Inspection·August 3, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm During an observation on 8/2/2023 at 6:05 AM with Staff K, Registered Nurse (RN), Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Review of Resident #35's physician order dated 7/27/2023 reads, Continuous O2 at 2 L/MIN via NC [Nasal Cannula] every shift. Residents Affected - Few Review of Resident #35's Quarterly MDS dated [DATE] reads, Section O. O0100. Special Treatments, Procedures and Programs . C. Oxygen . 2. While a Resident: No. Review of Resident #35's Weights and Vitals Summary reads, 05/23/2023, 17:11 [5:11 PM] 94% (Oxygen via Nasal Cannula), 05/21/2023, 17:37 [5:37 PM] 98% (Oxygen via Nasal Cannula). During an interview on 8/2/203 at 7:58 AM, the MDS Coordinator stated, [Resident #35's name] has so many things going on with her. She sure did use oxygen. 3. Review of Resident #78's records revealed the resident was admitted to the facility on [DATE] with diagnoses including lobar pneumonia, pyuria, cardia murmur, congestive heart failure and chronic kidney disease. Resident #78 was discharged home with family on 7/7/2023. Review of Resident #78's MDS Assessment Discharge Return Not Anticipated dated 7/7/2023 reads, Section A. Identification Information . A2100. Discharge Status: 03. Acute hospital. Review of Resident #78's Social Services Progress Note dated 7/7/2023 reads, Pt [Patient] given d/c [discharge] instructions/ med list, verbalized understanding all. all meds sent with pt. discharged approx. [approximately] 12 noon . Discharge Planning- [Resident #78's name] has requested to discharge today at noon with her daughter . During an interview on 8/1/2023 at 2:00 PM, the MDS Coordinator confirmed that Resident #78's was discharged home with her daughter, but the discharge MDS showed the resident was discharged to a hospital. During an interview on 8/2/2023 at 10:30 AM, the Director of Nursing stated, Yes, [Resident #78's name] discharged home with her family. Her MDS shows she discharged to the hospital. Review of the facility policy and procedure titled MDS Assessments with the last review date of 1/17/2023 reads, Procedures: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 2 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was diagnosed with a serious mental illness was referred for level II Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents reviewed, Resident #49. Findings include: Review of Resident #49's admission records showed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit, dementia, major depressive disorder, anxiety disorder, and schizophrenia (onset date of 9/18/2022). Review of Resident #49's records revealed no referral for Level II PASRR screening when the resident received the diagnosis of schizophrenia. During an interview on 8/2/2023 at 10:00 AM, the Director of Nursing stated, We did not conduct a new Level I screen when [Resident #49's Name] was officially diagnosed with schizophrenia. Review of the facility policy and procedures titled P&P Role of Admissions and Social Services in PASRR last reviewed on 1/17/2023 reads, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services . Procedure . IV. Resident Review . 2. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition who experience a significant change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 3 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 Based on interview and record review, the facility failed to ensure a resident who was admitted with a diagnosis of a serious mental received a referral to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination for 1 of 3 residents reviewed, Resident #39. Residents Affected - Few Findings include: Review of Resident #39's admission record revealed the resident was admitted most recently to the facility on 6/3/2022 with diagnoses including cerebral atherosclerosis, psychotic disorder with delusions, unspecified psychosis not due to a substance or known physiological, general anxiety disorder, mood disorders, major depressive disorder, neurocognitive disorder with Lewy bodies and encounter for palliative care. Review of Resident #39's level II Preadmission Screening and Resident Review (PASRR) dated 6/3/2022 reads, Section IV: PASRR Screen Completion . Individual may not be admitted to an Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of [Check on of the following]: X Serious Mental Illness and Intellectual Disability. During an interview on 8/2/2023 at 10:00 AM, the Director of Nursing (DON) stated, We did not send out a referral for a level II screening for [Resident #39's Name]. It should have been referred out. Review of the facility policy and procedure titled P&P Role of Admissions and Social Services in PASRR) last reviewed on 1/17/2023 reads, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services . Procedure: I. Preadmission Screening . 