Inspection·November 10, 2023

F 0698 Level of Harm - Actual harm The facility's failure to respond appropriately to ongoing communication from the dialysis center and failure to coordinate care to ensure necessary services were arranged in a timely manner placed residents #1 and #3 at risk for potential complications and caused actual harm for resident #1, that was inconsistent with the goals of the resident and his representative. Residents Affected - Few Findings: 1. Review of the medical record revealed resident #1, a [AGE] year-old male, was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included end-stage renal disease with dependence on dialysis, coronary artery bypass graft or open heart surgery, type 2 diabetes, amputation of both legs above the knees, and hypertensive heart disease. According to the National Kidney Foundation, Dialysis is a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to. By performing some of the kidney's usual duties, dialysis helps to maintain safe levels of minerals in your blood, such as potassium, sodium, calcium, and bicarbonate. The organization's website indicated it was important to complete dialysis treatments according to the prescribed schedule and inform the dialysis provider about medications and supplements taken (retrieved on [DATE] from https://www.kidney.org/atoz/content/dialysisinfo). Hyperkalemia is a medical problem in which there is too much potassium in the blood. Potassium is necessary for the proper function of nerves and muscles, including the heart, but too much potassium can be dangerous as it can cause serious heart problems. According to the National Kidney Foundation, the normal level of potassium in the blood should be between 3.5 and 5.0 milli-equivalents per liter (mEq/L). Very high potassium needs immediate medical care as people will have few or no symptoms (retrieved on [DATE] from https://www.kidney.org/atoz/content/what-hyperkalemia). Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of [DATE] revealed resident #1 was cognitively intact. The document showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed resident #1 required dialysis. Review of the medical record revealed resident #1 had a care plan for dialysis related to end-stage kidney disease, initiated on [DATE]. The goal was the resident would not have any signs and symptoms of complications from dialysis. The care plan interventions instructed nurses to encourage resident #1 to go for scheduled dialysis appointments on Mondays, Wednesdays, and Fridays. On [DATE] at 11:28 AM, in a telephone interview, the dialysis center's Social Worker (SW) explained resident #1 received dialysis at the center three times weekly, on Mondays, Wednesdays, and Fridays. She recalled someone from the skilled nursing facility called the dialysis center on the morning of Wednesday, [DATE], shortly before the resident's scheduled treatment time. The SW stated the facility informed them resident #1 tested positive for COVID-19 and was on the way for his dialysis treatment. The SW explained she informed the facility staff member that the dialysis center was not able to accommodate patients with COVID-19 at that time, but she would reach out to other centers that might be able to treat resident #1. The SW stated she called the facility on Thursday [DATE] in the morning to inform them she still had not found a dialysis center that could offer services for resident #1 due to his communicable disease. She stated she informed them the resident should be transferred to the hospital for dialysis. The SW recalled she contacted the facility again on Thursday afternoon to inquire about resident #1's status and whether he had been transferred to the hospital yet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 2 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 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 0698 Level of Harm - Actual harm Residents Affected - Few The SW stated she was told the resident was still in the facility and she asked if the nurse could contact his attending physician to obtain an order for hospitalization for dialysis. The SW said, I was told that the physician would not send him to the hospital, and would continue to monitor him in the facility. I expressed my concerns and strongly advised hospitalization as he was a cardiac patient and they said they would let the physician know. The SW recalled on the morning of Friday [DATE] at about 10:00 AM, she asked the dialysis center's Clinical Coordinator to call the facility to explain the importance of sending the resident to the hospital as he had not been dialyzed since Monday. The SW emphasized the facility had been told multiple times that resident #1 needed to be treated in a hospital setting if a dialysis center was unavailable. She stated after the Clinical Coordinator spoke with the facility's Regional Director of Nursing (DON) there was no further communication that day. She stated