME OUT is done prior to lifting the resident off the bed or the transfer surface. TIME OUT is done as follows: Raise the lift arm until the strap loops are taut but the resident has not left the surface. Stop, check, and verbalize all loops are secure. Continue to observe all loops remain secure and attached to the hooks on the hanger bar. Two or more employees will use the total lift to transfer resident from surface to surface. Check the Kardex, kiosk, service plan, or care plan for the type and amount of assistance needed for repositioning. Place the total lift at bedside with the hanger bar over resident's midsection. Crisscross leg straps through each other and attach straps to the lift. Review of the CNA job description included, assists the resident in transferring, repositioning, and walking using correct, appropriate transfer techniques and equipment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 4 of 24 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 08/10/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The resident sample was expanded to include three additional residents who were identified as at risk for falls/actual falls. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 5 of 24 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 08/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 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 interview, and record review, the facility failed to thoroughly investigate an incident involving neglect and failed to report the results of the investigation to the State Survey Agency related to an avoidable fall with major injury for 1 of 7 residents sampled for falls, (#1). On 7/10/23 at approximately 9:30 AM, the facility failed to prevent an avoidable fall for a physically and cognitively impaired resident. The fall occurred during a transfer from a bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. The staff failed to follow the policy to have two trained staff for mechanical lift transfers, failed to ensure a time out safety stop and did not ensure that all straps were secure before moving the resident away from the surface. The Certified Nursing Assistant (CNA) moved the resident before she was assessed by a nurse and did not inform the facility that the resident fell from the sling to the floor. The nurse was not notified until after the resident was lifted back into the sling and transferred back into bed. The facility failed to ensure policies and procedures were implemented to ensure the safety of all 45 residents who required mechanical lifts for transfers. The facility used one brand of mechanical lift. The facility's failure to complete a thorough investigation resulted in Immediate Jeopardy starting on 7/10/23. The Immediate Jeopardy was removed on 8/10/23. Findings: Cross reference F689, F600, and F835 Resident #1, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus, dementia, Alzheimer's disease, anxiety disorder, and abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/22/23 revealed the Brief Interview for Mental status (BIMS) score was 3 out of 15 indicating the resident's cognition was severely impaired. Resident #1 required extensive assistance of one person for bed mobility and extensive assist of two persons for transfers. On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head. She stated Certified Nursing Assistant (CNA) A told her the resident was lying in bed and as she moved the lift bar over to the resident to hook her up to the mechanical lift, the resident moved her head and hit one of the bars on the lift. The Risk Manager said the two CNAs who were present at the time of the injury were asked for statements of how the injury occurred. She said the next day, she reviewed the statements from the CNAs regarding the resident hitting her head and said this did not make sense as the resident had a fractured clavicle. She said leadership wanted to interview both CNAs. She noted CNA A gave the same account of the injury but CNA B's demeanor changed when she attempted to provide the same account of the incident. She explained CNA B came back not long after that interview at 11:30 AM, crying. She recanted her statement and said the resident was already in the lift, off the bed and fell out of the lift onto the floor. The Risk Manager stated CNA B did a reenactment of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 6 of 24 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 08/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few incident using a mannequin and the mannequin fell feet first out of the sling with the head on the lift and her legs were over the lift. CNA B stated at that time, she asked CNA A if they should call the nurse and CNA A told her not to notify the nurse because she wanted to transfer the resident back in bed. The Risk Manager stated CNA B said she helped CNA A get resident #1 back into the sling from the floor and transferred the resident back to bed with the mechanical lift. She stated CNA A told her they had to agree to give a different account of the incident than what actually occurred or they would both get fired. The Risk Manager stated CNA B then said that CNA A cleaned up the blood from the floor first and then proceeded to notify the nurse. The Risk Manager indicated after CNA B provided a more factual account of the incident, she knew the facility had a different type of situation that she originally thought. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was the CNA did not follow the process of having two staff when using a mechanical lift for transfers and the sling was not secured properly. On 8/08/23 at 2:57 PM, the Regional Director of Clinical Operations stated the incident was discussed with the management team and decided that it was not neglect because CNA A was in the act of providing care to the resident to stop the bleeding. He explained it did not seem like a willful act and she did not leave the resident unattended. He said, She tried to provide care even if she did it in the wrong way. The Regional Director was questioned whether they considered neglect after they identified, CNA A gave false account of the fall, moved the resident who had head injury before she was assessed by the nurse and then tried to cover up the fall by cleaning the blood off the floor, the Director of Clinical Operations did not provide an answer. On 8/09/23 at approximately 12:15 PM, the Administrator, Risk Manager and Assistant Director of Nursing (ADON) demonstrated a reenactment of CNA B's demonstration of the lift incident that involved resident #1. The ADON placed a sling on the bed under the mannequin. When she moved the lift to the bed, the hanger bar was located over the midsection of the mannequin, not close to the head. The ADON and Risk Manager attached the upper 4 loops from the sling to the hooks on the hanger bar. Then they hooked the left leg loop to the right-side hook on the hanger bar in a crisscross fashion, leaving the right