3. If the result of the PASRR (Level 1) screening indicates that serious mental illness (SMI) and/or intellectual disability (ID) or related condition appears to exist (positive Level I screen) and the individual does not meet a Provisional or Hospital Discharge Exemption, the individual will be referred to KEPRO [Keystone Peer Review Organization] for a Level II screening prior to the individual being accepted for SNF [Skilled Nursing Facility] admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 4 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for 1 of 5 residents reviewed for nutrition, Resident #30, and failed to develop a person-centered care plan for 1 of 4 residents reviewed for respiratory services, Resident #13. Findings include: 1. During an observation on 7/31/2023 at 12:10 PM, Resident #30 was eating independently in her room. The meal tray had a plate with green beans and pasta on the same plate, rice pudding in a bowl and a cup of coffee. During an observation on 8/1/2023 at 8:13 AM, Resident #30 was eating independently in her room. The meal tray contained scrambled eggs and toast on the same plate and a bowl of oatmeal. During an observation on 8/1/2023 at 11:59 AM, Resident #30 was eating in the restorative dining room area. The plate contained macaroni and cheese, chopped meat, spinach, and a roll. All items were together on the same plate (Photographic evidence obtained). Review of Resident #30's care plan with revision date of 4/4/2022 reads, Focus: [Resident #30's name] has an alteration in visual function AEB [As Evidenced By]: dx [diagnosis] of glaucoma, is legally blind, is only able to see shapes, lights. Assist with meals as needed . Interventions: Per [Resident #30's name] request, her food will be put in separate bowls for easier self-feeding. During an interview on 8/2/2023 at 7:57 AM, the Registered Nurse Assessment Coordinator stated, [Resident #30's name] food should come in separate bowls. During an interview on 8/2/2023 at 1:27 PM, the Director of Nursing stated, [Resident #30's name] food should have come in separate containers as mentioned in the care plan. We had been talking about this with staff. 2. During an observation on 7/31/2023 at 12:00 PM, Resident #13 was sitting in her room, with oxygen being administered via nasal cannula. During an observation on 8/1/2023 at 9:00 AM, Resident #13 was sitting in her wheelchair, with oxygen being administered via nasal cannula. Review of Resident #13's physician order dated 5/4/2023 reads, Monitor O2 [oxygen] sats [saturation] as needed for SOB [Shortness of Breath]/Respiratory Distress . Monitor O2 sats every shift for O2 monitoring. Review of Resident #13's physician order dated 5/5/2023 reads, May apply O2 @ [at] 2 LPM [liters per minute] via nasal cannula as needed to maintain sats above 92% as needed for monitoring O2 sats > or = 92%. Review of Resident #13's care plan revealed no focus for respiratory care or oxygen use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 5 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/2/2023 at 7:49 AM, the Registered Nurse Assessment Coordinator stated, I see under cardiac functions to monitor O2 [oxygen] sats. I do not see [Resident #13's name] care plan for respiratory or oxygen concerns. I will add it. During an interview on 8/3/2023 at 8:54 AM, the Director of Nursing stated, I have been made aware that [Resident #13's name] did not have a respiratory/oxygen care plan developed. There should have been one. Review of the facility policy and procedure titled Oxygen Administration last reviewed on 1/17/2023 reads, Procedure . 9. The use of oxygen should be reflected in the resident's plan of care. Review of the facility policy and procedure titled Care plans, Comprehensive Person-Centered last reviewed on 1/17/2023 reads, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 6 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that residents received care in accordance with professional standards of practice for medication administration for 1 of 7 residents reviewed, Resident #180. Residents Affected - Few Finding include: During an observation of medication administration for Resident #180 on 8/2/2023 at 8:26 AM, Staff L, Registered Nurse (RN), pulled Depakote Delayed Release 250 mg (milligram) blister pack out of the medication cart and verified the order and medication on hand. Staff L placed one tablet in a clear plastic sleeve, crushed the medication, and placed the crushed medication into a plastic medication cup. Staff L proceeded to prepare Citalopram Hydrobromide 10 mg and Metoprolol 25 mg, crushed the medications individually and placed them in separate medication cups. Staff L stated to review how many milliliters of water each medication should be mixed with. When asked to review Depakote delayed release medication order one more time, Staff L stated, It says delayed release. We should not be crushing this medication, but that is what the order reads. I guess I can ask my DON [Director of Nursing] for clarification. Staff L walked to the DON's office. The DON was not available in her office. Staff L returned to the unit and asked Staff E, License Practical Nurse (LPN), about the medication. Staff E stated a delayed release medication could not be administered via gastric tube and would contact the doctor for clarifications. Review of Resident #180's physician order