when she arrived at work on the following Monday morning, she found out resident #1 died. The SW said, He was young and very compliant with his treatment. He would never have chosen to miss treatments. On [DATE] at 11:52 AM, in a telephone interview, the dialysis center's Clinical Coordinator recalled a telephone conversation with the facility's DON on Friday [DATE]. the Clinical Coordinator confirmed the telephone call was initiated by the dialysis center as the staff were concerned that resident #1 would miss yet another scheduled treatment. The Clinical Coordinator stated the DON began to read results from a lab report to her, but when she heard the resident's potassium level of 6.9, she interrupted immediately and warned that the level was too high. The Clinical Coordinator explained she recommended an immediate transfer to the hospital as she knew the resident had not been dialyzed for a long time and his potassium was too high. She stated in the three years resident #1 received dialysis at the center, she had never known him to have a high potassium level. The Clinical Coordinator explained dialysis removed excess potassium from the blood which was especially important for patients with cardiac diagnoses. She recalled the Regional DON stated the facility's physician did not want to send him out to the hospital as he was being monitored in-house. The Clinical Coordinator stated she told the Regional DON that if the facility physician was not a nephrologist, a doctor who specialized in treating diseases that affected the kidneys, resident #1 needed to be treated at a hospital. The Clinical Coordinator stated she was saddened but not shocked at the news of the resident's death as she was aware that was a potential outcome of missing dialysis. On [DATE] at 12:16 PM, in a telephone interview, resident #1's ex-wife explained she was his healthcare surrogate. She recalled the resident called her to let her know he tested positive for COVID-19, but he never told her he missed dialysis treatments. The ex-wife stated she would have expected the facility to notify her of the missed treatments. She said, If I had known, maybe I could have pushed more to get him to the hospital. The ex-wife stated she was informed the facility tried to give medication in place of dialysis, but the resident was ultimately transferred to the hospital on Friday, [DATE]. She recalled the following morning she received a call from the Emergency Department (ED) physician who explained the resident was put on dialysis to try and lower his potassium level. The ex-wife stated the ED physician explained at some point after dialysis, the resident had a cardiac event, his heart stopped, and he died. She stated she felt like the facility did not value her ex-husband as a human being and his death was devastating for the entire family. She confirmed he would never have wanted to miss dialysis treatments. On [DATE] at 12:35 PM, the facility's DON stated resident #1 tested positive for COVID-19 on a Tuesday and the facility notified the dialysis center. She explained the dialysis center could not accept the resident for treatment so the facility notified the attending physician and obtained an order for immediate labs on Thursday. The DON stated based on the lab results, the resident received an order for a drug to decrease the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 3 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 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 0698 Level of Harm - Actual harm Residents Affected - Few potassium level. She emphasized the resident only missed one dialysis treatment prior to being transferred to the hospital. When asked if it was possible for one missed treatment to have a negative impact on the resident's health, the DON did not respond. On [DATE] at approximately 12:40 PM, the Regional DON stated the facility's administrative and clinical leadership team met after they were informed resident #1 died in the hospital. She said, I asked what the current process was for missed treatments. They did not appear to have a process in place to address missed dialysis treatments. The Regional DON explained nursing staff thought that calling the physician and getting orders was adequate and they did not escalate the issue to nursing administration. She acknowledged she was called out of clinical meeting on Friday morning to speak with the dialysis center's SW and Clinical Coordinator. The Regional DON verified they expressed concerns about resident #1's labs and recommended sending him to the hospital. She confirmed the Clinical Coordinator informed her the dialysis center had called the facility prior to Friday regarding transferring the resident to the hospital. On [DATE] at approximately 12:45 PM, the DON stated after she was made aware of the situation on Friday morning, she called resident #1's attending physician who directed her to absolutely send the resident to