leg strap lying on the mannequin. When they lifted the sling above the mattress the mannequin remained in the sling. When they moved the mechanical lift away from the bed, the mannequin began sliding feetfirst out of the sling but was held in the sling by the left leg strap of the sling. The upper half of the mannequin remained in the sling. It was discussed at that time that the leg straps could not possibly have been attached properly. The mannequin was placed back in the bed, the leg straps were attached by the loops to the hanger bar not crisscrossed and as the mechanical lift was moved away from the bed, the mannequin slid feet first out of the sling to the floor. The Administrator acknowledged that not only was a loop left off the hook of the hanger bar, but the leg straps were not placed on the resident properly. On 8/09/23 at 11 :50 AM, the Director of Nursing (DON) and the Administrator spoke about investigating . The DON explained, neglect is when you have orders and do not fulfill the orders, if you know that something is going on with a resident, like a change in condition and you don't report it, or if the resident is asking for something and you refuse to help. That is highest level of neglect. The Administrator noted neglect was When you fail to give care to the resident or the right kind of care. The Administrator indicated their policy was to always have 2 staff present when transferring a resident with a mechanical lift. He said he didn't think to report the incident when they found out that one of the employees involved in the lift transfer was not their employee because the first thought was to investigate what happened and fix it to ensure it doesn't happen again. The Administrator stated CNA A was terminated and reported to the State Nurse Aide Registry when we found out the truthful account of resident #1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 7 of 24 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 08/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few fall. He stated the incident was discussed with their Corporate office and they did not feel it was neglect and the incident was not reported to the State Agency. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 8 of 24 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 08/10/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and/or revise comprehensive care plans for activities of daily living (ADLs) related to transfers, to reflect the appropriate device and sling size for 7 of 11 residents reviewed for mechanical lift use, out of a total sample of 11 residents, (#13, #14, #15, #16, #17, #20, and #21). Findings: Review of the facility's policy and procedures for Care Plans, revised on 9/22/22, revealed the Interdisciplinary Team (IDT) would review residents' care plans at least quarterly to ensure provision of appropriate care and services. The facility's policy and procedure for Comprehensive Care Plan and Care Conferences, revised on 10/21/22, revealed purposes to develop a person-centered care plan for each resident and to provide an ongoing method of assessing, evaluating, and updating the care plan. The document indicated a designated member of the IDT would implement a process for developing and updating care plans, which would be reviewed by each member of the IDT before the care conference. The policy revealed each resident's care plan would be driven by identified issues or concerns and his/her needs, and would be .a powerful, practical tool representing the best approach to providing quality of care and quality of life. The document indicated care plans were to be reviewed with each completed Minimum Data Set (MDS) assessment and in addition to updates during a care plan review, care plans must be revised as the resident's needs/status changes. 1. Review of the medical record revealed resident #13 was admitted to the facility on [DATE] with diagnoses including complete lesion at C2 level of the cervical spine, metabolic encephalopathy, generalized muscle weakness, and Parkinson's Disease. The MDS Quarterly assessment with assessment reference date (ARD) of 6/30/23 revealed resident #13 required assistance from two or more staff for transfers between surfaces including to or from the bed and wheelchair. The resident's balance was unsteady during surface-to-surface transfers and he was only able to stabilize with staff assistance. Resident #13's nursing care plan for ADL self-care performance deficit related to dementia was initiated on 3/25/23. The care plan intervention for transfers was revised on 3/27/23 to reflect the instruction to transfer the resident between surfaces with the assistance of two staff, and a total mechanical lift with a large full body sling. Resident #13's Certified Nursing Assistant (CNA) care plan or Kardex revealed care directives for Mobility and Transfers included use of a mechanical lift and a size large sling. Review of resident #13's medical record revealed his weight was 133 pounds on 6/05/23, 133 pounds on 7/10/23, and 135 pounds on 8/02/23. The sling manufacturer's guide revealed a medium sling was suitable for residents who weighed between 125 and 175 pounds. On 10/04/23 at 11:31 AM, the MDS Coordinator stated resident #13's most recent care plan meeting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 9 of 24 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 08/10/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was on 6/05/23. She acknowledged she was not aware the resident required a medium sling based on his weight, instead of the large sling noted on the nursing care plan and Kardex. 2. Review of the medical record revealed resident #14 was admitted to the facility on [DATE] with diagnoses of generalized muscle weakness, unsteadiness on her feet, lack of coordination, dementia, and a history of falling. The MDS admission assessment with ARD of 9/03/23 revealed resident #14 was totally dependent on two or more staff for transfers between surfaces. The resident's balance was unsteady during surface-to-surface transfers, and she was only able to stabilize with staff assistance. Review of resident #14's care plan for ADL self-care performance deficit, initiated on 8/29/23, revealed the resident required assistance from two staff with a full body mechanical lift and a medium sling for transfers. The intervention had a revision date of 9/06/23. Resident #14's Kardex directed CNAs to transfer her with a medium sling. The sling manufacturer's guide indicated the recommended size sling for the resident's weight of 210 pounds on 8/29/23 and 227.5 pounds on 10/04/23 was large, which was suitable for weights of 174 pounds to 250 pounds. 3. Review of the medical record revealed resident #15 was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included right-side weakness and paralysis due to a stroke, generalized muscle weakness, abnormal posture, unsteadiness on his feet, lack of coordination, and osteoarthritis. The MDS Quarterly assessment with ARD of 9/15/23 revealed resident #15 was totally dependent on two or more staff for surface-to-surface transfers. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of resident #15's care plan for ADL self-care performance deficit, initiated on 6/23/23 revealed an intervention for transfers that read, Transfer Between Surfaces: 2 staff assist, assistive support/device, lift type, high back, medium sling. The care plan had a revision date of 6/23/23 and the care directive was transcribed to the resident's Kardex to include a medium sling. Review of resident #15's weight revealed between June 2022 and October 2023, his weight ranged from 189 pounds to 214 pounds, which according to the sling manufacturer's guide, required a large sling. 4. Review of the medical record revealed resident #16 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included stroke, altered mental status, weakness, arthritis, and fibromyalgia or chronic, widespread pain. The MDS Quarterly assessment with ARD of 7/07/23 revealed resident #16 was totally dependent on two or more staff for surface-to surface transfers. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of the care plan for ADL self-care performance deficit, revised on 8/11/23, revealed an intervention for transfers with the assistance of two staff and a large sling, but it did not indicate the type of mechanical lift to be used. The resident's Kardex did not include the type of lift either (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 10 of 24 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 08/10/2023 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 0657 and included the instruction for CNAs to use a large sling for transfers. Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed on 7/10/23, resident #16 weighed 161.5 pounds, on 8/11/23 she weighed 164.5 pounds, and on 10/04/23 the resident weighed 156.5 pounds. The weights indicated the appropriate size sling for resident #16 was medium. Residents Affected - Some 5. Review of the medical record revealed resident #17 was admitted to the facility on [DATE] with diagnoses including stroke with left-side weakness and paralysis, contractures of the foot and knee, a history of falling, osteoarthritis, and lack of coordination. The MDS Quarterly assessment with ARD of 8/07/23 revealed resident #17 was totally dependent on staff for transfers. She had unsteady balance during surface-to-surface transfers and was only able to stabilize with staff assistance. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of resident #17's care plan for ADL self-care performance deficit, initiated on 5/25/13, revealed an intervention for transfers by two staff with a total lift and a large sling. The intervention had a revision date of 2/22/19. Review of resident #17's Kardex revealed Mobility and Transfer instructions for CNAs that included use of a large sling with the mechanical lift. The sling manufacturer's guide indicated the resident's weight of 157 pounds on 2/27/19 indicated she needed a medium sling on the date the intervention was initiated. Her weight ranged from 154 pounds on 1/11/22 to 139.5 pounds on 10/04/23, appropriate for a medium sling only at the time of all MDS assessments and care plan reviews during that period . 6. Review of the medical record revealed resident #20 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, adult failure to thrive, muscle spasm, left leg fracture, and osteoporosis. The MDS Annual assessment with assessment reference date of 8/25/23 revealed resident #20 was totally dependent on two or more staff members for transfers between surfaces including to or from the bed and wheelchair. The document indicated the resident had unsteady balance during surface-to-surface transfers and was only able to stabilize with staff assistance. Review of resident #20's care plan for ADL self-care performance deficit, initiated on 11/23/21 and revised on 9/14/23, revealed no active instructions or information related to transfers. Review of canceled and resolved care plan interventions showed the resident's last intervention related to transfers was initiated on 9/16/20 and resolved on 10/04/20. The intervention indicated the resident required assistance of two staff with a gait belt and walker to transfer between surfaces at that time. On 10/05/23 at 3:04 PM, the facility's Risk Manager (RM) explained after she was made aware of concerns related to inaccurate and/or incomplete care plans regarding to mechanical lifts and slings, she conducted an audit of the care plans for all residents who used mechanical lifts for transfers. The RM acknowledged during review of resident #20's care plans, she discovered there were no interventions regarding the type of equipment or level of assistance the resident needed during transfers. The RM stated nursing staff informed her they had been using a mechanical lift to transfer the resident but no staff had reported the care plan was missing instructions for transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 11 of 24 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 08/10/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. Review of the medical record revealed resident #21 was admitted to the facility on [DATE] with diagnoses including Guillain-Barre Syndrome, cervical spinal stenosis, lack of coordination, unsteadiness on his feet, polyneuropathy, and generalized muscle weakness. The MDS Quarterly assessment with ARD of 8/04/23 revealed resident #21 required extensive assistance from two or more staff for transfers. The resident's balance was unsteady, and he was only able to stabilize with staff assistance. The resident used a wheelchair for mobility. Review of resident #21's care plan for ADL self-care performance deficit, initiated on 4/29/23, noted he required assistance from two staff for transfers. The intervention was initiated on 5/01/23 and revised on 8/09/23. The care plan did not show the type of mechanical lift the resident required and indicated he required a large sling. Review of the medical record revealed on 8/02/2, resident #21 weighed 169.5 pounds and 9/04/23 he weighed 168 pounds, which indicated a medium sling was the appropriate size for him. On 10/04/23 at 11:31 AM and 3:08 PM, the MDS Coordinator stated she was the facility's care plan coordinator. She confirmed her duties included quarterly reviews of all care plans and more frequently if any change in status required the revision of a care plan. The MDS Coordinator explained although each section of a resident's care plan was reviewed by the appropriate member of the IDT, she was ultimately responsible for the accuracy of all care plans. The MDS Coordinator reviewed the ADL self-care performance deficit care plans for residents #13, #14, #15, #16, #17, #20, and #21 and validated the documents were not accurate and/or complete related to mechanical lift type and/or sling size for each resident. She stated residents' weights were available in the