dated 7/27/2023 reads, Depakote Oral Tablet Delayed Release 250 mg, give 3 tablet enterally three times a day for mood disorder. Review of Resident #180's physician order dated 7/26/2023 reads, Nothing by mouth diet, nothing by mouth texture, nothing by mouth consistency, for nutrition. Review of Resident #180's Medication Administration Record (MAR) for July 2023 revealed staff initials for administration of Depakote Oral Tablet Delayed Release 250 mg on 7/27/2023, 7/28/2023, 7/29/2023, 7/30/2023, 7/31/2023 at 9:00 AM, 1:00 PM and 5:00 PM Review of Resident #180's MAR for August 2023 reads revealed staff initials for administration of Depakote Oral Tablet Delayed Release 250 mg on 8/1/2023 at 9:00 AM, 1:00 PM and 5:00 PM. During an interview on 8/2/2023 at 10:43 AM, the Attending Physician A stated, Depakote delayed release should not be crushed. I was not notified prior to today that the order was incorrect. The medication should not be crushed because it is supposed to be released along some time. What will happen is that the resident will have a higher dose in a short period of time, but it will wear out in a short period of time. The facility will need to check levels. I have an order in place for the levels to be checked this upcoming Monday to make sure of the resident's therapeutic level. I do not see any potential harm since it takes time to build a steady level. It will not be immediately. I would not have a devastating consequence. The medication is not for seizures, but due to behavior. During an interview on 8/2/2023 at 11:04 AM, Staff E, LPN, stated, If I gave it, I probably gave it as ordered. Delayed release medication should not be usually crushed. I had not realized the medication was extended release until today when you and [Staff L's name] approached me. I kind of float all over the building and it is hard for me to keep up. When I am going to administer medication, I read the order and double check the route and dose. I missed that. I crushed the Depakote and put it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 7 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0684 through his tube. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/2/2023 at 11:57 AM, Staff G, LPN, stated, I do not recall. I do not know of any other way I would have administered medication other than [Resident #180's name] gastric tube. Honestly, I did not realize the Depakote was delayed release. I would have called the doctor since the resident is NPO [Nothing by Mouth] and had the doctor change it to something else. Residents Affected - Few During an interview on 8/2/2023 at 12:01 PM, Staff H, LPN, stated, I administered the medication via g-tube [gastric tube]. I did not realize the order was delayed released since I gave it via g-tube. I would have called the doctor to clarify and get it changed to something crushable. During an interview on 8/2/2023 at 1:24 PM, the Director of Nursing (DON) stated, I would have expected staff to call the doctor and get the medication changed to something that is not extended release and can be administered via gastric tube. [Resident #180's name] is NPO. During an interview on 8/2/2023 at 4:57 PM, Staff F, LPN, stated, I crushed and administered via [Resident #180's name] gastric tube. Next time, I will call the doctor and get clarification on the orders. Review of the facility policy and procedure titled Medication Administration Via Enteral Feeding Tube last reviewed on 1/17/2023 reads, Policy: Medications shall be prepared and administered according to the following established guidelines . Residents with enteral tubes should be provided liquid medications whenever possible to prevent buildup of residue within the tube inner lumen. Procedure . Common Medications Not to Crush: Some medications and dosage form should not be crushed. If there are any questions regarding the crushing of medications, call the pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 8 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 4 residents reviewed for respiratory services, Residents #26, #30, and #35 (Photographic evidence obtained). Residents Affected - Few Findings include: 1. During an observation on 7/31/2023 at 12:10 PM, Resident #26 was lying in bed, with the nebulizer mouthpiece on top of the drawer with no bag. There were vials of Albuterol next to the mouthpiece, and the oxygen tank tubing was dated 04/09. During an observation on 8/1/2023 at 8:32 AM, Resident #26 was lying in bed, with the nebulizer mouthpiece on top of the drawer with no bag. There were vials of Albuterol next to the mouthpiece, and the oxygen tank tubing was dated 04/09. During an observation on 8/2/2023 at 7:34 AM with Staff I, License Practical Nurse (LPN), Resident #26 was resting in bed with her eyes closed. The nebulizer mouthpiece was on top of the drawer with no bag. There were vials of albuterol next to the mouthpiece. The nebulizer mask was on top of the chair with no date on tubing or bag. The oxygen tubing connected to the oxygen tank attached to the wheelchair was dated 4/9/2023. During an interview on 8/2/2023 at 7:38 AM, Staff I, LPN, stated, Tubing should be changed every week by night shift. Tubing and mask should be bagged when not in use. Review of Resident #26's physician order dated 4/7/2023 reads, Continuous O2 [oxygen] at 3 L/MIN [liters per minute] via NC [Nasal Cannula] q [every] shift every shift. Review of Resident #26's physician order dated 4/18/2023 reads, Check oxygen saturations Q shift every shift. Review of Resident #26's physician order dated 6/7/2023 reads, Albuterol Sulfate (2.5 MCG/3 ML) [2.5 microgram per 3 milliliters] 0.083% Nebulization Solution, 3 ml inhale orally via nebulizer every 8 hours and as needed for COPD [Chronic Obstructive Pulmonary Disease]. Review of Resident #26's physician orders revealed no orders for tubing change. 