Health inspection·February 1, 2024

F 0610 Level of Harm - Minimal harm or potential for actual harm The DON recalled the facility reviewed copies of drug receipts, and some signatures were not readable. She said the investigation revealed narcotics were not being entered properly on the Controlled Drug Record. She verbalized the facility could not identify when the resident's Percocet tablets went missing, and they could not identify who was involved. She shared the Root Cause was due to varied staff, facility nurses and Agency nurses, and a lack of oversight. Residents Affected - Few An Investigation Statement dated [DATE] and documented by the SSD, revealed the resident stated he had not received his Percocet, and the SSD explained the facility had to report, and investigate the incident. No other statements could be identified, and when asked about statements from the staff, the DON said she did not see any other statements in her binder. When asked if an Ad Hoc Quality Assurance Performance Improvement (QAPI) was completed, the DON replied no, and said the Medical Director was made aware since he was the resident's physician. She stated the incident was discussed in QAPI on [DATE]. They spoke about what was identified and spoke about the education and process in place. Review of the AHCA 5-day Report, revealed documentation to indicate the facility would conduct audits weekly for four weeks, then monthly for two months. Review of the Controlled Medication Audit revealed audits were completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The completion instructions on the Audit form read, The DNS (Director of Nursing Service) or designee, to audit narcotic procurement and counting daily x 1 week then 2 times weekly x 2 weeks then weekly x 4. Questions/probes on the form were: Are controlled medications properly stored with double lock? Are appropriate medications counted with change of shift each day with signatures to indicate no concerns? Are all medications reviewed and signed in by the floor nurse with pharmacy courier when delivered? Narcotics that are discontinued, or expired of a discharged resident are immediately destroyed and/or returned as appropriate? A check mark should be in the yes or no column, and there was a column for any additional comments. The DON stated the audits were completed for two weeks, then the Regional Clinical Nurse directed the facility to discontinue the audits and change to probing questions. The audits did not address the accurate completion of the Controlled Drug Record. On [DATE] at 9:40 AM, the DON stated the facility could not prove the resident's medication was missing, and the facility did not have copies of invoices for medications delivered. Review of the Work with Order File provided by the facility, that was faxed from the Pharmacy on [DATE] at 5:04 PM, revealed the following: Oxycodone-Acetaminophen (Percocet): 5-325 Tab on [DATE], 30 tablets were ordered and shipped to the facility. On [DATE] 12 tablets were ordered and shipped, on [DATE] 12 tablets were ordered, and was shipped on [DATE]. On [DATE], 12 tablets were ordered and shipped, and on [DATE], 120 tablets were ordered and shipped to the facility. This revealed a total of 186 tablets of Percocet 5-325 mg was delivered to the facility between [DATE] to [DATE]. Review of the resident's MAR for the period [DATE] to [DATE] revealed a total of 82 tablets were administered to the resident, and from [DATE] until [DATE], 77 tablets were administered, a total of 159 tablets out of 186 tablets, leaving a balance of 27 tablets that were unaccounted for. The Work with Order File from the pharmacy was requested by the facility after interviews with the surveyor. The facility could not verify, and ensure an accurate inventory, and accounting of the Percocet received and administered for resident #76 prior to [DATE]. On [DATE] at 4:05 PM, the investigation was discussed with the DON, regarding missing statements from staff, and follow-up with the pharmacy. The DON said there was a lack all around and confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 2 of 11 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 02/01/2024 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 0610 that a thorough investigation was not done. Level of Harm - Minimal harm or potential for actual harm The facility's policy Abuse And Neglect-Rehab/Skilled, Therapy & Rehab reviewed and revised on [DATE], read, The investigation may include interviewing employees . Interview all involved (employee, resident and family) .Consider having each person write his or her memory of the event. If possible, get signed and dated statements from any witnesses. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 3 of 11 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 02/01/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed to evaluate the need for additional mental health resources and appropriate placement of a resident prior to admission for 1 of 1 residents reviewed for PASRRs of a total sample of 44 residents, (#29). Residents Affected - Few Findings: Resident #29 was admitted to the facility on [DATE] from an Assisted Living Facility with diagnoses that included unspecified dementia, Bipolar disorder, and Major Depressive Disorder. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] section A1500 (PASRR) coded O which incorrectly indicated resident #29 did not have a serious mental illness and/or an intellectual disability according to the stated level II PASRR. Review of the MDS Section I, Active Diagnosis revealed resident #29 was diagnosed with Non-Alzheimer's dementia and Manic depression/Bipolar disease. A Psychology Evaluation Note dated 3/07/23 revealed resident #29 reported recurrent, mild depressive symptoms which included trouble concentrating, fatigue, decreased self-esteem, a lack of pleasure and a loss of interest in activities she normally found pleasurable. The psychologist described resident #29 as having mild cognitive impairment with a psychiatric history of depression, anxiety and episodic mood difficulties. Review of resident #29's medical record revealed no documentation of a level I PASRR, nor a level II PASRR in her record. On 2/01/24 at 10:48 AM, the Social Service Director described a level I PASRR was used during pre-admission to assess a possible resident's mental, physical and psychological abilities to determine if a resident with psychiatric history was appropriate for the long-term care or skilled nursing setting. She explained the screening also determined if a resident needed further screening for additional specialized services for their serious mental illness or intellectual disability. The Social Service Director stated the PASRR screenings were important to help meet the residents' needs, properly develop their plan of care and ensure the resident would be the right fit for the facility. She further explained the level I PASRR was supposed to be completed before admission to the facility, and if a resident was found without screening completed, she would be tasked to complete it. On 1/31/24 at 2:36 PM, the station 1 Unit Manager (UM) stated she was not able to find a level I nor a level II PASRR in resident #29's medical records. She confirmed resident #29 had a psychiatric history and should have had a level I PASRR on admission. She was unsure if resident #2 required a level II PASRR. About an hour later at 3:28 PM, the station 1 UM confirmed the facility could not provide documentation of a level I nor a level II PASRR for resident #29. She explained that because the level I screening had not been done, the Social Service Director had just completed one which indicated resident #28 had a serious mental illness and required a level II PASRR which was to be scheduled. On 2/01/24 at 9:51 AM, the Social Service Director stated the level I PASRR was usually included in the paperwork that came from the hospital but if a resident was admitted from home or from an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 4 of 11 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 02/01/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assisted Living facility like resident #29, they usually would not have one performed prior to admission. She explained the previous Health Information Management (HIM) supervisor had done audits on all new admissions to check the needed paperwork, but she was not sure who, if anyone was currently responsible for that task. On 2/01/24 at 10:26 AM, the current HIM supervisor stated she was unaware of any audits of new admission documents by the previous supervisor nor of any problem with missing PASRR screenings. She explained she assumed nurses were responsible to ensure the correct paperwork was included in the admission documents and that they should notify the Social Service Director if the screening was needed. The HIM supervisor stated a facility wide audit was needed to ensure all applicable residents had a PASRR completed. On 2/01/24 at 3:18 PM, the Social Service Director stated they had not started an audit to determine how many residents were missing the PASRR, but she could see from her notebook at least five other residents who came from home were missing them. The Social Service Director stated this was a problem. Review of the job description, Health Information Management Technician, Long Term Care dated 11/13/23 revealed the employee would understand regulatory standards for accurate medical records. They would also complete admission-related functions including retrieval of previous medical records. The Pre-admission Screening and Resident Review policy dated 12/11/23 described the purpose to determine admission criteria for residents with mental illness and ensure those individuals would receive the care and services needed in the most appropriate setting. The policy defined serious mental illness to include mood, or severe anxiety disorders and others. The document indicated, All prospective residents will be screened for possible serious mental disorders or intellectual