medical record and she was usually informed of any residents who lost or gained weight. The MDS Coordinator acknowledged quarterly care plan reviews were the opportune time to verify the type of mechanical lift, weight, and the appropriate size sling for each resident who used a device for transfers. Review of the job description for Long Term Care MDS Nurse, dated 8/23/23, revealed she evaluates care provided to each resident and keeps care plans current. The MDS Nurse was expected to collaborate with other members of the IDT to ensure the best quality of life possible for each resident. On 10/05/23 at 10:48 AM, the Director of Nursing (DON) stated her expectation was the MDS Coordinator would regularly review residents' care plans in their entirety and revise them if necessary, to ensure they were accurate and met residents' needs. On 10/05/23 at 12:05 PM, the RM explained the quarterly care plan review for every resident was the opportunity to examine all interventions and crosscheck that goals and interventions were still appropriate. The RM acknowledged it was important for each care plan to reflect the unique needs of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 12 of 24 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 08/10/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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 interview, and record review, the facility failed to prevent an avoidable fall with major injury for a vulnerable, physically, and cognitively impaired resident, and failed to ensure the correct procedure was followed when using a full body mechanical lift to transfer residents for 1 of 7 residents sampled for accidents, of a total of 45 residents requiring mechanical lifts for transfers, (#1). This failure resulted in the resident sustaining a fractured left clavicle and laceration to the head requiring staples. Clavicle fracture (collarbone), is diagnosed through physical examination and x-rays. Resident #1 likely experienced severe pain and swelling at the collarbone fracture and with possible visible deformity. On 7/10/23 at approximately 9:30 AM, resident #1 fell during a transfer from bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. The staff neglected to follow the policy to have two trained staff for mechanical lift transfers, failed to do a safety stop, and did not ensure that all straps were secure before moving the resident away from the surface. After the resident fell, the Certified Nursing Assistant (CNA) moved the resident prior to having her assessed by a nurse and did not inform the facility that the resident fell from the sling to the floor. The nurse was not notified until after the resident was lifted back into the sling and transferred back to bed. The facility's failure to conduct mechanical lift monitoring to ensure staff were competent in performing transfers, placed all 45 residents who required a mechanical lift for transfers at risk and resulted in Immediate Jeopardy starting on 7/10/23. The Immediate Jeopardy was removed on 8/10/23. Findings: Cross reference F600, F609, and F835 Resident #1, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus, dementia, Alzheimer's disease, anxiety disorder, and abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/22/23 revealed the Brief Interview for Mental status (BIMS) score was 3 out of 15 indicating the resident's cognition was severely impaired. Resident #1 required extensive assistance of one person for bed mobility and extensive assist of two persons for transfers. Review of the resident's annual MDS assessment with ARD of 7/21/23 revealed the BIMS score was not completed as the resident was rarely or never understood. The assessment showed the resident required extensive assist of two staff persons for bed mobility and total assistance of two persons for transfers. Review of resident #1's medical record revealed a care plan dated 7/12/23 for acute pain/discomfort related to a fracture of the left clavicle. A care plan initiated 11/12/18 and revised on 7/11/23 for activities of daily living (ADL) noted the resident required physical assistance of two staff for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 13 of 24 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 08/10/2023 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 0689 transfers with total lift with high back medium sling. Level of Harm - Immediate jeopardy to resident health or safety Review of the Task List Report instructed physical assist of two staff for transfers with total lift with high back medium sling. Residents Affected - Few A Progress Note dated 7/10/23 at 1:32 PM read, resident sent out to ED [emergency department] to get CT [computed tomography] scan for injury on back of head. CNA stated the resident hit her head on one of the bars of the mechanical lift while in the lift. Resident not able to explain what happened. Resident has an open and bleeding laceration to the back of her head, alert and oriented to person, sent to ED for further assessment. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 7/11/23 revealed resident #1 was hospitalized for a primary diagnosis of hit by (mechanical) lift. The form indicated she was not ambulatory and required two assistants for transfers. The skin care assessment indicated the resident had a bruise to her left clavicle, bruise to left foot and a laceration to posterior scalp. On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head. She stated CNA A told her the resident was lying in bed and as she moved the lift bar over to the resident to hook her up to the mechanical lift, the resident moved her head and hit one of the bars on the lift. The Risk Manager said the two CNAs who were present at the time of the injury were asked for statements of how the injury occurred. Review of CNA A's statement noted, 7/10/23 at 9:30 AM, I was preparing the resident for the (mechanical) lift and at a moment she moved her head to the wall and when the machine moved and it hit hard to her head when I look, she was bleeding and I told the nurse. Review of CNA B's statement read, 7/10/23, while I was passing by after giving care to my patient around 9:30 the CNA stopped me to watch her transfer the pt (patient) with lift. While she was putting the adjustment pt made fast movement with her head a get head hit. Accident in the machine. The Risk Manager explained she reviewed the information from the hospital that showed the resident had a fractured left clavicle. She said the statements from the CNAs that the resident's head was hit by the lift and the hospital's findings of fractured clavicle did not make sense. She indicated she notified the management team and they interviewed the two CNAs again. She said CNA A told the same story but CNA B's demeanor had changed while trying to tell the details of the incident. The Risk Manager recalled CNA B came back shortly after the interview, crying and recanted her statement. She explained the resident was in the