2. During an observation on 7/31/2023 at 10:26 AM, Resident #30 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. During an observation on 8/1/2023 at 8:00 AM, Resident #30 was lying in bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. Review of Resident #30's physician order dated 1/19/2023 reads, Continuous O2 at 2 L/MIN via NC q shift. During an interview on 8/2/2023 at 7:44 AM, the Director of Nursing stated, Oxygen tubing should be changed weekly, and equipment should be stored in a bag when not in use. Staff are expected to follow physician orders and verify flow rates unless resident is prn [as needed] or has orders to wean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 9 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. During an observation on 7/31/2023 at 10:27 AM, Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Oxygen tubing was not dated. During an observation on 8/2/2023 at 6:05 AM with Staff K, Registered Nurse (RN), Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Oxygen tubing was not dated. During an interview on 8/2/2023 at 6:07 AM, Staff K, RN, stated, [Resident #35's name] oxygen is supposed to be running at 2 liters per minute not at 3 liters and tubing should be dated. Review of Resident #35's physician order dated 7/27/2023 reads, Continuous O2 at 2 L/MIN via NC q shift. Review of the facility policy and procedures titled Oxygen Administration last reviewed on 1/17/2023 reads, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 3. Assemble the equipment and supplies as need . 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 10 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 3 reviewed medication carts, and failed to ensure the medications were not unattended (Photographic evidence obtained). Findings include: During an observation on 7/31/2023 at 9:00 AM, there was a bag on the floor in the conference room, which contained four unopened normal saline syringes. During an interview on 7/31/2023 at 9:15 AM, the Director of Nursing (DON) stated, We had an IV [intravenous] class for nurses that is why it was there. During an observation of North Wing Medication Cart on 7/31/2023 at 9:30 AM with Staff A, License Practical Nurse (LPN), there were one opened Advair with opened date of 5/14/2023, three opened bottles of Latanoprost with no opened date, and one opened Lantus insulin pen with no opened or expiration date. During an interview on 7/31/2023 at 9:37 AM, Staff A, LPN, stated, Upon opening medication, we should label it with an open and expiration date, and if medication is expired, it should come off the cart and it should be reordered. During an observation of [NAME] Wing Medication Cart on 7/31/2023 at 9:41 AM with Staff B, LPN, there were two opened bottles of Artificial Tears eye drops with opened dates of 6/25/2023, and two opened bottles of Artificial Tears eye drop with opened dates of 6/20/2023. During an interview on 7/31/2023 at 9:47 AM, Staff B, LPN, stated, Once expired, medication should be taken out of the cart. During an observation of East Wing Medication Cart on 7/31/2023 at 9:50 AM with Staff C, LPN, there were two opened bottles of Artificial Tears eye drops with no opened dates. During an interview on 7/31/2023 at 9:55 AM, Staff C, LPN, stated, Once medication is opened, the bottle should be labeled with an open date. The staff wrote the actual expiration of the medication. I think eye drops are good for 90 days after opening them. During an observation of Resident #13's room on 7/31/2023 at 9:58 AM, there was a tube of Zinc Oxide ointment on top of the drawer. During an observation Resident #26's room on 7/31/2023 at 10:26 AM, there were vials of Albuterol Sulfate Inhalation Solution on top of the drawer next to the nebulizer mouthpiece. During an interview on 8/2/2023 at 7:34 AM, Staff I, LPN, stated, [Resident #26's name] should not have any Albuterol vials in her room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 11 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 8/2/2023 at 7:40 AM, the Director of Nursing stated, There should not be any expired medications in the medication carts. Anything that is open should be labeled. We administer [Resident #13's name] medication for her. The ointment should not have been in her room. [Resident #26's name] does not have a self-administration order. The staff would do a self-administration assessment making sure resident is able to administer the medication. We would provide a lock box for medication storage in room. Review of the facility policy and procedures titled Medication/Biological Storage last reviewed on 1/17/2023 reads, Policy: It will be the policy of this facility to store medications, drugs and biologicals, in a safe, secure and orderly manner. Procedure . 