the hospital. The DON confirmed the facility did not utilize 911 for Emergency Medical Services (EMS); instead staff contacted a non-emergency ambulance service at about 11:00 AM and they provided an estimated time of arrival of two hours later. On [DATE] at 1:07 PM, the Station 1 Registered Nurse (RN) Unit manager (UM) recalled resident #1 tested positive for COVID-19 during facility-wide testing on Tuesday, [DATE]. She explained she notified the dialysis center on Wednesday, [DATE] at about 8:45 AM, just before the resident was to leave for his dialysis treatment, and was informed he could not receive his treatment at that location. She said, I expected them to take him that day. She did not provide a response when asked why the facility did not notify the dialysis center on Tuesday morning when the resident tested positive. The RN UM described multiple conversations with the dialysis center SW on Wednesday and Thursday, with no positive feedback on a dialysis location that could meet the needs of a patient with COVID-19. She stated at about 12:35 PM on Thursday, [DATE], she called the Physician Assistant (PA) who worked under the supervision of resident #1's attending physician. The RN UM stated the PA ordered immediate labs and instructed her to monitor the resident for changes in status. She recalled she asked the PA if the resident would be transferred out, and he wanted the labs done first. She said, I spoke to resident and evaluated him. No negative findings at that time. I explained the issues with dialysis center. He was not happy about that. I told him that if they don't find a way to dialyze him, he would have to go to the hospital. The RN UM stated the lab results showed a high potassium level and the PA ordered a daily oral medication to treat the condition, Sodium Polystyrene Sulfonate for three days, with follow up labs on Monday [DATE]. She stated the PA also discontinued resident #1's daily potassium supplement. On [DATE] at 3:39 PM and [DATE] at 9:39 AM, in telephone interviews, the dialysis center's Advance Practice Registered Nurse (APRN) recalled the SW informed her resident #1 tested positive for COVID-19 and the nursing facility did not want to send him to the hospital for dialysis. She stated she told the SW the resident must be sent to the hospital if the facility was not able to provide in-house dialysis. The APRN stated she was not surprised resident #1 had a high potassium level on Thursday afternoon as his last dialysis treatment was on Monday. When asked about the effect of a potassium supplement in that situation, she expressed surprise and stated that drug was not on the resident's medication list at the dialysis center. The APRN emphasized if she had seen it, she would have discontinued the potassium supplement. She explained the dialysis center expected the facility to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 4 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 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 0698 Level of Harm - Actual harm Residents Affected - Few current medication lists so dialysis providers would be aware of clinical conditions that might affect the individual's treatment plan. She confirmed that lack of communication affected effective collaboration on the plan of care. She said, I would expect collaboration with medication changes at the very least. She explained daily potassium supplements were discouraged for dialysis patients. She stated she usually did not replace this electrolyte unless the level was below 3.0, and then only with a one-time dose. The APRN explained low potassium levels were usually treated by adjusting the potassium level in the cleansing fluid used during dialysis treatments. She said, I would expect them to communicate and call before or after they add something like potassium. The APRN stated her expectation was the facility would have used EMS, not non-emergency transport, to transfer resident #1 to the hospital when his lab result showed a potassium level of 6.9. She stated treatment with Sodium Polystyrene Sulfonate was appropriate in situations where a dialysis machine was not immediately available, but dialysis should be started as soon as possible. She explained the drug would lower potassium levels temporarily, but within a few hours the levels would increase. The APRN explained resident #1 was at high risk for an acute cardiac event. On [DATE] at 12:20 PM, in a telephone interview, the dialysis center's nephrologist confirmed he completed resident #1's monthly assessment on Monday, [DATE], his last day of dialysis. The nephrologist explained it was standard for dialysis to be scheduled three times weekly as it is an intermittent treatment for patients with little or no residual kidney function. He verified resident #1 needed dialysis three times weekly. The nephrologist explained there was the potential for multiple complications if dialysis was not done, including