lift away from the bed and fell out of the lift onto the floor. The Risk Manager stated CNA B did a reenactment of the incident using a mannequin that showed the resident fell feet first out of the sling with her head on the lift and her legs over the lift. She said after the fall, CNA B asked CNA A if they should call the nurse and CNA A told her not to notify the nurse because she wanted to transfer the resident back in bed. The Risk Manager stated CNA B said she helped CNA A get resident #1 back into the sling from the floor and transferred the resident back to bed with the mechanical lift. She stated CNA A told her they had to agree to give a different account of the incident than what actually occurred so they would not lose their jobs. She said CNA A cleaned up the blood from the floor first and then proceeded to notify the nurse. The Risk Manager indicated after CNA B provided a more factual account of the incident, she knew the facility had a more serious issue to deal with. The Risk Manager explained CNA B did not assist CNA A to get the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 14 of 24 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 08/10/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety resident out of bed with the lift but she did assist in helping CNA A get the resident back into bed after the fall. The Risk Manager indicated CNA B should not have assisted with the resident's transfer back into bed as she was not their employee, she was from a contracted hospice agency and they could not ensure if she had mechanical lift training. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was CNA A did not follow the process to have two staff to transfer a resident with a mechanical lift and the sling was not secured properly. Residents Affected - Few On 8/07/23 at 1:09 PM, during a telephone interview, CNA A asserted resident #1 did not fall. She said she was going to transfer the resident with the mechanical lift but when she pushed the lift toward the bed, the resident turned and hit her head on the lift. It was an accident, I did not mean to hit her. I did not hook the sling to the lift because the lady moved her head when I was bringing the lift to the bed and hit her head. She did not fall, only got hit in the head with the lift. CNA A stated, you need two people when you use the lift. There was another CNA in the hall and I asked her to help me. I did not know if she was a staff of the facility. She reiterated the resident did not fall and that she did not even get the resident out of bed. She insisted the resident remained in bed before and after being hit in the head by the lift. She did not explain how the resident sustained a fractured collar bone but stated she may have applied too much pressure when she tried to stop the bleeding from the head laceration. On 8/07/23 at 4:00 PM, during a telephone interview with CNA B, she stated she worked for a contracted Hospice service and was in the hall when CNA A asked her to help transfer resident #1. She explained the resident fell, hit her head and it was bleeding and CNA A wanted to put the resident back to bed because she did not want to tell the staff the resident fell. She indicated CNA A told her to write that resident #1 accidentally hit the pole of the lift and if their explanation did not match, they would both lose their jobs. CNA B said when she first spoke to administration, she told them the same explanation as CNA A. She said, my consciousness was bothering me so bad that I couldn't stand it. I went and talked to the hospice nurse and told her what really happened. She asked me what I was going to do, and I told her I want to tell them [the facility] the truth. The nurse went with me when I talked to them. I went to them and told them the truth. CNA B stated she told the administration team that resident #1 fell out of the lift. She said one of the hooks was not fastened to the lift and she fell out. She said, the resident was moaning when she fell. There was blood on the floor and the other CNA cleaned it up before she called the nurse. On 8/09/23 at approximately 12:15 PM, the Administrator, Risk Manager and Assistant Director of Nursing (ADON) demonstrated a reenactment of CNA B's demonstration of the lift incident with resident #1. The ADON placed a sling on the bed under the mannequin. When she moved the lift to the bed, the hanger bar was located over the midsection of the mannequin, not anywhere near the head. The ADON and Risk Manager attached the upper 4 loops to the hooks on the hanger bar. They hooked the left leg loop to the right-side hook on the hanger bar (crisscrossed), leaving the right leg strap lying on the mannequin. When they lifted the sling above the mattress, the mannequin remained in the sling. When they moved the mechanical lift away from the bed the mannequin began sliding feet first out of the sling but was held in the sling by the sling's left leg strap. The upper half of the mannequin remained in the sling. The reenactment identified that not only was a time out not done but a loop was left off the hook of the hanger bar and the leg straps were not placed properly on the resident. The Administrator stated their mechanical lift policy instructs there must be two employees to operate the lift. A hospice contracted staff is not an employee of the facility. He said they identified CNA B was not their employee, but was contracted Hospice staff. He explained it was imperative to fully investigate what happened and fix it to ensure it did not happen again. The Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 15 of 24 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 08/10/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated CNA A was terminated and was reported to the state certification board. He added the Hospice contractor was notified that CNA B could not return to the facility. He explained the incident was discussed with their Corporate office and decided the incident did not qualify as neglect. Review of the Mobility Support and Positioning Policy reviewed 3/29/23 read: TIME OUT is done prior to lifting the resident off the bed or the transfer surface. TIME OUT is done as follows: Raise the lift arm until the strap loops are taut but the resident has not left the surface. Stop, check, and verbalize all loops are secure. Continue to observe all loops remain secure and attached to the hooks on the hanger bar. Two or more employees will use the total lift to transfer resident from surface to surface. Check the Kardex, kiosk, service plan, or care plan for the type and amount of assistance needed for repositioning. Place the total lift at bedside with the hanger bar over resident's midsection. Crisscross leg straps through each other and attach straps to the lift. Review of the CNA job description included, assists the resident in transferring, repositioning, and walking using corrects appropriate transfer techniques and equipment. The resident sample was expanded to include three additional residents who were identified as requiring a mechanical lift for transfer, and three residents at risk for falls/actual falls. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 16 of 24 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 08/10/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 17 of 24 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 08/10/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 administration of tube feedings via gastrostomy tube and monitoring weights according to physician orders and professional standards of practice; and failed to implement a recommendation by the dietitian to discontinue tube feeding that was no longer clinically indicated, for 1 of 1 resident reviewed for tube feeding, out of a total of 3 residents in the facility who received tube feedings, (#13). Findings: Review of the medical record revealed resident #13 was admitted to the facility on [DATE] with diagnoses including gastrostomy status, metabolic encephalopathy, generalized muscle weakness, Parkinson's Disease, and dementia. A gastrostomy is a surgical procedure in which a tube is inserted directly into the stomach through an incision in the abdomen wall. The tube is used to provide feeding or medications (retrieved on 10/09/23 from www. medical-dictionary.thefreedictionary.com/gastrostomy) The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/30/23 revealed resident #13 required supervision of one staff member for eating and drinking. The MDS assessment indicated the resident was 68 inches tall and weighed 140 pounds. The document revealed during the 7-day look back period, the resident's nutritional approaches included a feeding tube, a mechanically altered diet, and a therapeutic diet. Resident #13 received 51% or more of his total calories by tube feeding and his average fluid intake was 501 cubic centimeters per day by tube feeding. Review of resident #13's medical record revealed a care plan for activities of daily living self-care performance deficit related to dementia was initiated on 3/25/23. The interventions included assistance of one staff member for tube feeding. A care plan for tube feeding related to inadequate oral intake, initiated on 3/25/23, instructed staff to elevate the head of the resident's bed during tube feedings and monitor for complications. Resident #13 had a care plan for a nutritional problem related to dysphagia or difficulty swallowing initiated on 3/28/23. The goal was for the resident to maintain stable weight. The care plan was revised on 6/27/23 to reflect new interventions of a therapeutic diet and food with modified texture. Review of the Order Summary Report dated 10/04/23 revealed a physician order dated 3/25/23 to document the resident's 24-hour intake one time daily. An order dated 4/20/23 indicated the resident was placed on a Consistent Carbohydrate diet with level 2 mechanical texture, and thin consistency liquids. An order dated 5/10/23 directed nurses to provide 150 milliliters (ml) water flushes four times daily every four hours. An order dated 8/24/23 revealed resident #13 was to receive Diabetisource tube feeding at the rate of 55 ml per hour for 12 hours daily, on at 8:00 PM and off at 8:00 AM. On 10/04/23 at 10:40 AM, a bag of Diabetisource tube feeding dated 10/02 and a full bag of water hung from a pole at resident #13's bedside. The tube feeding pump was off and the tubing was not connected to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 18 of 24 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 08/10/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/04/23 at 11:31 AM, the MDS Coordinator reviewed resident #13's medical record and discovered a progress note written by the dietitian on 9/24/23 that indicated the resident no longer required tube feeding. The MDS Coordinator stated the facility's contracted dietitian was in the building once weekly on Sunday and she usually emailed the management team weekly with information about the residents she assessed. The MDS Coordinator did not recall any email communication or physician order regarding discontinuing the resident's tube feeding. She was informed there were bags of water and tube feeding on the pole at the resident's bedside. The MDS Coordinator confirmed the medical record showed resident #13 still had an active physician order for Diabetisource at 55 ml per hour from 8:00 PM to 8:00 AM every night. She explained the dietitian was able to enter orders and all new orders were reviewed in the daily clinical management meeting. The MDS Coordinator acknowledged it did not benefit the resident if the dietitian did not enter orders and communicate with the Interdisciplinary Team (IDT) to ensure implementation of her recommendations. On 10/04/23 at 11:44 AM, the Station 2 Unit Manager (UM) validated the bag of tube feeding at resident #13's bedside had been accessed and was dated 10/02. The UM confirmed the 1000 ml bag appeared full and since there was no time noted on the bag, it was impossible to know when the feeding should be discarded. Review of the label revealed the instruction to use for a maximum of 48 hours. Review of resident #13's medical record revealed a Nutritional Status Quarterly Nutrition Note dated 9/24/23 at 2:57 PM, signed by the dietitian. The document indicated the resident's weight was stable and listed his weights as 126 pounds on 4/03/23, 133 pounds on 6/05/23, 133 pounds on 7/10/23, and 135 pounds on 8/02/23. The note revealed the dietitian observed the resident in the dining room and he tolerated his diet well. She wrote, No longer reliant on enteral nutrition, meeting needs via [oral] intake. Pending September [weight]. The note indicated resident #13 would continue to receive 150 ml water flushes every four hours and the dietitian would continue to monitor his weight and oral intake and alter dietary approaches as needed. Review of the medical record revealed as of 10/04/23, resident #13's last recorded weight was obtained on 8/02/23. Review of the medical record on 10/05/23, revealed additional weights were included in the medial record, 136 pounds in September 2023 and 134 pounds for October 2023. On 10/04/23 at 1:17 PM and 5:16 PM, in telephone interviews, the dietitian explained she was previously the facility's full-time dietitian but recently accepted another job, and since the beginning of September she only worked one day on the weekends. She explained she was usually in the building on Sundays and occasionally switched to a Saturday if necessary. The dietitian validated she discontinued resident #13's tube feeding on 9/24/23 as he was eating his meals adequately. She stated the goal was for residents to eat by mouth if at all possible and this resident's daughter preferred him not to be on tube feedings The dietitian explained the advantages of eating by mouth included more probiotics, a better quality of life, and decreased risk of aspiration. She stated she wanted to continue water