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 12 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy and procedure review, the facility failed to ensure foods in the refrigerator and storage area of the kitchen were dated and/or labeled, and failed to ensure the expired or outdated foods were discarded. Findings include: During an initial walk-through of the kitchen on 7/31/2023 at 9:17 AM with the Dietary Manager (DM), there were eight containers of cranberry juice cocktail with a manufacturer stamped expiration date of 7/18/23 on the shelves in the stock room; a container of sour cream with a manufacturer used by date of 7/23/23 in the reach-in cooler; an unidentified Styrofoam hinged container with no label or date in the walk-in cooler; and a large container of red potatoes, a large container of sauce, and a large container of sliced ham with no label identifying the contents and a date of 7/27/23 on the lid. During an interview on 7/31/2023 at 9:29 AM, the DM stated that the cranberry juice cocktail was expired and should have been pulled and discarded on 7/18/2023, the sour cream container showed an expiration date of 7/23/23 and should have been discarded on that date, the hinged Styrofoam container should have been labeled with the contents and dated, and the containers of potatoes, sauce, and ham should have had identifying labels as well as the date to show when the item was prepared and a use by date. Review of the facility policy and procedures titled Receiving with the last review date of 7/19/2023 reads, Policy Statement: It is the center policy that safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Action Steps . 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 13 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 4. Review of Resident #61's shower task record for July 2023 reads, Task: Resident shower days are on Monday-Wednesday-Friday on 7-3 with assist of 1 and shower chair between the hours of 7 am and 8 am. Review of the calendar showed no entries documented for Friday 7/14/2023, Monday 7/17/2023, Friday 7/21/2023, and Wednesday 7/26/2023. During an interview on 8/2/2023 at 2:20 PM, the DON stated, My expectation is for the staff to document on the shower task sheet each time they give a shower or when the resident refuses. During an interview on 8/3/2023 at 8:03 AM, Staff J, CNA, stated, When it shows on the task list that a resident is due a shower, we mark on the list on the computer that we give it or that they have refused. We also document any PRN [as needed] showers on the list. Review of the facility policy and procedures titled Charting and Documentation with last review date of 1/17/2023, reads, Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. 3. Review of Resident #182's bladder continence task record from 7/14/2023 through 7/31/2023 reads, Task: Bladder Continence: Resident is incontinent of bladder and requires assistance of 1 for all per care. Review of the calendar showed no entries documented for 7/24/2023 and 7/25/2023. During an interview on 8/1/2023 at 11:30 AM, the DON stated that her expectations was for the staff to chart in the task area when changing an incontinent resident, and staff were expected to accurately document and only document when they performed the task. During an interview on 8/1/2023 at 1:55 PM, Staff D, Certified Nursing Assistant (CNA), stated, We check incontinent residents every 2 hours, and it is an error of data input as I don't put it in the computer every time. Review of the facility policy and procedure titled Perineal/Incontinent Care last reviewed on 7/17/2023 reads, Procedure . 8. Document completion of care rendered as is appropriate or required to demonstrate needs of resident have been met. Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 4 of 15 residents reviewed, Residents #42, #229, #61, and #182. Findings include: 1. Review of Resident #42's physician order dated 7/6/2023 reads, Weight resident daily on 11-7 shift. Notify MD [Medical Doctor] for 3 lbs [pounds] weight gain in 24 hours or 5 lbs weight gain in 1 week. every night shift for prophylaxis. Review of Resident #42's Treatment Administration Record (TAR) for July 2023 revealed no weights recorded for 7/6/2023, 7/10/2023, 7/15/2023, 7/23/2023, 7/24/2023, and 7/25/2023, and NA [Not Applicable] recorded for 7/7/2023, 7/8/2023, 7/9/2023, 7/12/2023, 7/17/2023, 7/21/2023 and 7/22/2023. Review of Resident #42's Weight and Vital Summary reads, 7/7/2023: 260 lbs, 7/12/2023: 259 lbs, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 14 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm 7/15/2023: 262 lbs, 7/17/2023: 261.7 lbs, 7/19/2023: 260 lbs, 7/20/2023: 258.4 lbs, 7/27/2023: 261 lbs, 7/31/2023: 259.6 lbs. Review of