disabilities and related conditions. The policy further detailed a positive level I screen necessitated an, in-depth evaluation of the individual, known as a PASRR level II conducted by a state- designated authority prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 5 of 11 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 02/01/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure accurate record for receipt and disposition of controlled medications was completed to enable accurate reconciliation, and to account for missing Percocet tablets for 1 of 1 resident of a total sample of 44 residents, (#76). Findings: Clinical record review revealed resident # 76 a [AGE] year-old-male was admitted to the facility on [DATE]. His diagnoses included cellulitis to the right lower limb, peripheral vascular disease, chronic pain syndrome, and dorsalgia Review of the resident's physician orders revealed an order dated 3/09/23 for Percocet 5-325 milligram (mg) one tablet every six hours as needed for moderate pain. The order was discontinued on 9/26/23, and a new order was noted for Percocet 5-325 mg one tablet every six hours. Review of the facility's Reportable log revealed an entry on 10/20/23 for misappropriation of property, and documentation revealed twenty-four (24) tablets of Percocet 5-325 mg for resident #76 was unaccounted for. On 1/30/24 at 4:23 PM, the incident was discussed with the Administrator, the Director of Nursing (DON, and the Social Services Director (SSD). The SSD explained she was responsible to complete the Agency For Health Care Administration (AHCA) Nursing Homes Federal Reporting Immediate and 5-day reports, notify the ombudsman, and law enforcement of the incident, and submit the Department of Children and Family (DCF) report. She stated the investigations for reportable incidents was done by the Interdisciplinary Team (IDT). The DON recalled on 10/20/23 at 6:45 PM, she was notified by the Clinical Care Leader of a discrepancy in narcotic count, and that 24 Percocet tablets were missing for resident #76. The DON stated a search of the medication cart, the medication room on Station 2, and the remaining four medication carts in the facility was conducted. The resident's Medication Administration Record (MAR) was reviewed, staff on duty at the time were interviewed, and an inquiry was made to the Pharmacy regarding delivery of the medication. She stated the Physician Assistant was made aware, and a prescription was obtained for pain medication for the resident, to be replaced at the facility's expense. The DON stated the Pharmacy confirmed delivery of Percocet for the resident on 9/22/23 of 30 tablets, and on 9/26/23, of 120 tablets. She stated that initially, the resident was on Percocet every 6 hours as needed, but with the frequency of use, the medication was then changed on 9/26/23, and scheduled for every 6 hours around the clock. The DON recalled the resident's MAR reviewed for the period 9/17/23 to 9/25/23, and 9/26/23 to 10/20/23, revealed the resident received Percocet 5-325 mg every 6 hours, and the facility verified that 24 tablets of Percocet were missing. She stated no medication was available for the resident on investigation, and to address the resident's pain, the facility called the physician, and the pharmacy, and the facility assumed payment for the medication sent by pharmacy, and an authorization code was received from the pharmacy to retrieve the medication from their onsite emergency medication dispenser for immediate administration. The DON stated drug test was performed on 10/21/23, and on 10/23/23, on three nurses who worked the 7 AM to 7 PM, and 7 PM to 7 AM shifts and results were all negative. She said statements were obtained from the nurses; however, the facility could not provide documentation of the statements. The DON recalled the facility reviewed copies of drug receipt, and some signatures were not readable. She said the investigation revealed narcotics were not being entered properly on the Controlled Drug Record. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 6 of 11 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 02/01/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verbalized the facility could not identify when the resident's Percocet tablets went missing, and they could not identify who was involved. She shared the Root Cause was due to varied staff, facility nurses and Agency nurses, and a lack of oversight. She stated in-service education to address the delivery of narcotics was initiated, and staff were educated that two nurses must receive and sign the receipt for the drug and obtain a copy of the receipt. The DON said audits were started on 10/25/23 to 10/30/23, however, no documentation could be identified to indicate the Controlled Drug Record, the Controlled Medication Utilization Record were checked, and reconciled with the medication packets. She stated the Pharmacy Consultant did not review the resident's Controlled Medication Utilization Record, but she was informed by the