electrolyte issues. He validated a potassium level of 6.9 was very concerning and when informed the resident was treated in the facility with Sodium Polystyrene Sulfonate, the nephrologist said, That is not appropriate to manage hyperkalemia for a dialysis patient. He would need to be dialyzed. He was not aware resident #1 received a potassium supplement and explained he should not have been receiving it; however, he acknowledged the facility and community physicians had autonomy to treat their patients. The nephrologist stated on Friday, [DATE], the day the resident was transferred to the hospital, he was on call for the hospital Emergency Department (ED) and they called me because he was there. The nephrologist explained it took time to set up a dialysis, but resident #1 was put on the machine as soon as possible, and he died later that night after the treatment was complete. The nephrologist stated it was a very unfortunate situation. On [DATE] at 2:19 PM, in a telephone interview, the PA recalled when he was informed resident #1 missed dialysis, he asked how the resident felt and was told he had no complaints. The PA stated he understood the resident would probably have his dialysis treatment on the following day, Friday [DATE]. The PA denied any conversations between him and facility staff regarding the possibility the resident would not receive dialysis the next day, and he stated he never received messages from the dialysis center regarding sending the resident to the hospital. The PA verified he ordered Sodium Polystyrene Sulfonate on the evening of Thursday [DATE], to treat resident #1's high potassium level. He explained the drug could work quickly, possibly in one day, or after one to two doses. He said, Nobody told me at any time that [dialysis] was not definitely arranged. If I would have known, I may have made a different decision on Thursday. On [DATE] at 2:54 PM, the Station 1 RN UM stated when she spoke with the PA on Thursday afternoon, she was hopeful resident #1 would be able to get his dialysis treatment on Friday morning as the dialysis center was still actively searching for a location. The RN UM did not recall telling the PA that resident #1's dialysis treatment was confirmed for Friday, [DATE]. She said, Even during the last conversation on Thursday, [the dialysis center] did not sound very sure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 5 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 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 0698 Level of Harm - Actual harm Review of Progress Notes revealed the Station 1 RN UM contacted the dialysis center on Thursday, [DATE] at 12:35 PM. The note indicated the dialysis center was unable to treat residents who were positive for COVID-19. A progress note dated [DATE] at 1:35 PM revealed the RN UM spoke with the dialysis center's SW and was informed they still had not found a dialysis site for resident #1. Residents Affected - Few On [DATE] at 9:56 AM, the DON stated the facility was aware resident #1 needed his dialysis treatments and they proceeded step by step towards that end after he tested positive for COVID-19 with a rapid antigen test on Tuesday, [DATE]. The DON acknowledged the resident's medical record did not show any documentation of the facility's attempts to secure dialysis treatment for resident #1 in the hospital until dialysis center staff contacted the facility's Regional DON on Friday, [DATE]. She explained after a positive antigen test, the facility's process was to collect another specimen and obtain a follow up polymerase chain reaction (PCR) test from the lab for confirmation of the COVID-19 diagnosis. The DON stated the facility sent the PCR test to the lab and a negative result was reported on [DATE], after resident #1's death. On [DATE] at 10:31 AM, the facility's Staff Educator stated the facility did not provide detailed education to nurse on the care of residents who required dialysis. However, she explained each resident who went out to dialysis treatments had a binder with a communication form to guide the nursing assessment and ensure necessary monitoring was completed. The Staff Educator stated she expected nurses to check the binder prior to each dialysis appointment to verify there was a face sheet with demographic information and an updated medication list when if there was a change in physician orders. She stated on return from dialysis, the facility nurse should review the resident's form for pertinent information and/or recommendations from the dialysis center in case there are new orders. On [DATE] at 11:55 AM, the Station 1 RN UM verified the assigned nurse was to complete a communication form before a resident left for dialysis, and if the form was not returned with the resident, the nurse had to call the dialysis center to obtain the required information. She validated she would have expected nurses to provide the dialysis center with resident #1's new