flushes to ensure adequate hydration and maintain patency of the gastrostomy tube as it was still used for medication administration. When asked how she communicated her recommendations to the facility, the dietitian stated she had access to the electronic medical record and could enter and discontinue orders as indicated. She was informed the order for Diabetisource at 55 ml per hour remained active. The dietitian said, I believe it was an oversight on my part. The tube feeding is no longer necessary. She acknowledged her decision to discontinue resident #13's tube feeding was made without review of his weight in September as it was not available on 9/24/23. The dietitian was informed the facility's policy and procedure indicated residents on tube feedings were to be weighed weekly. She stated she had been informed she could discontinue weekly weights if she determined them to be unnecessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 19 of 24 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 08/10/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy and procedures for Responsibilities of the Dietitian, revised on 5/12/23, revealed the dietitian was accountable and responsible for her practice and would communicate with and review recommendations with a designated facility staff member. The policy indicated the dietitian would be involved in the nutrition risk committee and the interdisciplinary care plan team. The document indicated the dietitian would document in the medical record, and the facility would ensure she had access to paper and electronic documents that were necessary for resident reviews. On 10/05/23 at 10:48 AM, the Director of Nursing (DON) stated once informed about the concerns regarding administration of resident #13's tube feeding, she initiated an investigation. The DON stated her preliminary findings were that the night nurse on 10/02/23 spiked or accessed the tube feeding but did not infuse it as ordered from 8:00 PM to 8:00 AM, and the night nurse on 10/03/23 did not administer the feeding either. The DON was informed of the conflict noted in water flush order that was written as 150 ml four times daily and every four hour which would be every six hours. The DON stated her expectation was nurses would follow physician orders as written, and if confused about any order, they should reach out to the physician for clarification or ask the UM for advice. She confirmed the IDT was responsible for ensuring orders and recommendations were entered into the medical record and implemented. The DON explained the dietitian usually communicated with the IDT via emails, but she did not recall any email regarding discontinuation of the resident's tube feeding. Review of the Enteral Feed Record for October 2023 revealed no initials to indicate the night nurse infused resident #13's tube feeding on 10/02/23. Review of the facility's policy and procedure for Enteral Nutrition (Tube Feeding), revised 6/07/23, revealed a purpose of providing guidance when the inability to eat indicated the use of tube feeding was unavoidable. The policy indicated residents on tube feeding would receive appropriate treatment and services to restore oral eating skills if possible. The procedure revealed physician orders would include the amount and frequency of fluid boluses. The document read, Residents on enteral feedings will be weighed at least weekly. On 10/05/23 at 12:05 PM and 3:16 PM, the facility's Risk Manager (RM) confirmed the facility did not currently have a dietitian on site. She stated residents on tube feedings and those being monitored for weight loss were usually reviewed during the weekly Nutritional at Risk meeting. The RM explained the meetings were usually led by the dietitian; however, the last meeting was held a few weeks ago as the facility's full-time dietitian left. When asked who decided to terminate the Nutritional at Risk meetings, the RM said, I don't think it was a decision. We just didn't have them. She stated when a dietitian worked in the facility, they were expected to attend the daily clinical meeting and report or discuss any concerns with the IDT, but recently the facility had to rely on email communication from the contracted dietitian. The RM validated the dietitian was expected to adhere to the facility's policies and procedure regarding weekly weights for residents who received tube feedings. She acknowledged the DON had oversight of clinical issues and the dietitian should have communicated with the DON regarding discontinuing tube feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 20 of 24 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 08/10/2023 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety Based on interview, and record review, the facility failed to effectively use its resources to identify safety concerns related to the use of mechanical lifts and slings; and failed to ensure staff were knowledgeable of mechanical lift transfer techniques, for 1 of 7 residents reviewed for accidents and mechanical lift use, (#1). Residents Affected - Few On 7/10/23 at approximately 9:30 AM, the facility failed to prevent an avoidable fall for a physically and cognitively impaired resident. The fall occurred during a transfer from bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling of the lift while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. The staff failed to follow the policy to have two trained staff to transfer using mechanical lift and failed to do a time out safety stop to ensure all straps were secure before moving the resident away from the surface. The Certified Nursing Assistant (CNAs) did not immediately notify the assigned nurse of the fall with possible head injury. Instead, they placed resident #1 back in the sling, attached it to the mechanical lift and transferred her from the floor to her bed without any interventions to prevent further injury. The facility used one brand of mechanical lift. The facility's failure to conduct mechanical lift spot monitoring to ensure staff were competent in performing transfers placed all 45 residents who required a mechanical lift for transfers at risk and resulted in Immediate Jeopardy starting on 7/10/23. The Immediate Jeopardy was removed on 8/10/23. Findings: Cross reference F600, F609, and F689 On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head with the mechanical lift. She said CNA A told her the resident was lying in bed and as she moved the mechanical lift closer to the resident to attach her to the sling, the resident moved her head and hit one of the bars on the lift. The Risk Manager noted they obtained statements from both CNAs A and B that were involved in the incident. She explained the next day she reviewed the information from the hospital that documented resident #1 had a fracture of the left clavicle. She indicated the statements from the CNA did not make sense as they reported the resident hit her head and not the shoulder. She said she informed