Consultant Pharmacist, that the incident was discussed at the Pharmacy Corporate level. On 1/30/24 at 5:16 PM, Licensed Practical Nurse (LPN) A confirmed that he cared for resident #76 on 10/20/23. He recalled the resident was scheduled to receive Percocet 5-325 mg but when he checked the medication cart, there was no Percocet for the resident. LPN A stated he called the pharmacy and was told three packets of Percocet for resident #76 had been delivered to the facility. He recalled he informed the pharmacy there was no Percocet and was told the Pharmacy could not dispense any more. The LPN said the supervisor followed up with the pharmacy and was told the pharmacy could not send any more Percocet. LPN A stated the supervisor reviewed the resident's narcotic sheet, and at first thought the Percocet was missing, but it was a miscalculation of the medication, and no medication card was missing. On 1/31/24 at 9:40 AM, the DON stated that initially, the facility thought 24 tablets of Percocet were missing. She said the pharmacy had sent 120 tablets on 9/26/23. She stated the facility could not prove the medication was missing. The Controlled Medication Utilization Record for the resident was reviewed with the DON. On 9/15/23, and on 9/22/23, 12 tablets of Percocet 5-325 mg was received and administered leaving a balance of 0 on the respective Records. On 9/26/23, 120 tablets of Percocet 5-325 mg was received. Between 9/28/23 to 10/05/23, 30 tablets were administered. A Controlled Medication Utilization Record for resident #76 could not be identified for the period 9/23/23 to 9/25/23, and for the period 10/06/23 to 11/05/23. The DON stated the records could not be found, verbalizing there was an issue with missing records in the Health Information Management (HIM). Based on information reviewed on the resident's Controlled Medication Utilization Records, a total of 144 tablets of Percocet 5-325 mg was received by the facility between 9/15/23 to 9/26/23. Review of the resident's Medication Administration Record (MAR) revealed documentation to indicate the resident received Percocet 5-325 mg on 9/23/23 at 12:34 AM, at 12:45 PM, and at 6:45 PM. On 9/24/23 at 7:14 PM, and on 9/25/23 at 11:00 AM, and 11:15 PM. The resident's Controlled Medication Utilization Record for this period could not be found. As per the DON, doses were obtained from their onsite emergency medication dispenser with authorization. Review of the resident's MARs from 10/05/23 to 10/20/23 revealed 41 tablets of Percocet 5-325 mg was administered to the resident. The total amount of Percocet tablets administered to the resident based on review of Controlled Medication Utilization Records, and his MAR for the period 9/01/23 to 10/20/23 was 125. From 9/15/23, to 9/26/23, 144 tablets of Percocet was delivered to the facility, which indicated nineteen (19) tablets were unaccounted for. This was confirmed by the DON. She said the facility did not know if the medication was sent by the pharmacy, since the facility did not have any paperwork to prove the delivery. She stated the facility did not have copies of the invoices for the medications delivered. The DON stated the Controlled Drug Record was not completed accurately by the nurses when narcotics were received, so the facility could not account for medications received, or the name of the resident the medication was for. She stated the incident was discussed in the facility's Quality Assurance Performance Improvement (QAPI) meeting on 11/25/23. They spoke about what was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 7 of 11 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 02/01/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few identified, and the education and process in place. The DON stated the allegation was not substantiated, because the facility did not have any proof that the resident's Percocet tablets were missing, as there was a lack of documentation. She said they were unable to prove what was on hand, and what was missing, and said there must be paperwork somewhere, but the facility did not have it. On 1/31/24 at 10:32 AM, the Administrator stated that review of the report of medications retrieved from the onsite emergency medication dispenser revealed no medication was retrieved for the period 9/20/23 to 9/24/23. The facility was unable to explain where the medication documented on the MAR as administered to the resident on the dates mentioned was obtained. On 01/31/24 12:16 PM, Registered Nurse (RN) D, recalled it was on a Friday night in October 2023, the Administrator called her and said she had to come to the facility within twenty-four to forty-eight hours for a drug test as some narcotics were missing. RN D stated she came to facility and had the test done, and it was negative. She said she was not told which resident's narcotic was missing, only that some Percocet were missing for a resident she was assigned to. On 01/31/24 at 2:15 PM, resident #76 stated he recalled when he could not get his medication, because it was not in the