medication order for a potassium supplement and also a copy of the lab result that triggered the order when the change was made in September. The DON acknowledged it was important for the facility and dialysis providers to communicate regarding medications administered at both sites. She stated a current medication list should always accompany residents to dialysis treatments. Review of the Dialysis Communication/Referral (For Visits to Dialysis) form, dated [DATE], revealed the document was to be completed by the facility's licensed nurses and dialysis staff. The form included a section for staff to check if additional information such as lab results, physician orders, and medication and/or treatment administration records were attached. On [DATE] at 11:59 AM, the Health Information Management Coordinator stated she reviewed resident #1's medical record and did not find any dialysis communication forms in the facility's document storage system. On [DATE] at 4:18 PM, the dialysis center's Assistant Administrator stated to her knowledge, resident #1 had not brought communication forms to his dialysis treatments for a while. She stated the dialysis center faxed a weekly update to some skilled nursing facilities at their request. However, the Assistant Administrator said, [Name of the facility] never asked for weekly updates, and we never sent them. Review of resident #1's medical record revealed a physician order dated [DATE] for a Comprehensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 6 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 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 0698 Level of Harm - Actual harm Residents Affected - Few Metabolic Panel (CMP) lab test. The result report dated [DATE] showed the resident's potassium level was L or low at 3.10 mEq/L. A physician order for Potassium Chloride Extended Release tablet 10 mEq once daily was obtained on [DATE]. Review of the Treatment Administration Record (TAR) showed resident #1 had a CMP ordered for chronic kidney disease on [DATE]. The lab report showed the sample was collected on [DATE] at 4:30 PM and the result indicated the resident's potassium level was CH or critically high at 6.9 mEq/L. The Order Summary Report showed physician orders dated [DATE] to discontinue the Potassium Chloride supplement and give Sodium Polystyrene Sulfonate 120 milliliters (ml) daily until [DATE], to treat resident #1's hyperkalemia. The TAR showed the facility obtained a physician order on [DATE] at 10:30 AM to transfer resident #1 to the hospital via non-emergency transportation to be dialyzed. The document indicated the resident left the facility for the hospital over five hours later, at 3:44 PM. Review of the hospital record revealed resident #1 was seen in the ED on [DATE] at 4:08 PM. Lab tests done a few minutes later at 4:21 PM revealed his potassium level remained critically high and by then had increased to 7.2 mEq/L. An electrocardiogram (EKG) was done and it showed changes associated with high potassium levels. The ED physician noted the resident was critically ill and treatments included a cardiac monitor, labs, EKG, hyperkalemia protocol, and nephrology consult for immediate dialysis. The ED physician wrote, The high probability of sudden, clinically significant deterioration in the patent's condition required the highest level of my preparedness to intervene urgently. Review of resident #1's medical record revealed a Change in Condition Evaluation dated [DATE] at 10:28 AM that showed he tested positive for COVID-19. There was no documentation of notification of the dialysis center until [DATE] at 8:44 AM when the Station 1 RN UM called to inform the dialysis center just before the resident was scheduled to leave for his scheduled treatment. The TAR indicated the PCR lab test to confirm COVID-19 status was scheduled for Wednesday, [DATE], but the specimen was not collected. A progress note dated [DATE] at 5:58 AM read, PCR testing supplies not available. Notified lab and was advised that supplies will be delivered in the morning. Specimen to be collected tomorrow. The TAR revealed the PCR lab test was rescheduled for Thursday, [DATE], but was again not collected. A progress note written by the RN UM on [DATE] at 7:55 AM read, Rescheduled due to lab not bringing specimen packet. The medical record did not show that the physician was notified the PCR test was not done, and there was no evidence the rapid antigen test was repeated to determine if resident #1 actually had COVID-19. A lab result form revealed the PCR specimen was collected on Friday, [DATE] at 4:27 AM. The result was reported to the facility on [DATE], after resident #1 died, and showed that the specimen was negative for COVID-19. Review of the facility's policy and procedure for Dialysis Services, revised on [DATE], revealed the purpose was to provide dialysis services to residents when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 7 of 7