the management team and the CNAs were interviewed again. She recalled CNA A told the same story but CNA B's demeanor was different when she conveyed details of the incident. The Risk Manager explained CNA B came back shortly after, crying and recanted her statement. She said CNA B reported the resident was in the lift, and when the lift was moved away from the bed, the resident fell out of the lift and hit her head. The Risk Manager stated they asked CNA B to do a reenactment of the incident using a mannequin. She said during the reenactment, the mannequin fell feet first out of the sling and hit head against the lift. She said CNA B asked CNA A if they should call the nurse and CNA A said she wanted to get the resident back in the bed first. The Risk Manager stated CNA B then helped CNA A get resident #1 back in the sling from the floor and hooked the sling to the mechanical lift. She stated CNA A told her CNA B that their stories had to be the same or they would both get fired. The Risk Manager explained CNA A cleaned up the blood from the floor and then notified the nurse. The Risk Manager acknowledged the CNAs did not do a time out safety check before moving the resident in the mechanical lift and gave false statements about the facts of the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 21 of 24 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 08/10/2023 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 8/07/23 at 1:09 PM, during a telephone interview, CNA A asserted resident #1 did not fall. She said she was going to transfer the resident with the mechanical lift but when she pushed the lift toward the bed, the resident turned and hit her head on the lift. It was an accident, I did not mean to hit her. I did not hook the sling to the lift because the lady moved her head when I was bringing the lift to the bed and hit her head. She did not fall, only got hit in the head with the lift. CNA A stated, you need two people when you use the lift. There was another CNA in the hall and I asked her to help me. I did not know if she was a staff of the facility. She reiterated the resident did not fall and that she did not even get the resident out of bed. She insisted the resident remained in bed before and after being hit in the head by the lift. She did not explain how the resident sustained a fractured shoulder bone but stated she may have applied too much pressure when she tried to stop the bleeding from the head laceration. CNA stated she had received mechanical lift training when she was hired and in February of 2023. On 8/07/23 at 4:00 PM, during a telephone interview with CNA B, she stated she worked for a contracted Hospice service and was in the hall when CNA A asked her to help transfer resident #1. She explained she was not aware if she could assist another CNA with mechanical lift transfers. She stated CNA A lifted the resident out of bed with the mechanical lift, and the resident fell out of the sling, and hit her head. She said the resident's head was bleeding and CNA A asked her to assist to get the resident back to bed. She conveyed CNA A did not want to tell the staff the resident fell but wanted to give a different account of the incident. She said CNA A told her to write that resident #1 accidentally hit the pole of the lift and if their explanations did not match, they would both lose their jobs. CNA B said when she first spoke to Administration, she told them the same explanation as CNA A. She said, my conscience was bothering me so bad that I couldn't stand it. I went and talked to the Hospice nurse and told her what really happened. She asked me what I was going to do, and I told her I want to tell them [the facility] the truth. The Hospice nurse went with me when I talked to them. I went to them and told them the truth. CNA B stated she told the administration team that resident #1 fell out of the lift. She said she saw one of the hooks was not fastened to the lift and she fell out. She said, the resident was moaning when she fell. There was blood on the floor and the other CNA cleaned it up before she called the nurse. On 8/08/23 at 2:57 PM, The Regional Director Clinical Operations stated the incident was discussed among the group and the group decided that it was not neglect because the CNA was in the act of providing care to the resident by trying to stop the bleeding. It did not seem like a willful act and it was not like she left the resident unattended. He said, She tried to provide care even if she did it in the wrong way. When asked if moving a resident who fell before being assessed by a nurse, and cleaning up blood off the floor before giving care to the resident and notifying the nurse was providing care or was it neglect, the Director of Clinical Operations gave no response. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was that the CNA did not follow the process for two people when using a mechanical lift and the sling was not secured properly. The Administrator stated their mechanical lift policy instructs there must be two employees to operate the lift. A hospice contracted staff is not an employee of the facility. He said he didn't think to report the incident when they discovered one of the employees involved in the lift transfer incident was not their employee, but was contracted staff, because it was imperative to fully investigate what happened and fix it to ensure it did not happen again. The Administrator stated CNA A was terminated and was reported to the state certification board. He added the Hospice contractor was notified that CNA B could not return to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 22 of 24 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 08/10/2023 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of CNA A's completed training included Safe Resident Handling was completed on 2/07/23. The return demonstration included the time out session for the operator and partner to ensure sling hooks and loops were secure prior to moving the resident. On 8/09/23 at 12:45 PM the Administrative team explained they had not done any spot monitoring of staff's competency with mechanical lifts. They stated staff were educated when they were hired then annually. They stated the equipment was used improperly which caused resident #1 to fall from the sling to the floor. They asserted CNA A did not follow the mechanical lift transfer procedure despite having been trained several times. Review of the Director of Nursing job description read, Monitors the operations of the nursing staff and ensures compliance with regulations on organizational and governmental standards of practice. Responsible for the overall quality of care provided by the organization's nursing personnel. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 23 of 24 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 08/10/2023 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test. Event ID: Facility ID: 105559 If continuation sheet Page 24 of 24