medication cart, and the nurse did not know the code for the emergency dispenser. When asked if he was told why the medication was not available, the resident said it was because the nurse did not have a code. Review of the Work with Order File provided by facility, that was faxed from the Pharmacy on 1/31/24 at 5:04 PM revealed the following: Oxycodone-Acetaminophen (Percocet): 5-325 Tab that on 9/05/23 30 tablets were ordered and shipped to the facility. On 9/15/23 12 tablets were ordered and shipped, on 9/17/23 12 tablets were ordered, and was shipped on 9/18/23. On 9/22/23, 12 tablets were ordered and shipped, and on 9/26/2023, 120 tablets were ordered and shipped to the facility. This revealed a total of 186 tablets of Percocet 5-325 mg was delivered to the facility between 9/05/23 to 9/26/23. Review of the resident's MAR for the period 9/01/23 to 9/30/23 revealed a total of 82 tablets were administered to the resident, and from 10/01/23 up until 10/20/23, 77 tablets were administered, a total of 159 tablets out of 186 tablets, leaving a balance of 27 tablets that were unaccounted for. The Work with Order File from the pharmacy was requested by the facility after interviews with the surveyor, hence the facility could not verify, and ensure an accurate inventory, and accounting of the Percocet received and administered for resident #76 prior to 1/31/24. The facility's policy Medications: Controlled reviewed and revised on 6/13/2023 documented purpose was, To provide verification and reconciliation of all controlled medications Reconciliation: refers to a system of recordkeeping that ensures as accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered and/or including the process of disposition. The policy Medication: Missing/Diversion of Medications reviewed/revised on 9/18/2023 outlined the steps to be taken by the facility in the event of missing/diverted medications, and directs that an investigation should be performed, and the facility should work closely with the pharmacy staff to prove when and what amount of the medication was sent to the location. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 8 of 11 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 02/01/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to act on PRN (as needed) psychotropic medication duration limits for 2 of 5 residents reviewed for Unnecessary Medications from a total sample of 44 residents, (#91, #98). Findings: 1. Review of the medical record revealed resident #98, a [AGE] year old male was admitted to the facility on [DATE] and re-admitted from an acute care hospital on [DATE] with diagnoses that included cerebral vascular accident (stroke), aphasia (inability to formulate speech), dementia, lack of coordination, type 2 diabetes mellitus, and unsteadiness on feet. The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 8/03/23 identified the resident was unable to complete a Brief Interview for Mental Status (BIMS), was rarely or never understood, noted by staff to have short-term and long-term memory problems, severely impaired cognitive decision making abilities, disorganized thinking that fluctuated and changed in severity, and he had no behaviors or rejections of care. The assessment showed the resident required assistance from staff to complete Activities of Daily Living (ADLs), mobility functions in and out of bed, and to walk; he fell two or more times, and he received high risk antipsychotic and antianxiety medications five out of seven days, and antidepressant medication for seven out of seven days during the look-back period. The Comprehensive Care Plan Focus included communication problems related to expression of thoughts, behavior symptoms, grief, risk for acute pain, ADL self-care deficits, history of falls, and risk for injuries from falls. On 1/29/24 at 11:20 AM, resident #98 was observed on the nursing unit sitting at a group table of four. He was not able to verbally communicate. On 1/30/24 at 3:01 PM, the resident was observed walking in the hallway using a walker, assisted and supervised by two facility staff. Review of the Electronic Health Record (EHR) showed from 7/11/23 to 8/15/23, PRN medication orders were implemented for Lorazepam (anti-anxiety), Benadryl (antihistamine), and Haldol (anti-psychotic) 1 Milliliter (ml) combined in a transdermal (absorbed through the skin) gel for anxiety, every four hours. The Medication Administration Record (MAR) documented nurses administered the medication 27 times, over 36 days. From 8/15/23 to 9/05/23, PRN orders were implemented for Ativan (anti-anxiety) 1 milligram (MG) transdermal gel for anxiety, every four hours. The MAR documented nurses administered the medication 9 times, over 21 days. From 9/12/23 to 10/10/23, orders were implemented for Ativan (anti-anxiety) 0.5 MG transdermal gel for anxiety, every six hours. The MAR documented nurses administered the medication 8 times, over 28 days. The August 2023 Pharmacy Consultant Report read, resident has a PRN order for an anxiolytic, without a stop date: Ativan gel . Rationale for Recommendation: CMS (Centers for Medicare and Medicaid Services) requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days. On 2/01/24 at 3:26 PM, the Director of Nursing (DON) explained the facility's process for ensuring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 9 of 11 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 02/01/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PRN psychotropic medications had a 14-day duration limit included reconciliation reviews upon resident admissions, psychiatric provider assessments, nursing management tracking, and monthly Medication Regimen Review (MRR) reports. She checked resident #98's medical record, and acknowledged there were three PRN psychotropic medication orders in place from 7/11/23 to 10/10/23 that were not reviewed by nursing management while they had extended well beyond the 14-day limit. She said she had only been working at the facility for three months and stated, there should have been a 14 day stop date. In a joint telephone interview with the DON and the facility's Pharmacy Consultant on 2/1/24 at 3:47 PM, the Pharmacy Consultant stated reports were submitted to the facility every month with recommendations that included orders that showed PRN psychotropic medication orders that were missing a stop date. He explained, the use of PRN anti-anxiety and anxiolytics were high-risk, especially in the elderly and they required special monitoring for over-use because they could mask other underlying root causes. 2. Resident #91, [AGE] year-old female, was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease, anxiety disorder, major depressive disorder, and persistent mood disorder. Review of the resident's Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/10/23 revealed resident #91 had severely impaired cognitive skills for daily decision making. She had indicators of behavior symptoms and rejection of care with no indicators of psychosis. She was dependent on staff for her Activities of Daily Living (ADLs) and received antianxiety and antidepressant medications. Review of resident #91's discontinued/completed physician orders dated 5/2/23 noted Ativan Transdermal Gel 1 milligram (mg) every four hours as needed (PRN) for anxiety with a discontinue date of 8/15/23. Further review of the medical record revealed the physician did not provide a rationale for the extended time frame for Ativan beyond the 14-day use. Review of the Medication Administration Record (MAR) reflected the resident received 10 doses of Ativan Gel PRN beyond the 14 days. Review of the Pharmacy Consultation Report dated 5/15/23 noted resident # 91 had a PRN order for Lorazepam (Ativan) 1 milligram (mg) without a stop date. It was recommended to document the intended duration of therapy, and the rationale for the extended time frame. The rationale for the recommendation indicated CMS requires that PRN orders for non-antipsychotic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. Review of the resident's active physician orders revealed resident #91 had an active order since 10/26/23 for Ativan Transdermal Gel 0.5 milligram (mg) every twelve hours as needed (PRN) for anxiety. Further review of the medical record revealed the physician did not provide a rationale for the extended time frame for Ativan beyond the 14-day use and did not indicate a specific duration or stop date. The resident's MAR showed he received 17 doses of Ativan Gel PRN beyond the 14 days. On 02/01/24 at 3:26 PM the DON stated that anxiolytics prescribed as needed (PRN) should receive a 14 day stop date. She stated resident # 91 had Ativan Gel prescribed as needed (PRN) on 5/2/23 with a stop date of 8/15/23. She stated it should have had a 14 day stop date and the resident should not have received the medications past the 14 days. The DON also acknowledged the resident had an active order for Ativan Gel as needed (PRN) since 10/26/23. She stated there should have been a 14 day stop date and the resident should not have received the Ativan Gel PRN past 14 days unless the provider noted a rationale and duration for the extended time frame. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105559 If continuation sheet Page 10 of 11 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 02/01/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 02/01/24 at 3:47 PM, the Pharmacist stated that Anxiolytics prescribed as needed (PRN) need a stop date of 14 days or a rationale with the duration of the extended time period noted. He stated the Ativan given to the resident on an as needed basis ought to have been limited to a 14-day duration. The facility's standards and guidelines dated 2/10/23 and titled, Medication: Drug Regimen Review read, PURPOSE To prevent medication errors that could cause harm to a resident or result in resident hospitalization. To identify the potential for adverse events. pharmacists and nurses play a vital role in improving health care . Event ID: Facility ID: 105559 If continuation sheet Page 11 of 11