Resident #42's care plan revised on 6/28/2023 reads, Interventions . Provide diet as ordered. Observe for compliance with diet. Weights as scheduled. Residents Affected - Few During an interview on 8/1/2023 at 1:29 PM, the Director of Nursing (DON) stated, [Resident #42's name] has some refusals and some weights documented. The empty spaces on the treatment record mean staff are not documenting the weights in the system like they should be. 2. During an observation of Staff E, Licensed Practical Nurse (LPN), and Staff F, LPN, providing wound care for Resident #229 on 8/2/2023 at 4:25 PM, Staff E washed her hands and proceeded to place barrier under the resident's legs. Resident #229's right leg had a gauze dressing dated 8/2/2022. Staff E performed wound care on the resident's right leg. During an interview on 8/2/2023 at 4:26 PM, Staff E, LPN, stated [Resident #229's name] wounds are all located in his right leg. Review of Resident #229's physician order dated 7/26/2023 reads, Cleanse left shin with ns [normal saline], pat dry, apply xeroform, abd [abdominal] and wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's physician order dated 8/1/2023 reads, Cleanse left heel with ns, pat dry, apply betadine and leave open to air every evening shift for wound healing . Cleanse top of left foot with ns, pat dry, apply Santyl and medihoney and cover/wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's Healing Partners Wound Assessment Report dated 7/28/2023 reads, Location: right heel, Etiology: Pressure, Stage/Severity: Unstageable . Location: right foot, Etiology: Pressure, Stage/Severity: Stage 3. During an interview on 8/3/2023 at 9:15 AM, the Regional Nursing Consultant stated, I will review [Resident #229's name] record and see. Sometimes it can get confusing, the labeling of side. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 15 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards to help prevent the possible development and transmission of communicable diseases and infections during wound care for 1 of 2 residents reviewed for pressure ulcers, Resident #229. Residents Affected - Few Findings include: During an observation of Staff E, Licensed Practical Nurse (LPN), and Staff F, LPN, providing wound care for Resident #229 on 8/2/2023 at 4:25 PM, Staff E washed her hands and proceeded to place barrier under the resident's legs. The resident's right leg had a gauze dressing dated 8/2/2022. Staff E removed the old dressing and placed the resident's leg on top of the barrier. Staff F handed Staff E a sterile saline wipe. Staff E used the wipe to clean the right shin without washing her hands. Staff F handed Staff E a 4x4 gauze. Without performing hand hygiene or changing gloves, Staff E patted dry the area. Staff E applied xeroform to the right shin, covered it with an abdominal pad and wrapped the right shin area with kerlix gauze. Staff E removed her gloves and washed her hands with soap and water. Staff E donned gloves and Staff F handed a sterile saline wipe. Staff E lifted the resident's right leg and cleaned the right heel open wound with wipe. Staff E did not perform hand hygiene and patted dry the right heel. Staff E did not change the contaminated barrier. Staff E placed the resident's clean open heel wound back down on the contaminated barrier. The barrier had blood stains where the heel wound had been placed before cleaning. Staff F handed Staff E betadine. Staff E lifted the resident's right foot, applied betadine to the right heel wound, and returned the right heel back down on the contaminated barrier. Staff E removed her gloves and washed her hands. Staff F handed Staff E a sterile saline wipe. Staff E cleaned the resident's top of right foot wound. Staff E did not perform hand hygiene. Staff E patted dry the area. Staff E removed her gloves and performed hand hygiene. Staff E donned her gloves and washed her hands. Staff F handed Santyl to Staff E, and Staff E applied it to the right foot wound. Staff F applied medihoney to abdominal pad and Staff E placed it on top of the resident's foot wound. Staff E wrapped the resident's right foot wound with kerlix gauze. During an interview on 8/2/2023 at 4:54 PM, Staff E, LPN, stated, I thought I had washed my hands. I do not recall if I did or not. I should have changed the barrier once I cleaned the heel wound before placing the foot back down. During an interview on 8/2/2023 at 4:54 PM, Staff F, LPN, stated, I am not sure if [Staff E's name] washed her hands since I was standing on the other side. We should have washed our hands three times instead of just two times. We skipped the step. The barrier should have been changed once it was contaminated before putting the foot back down after it was cleaned. Review of Resident #229's physician order dated 7/26/2023 reads, Cleanse left shin with ns [normal saline], pat dry, apply xeroform, abd [abdominal] and wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's physician order dated 8/1/2023 reads, Cleanse left heel with ns, pat dry, apply betadine and leave open to air every evening shift for wound healing . Cleanse top of left foot with ns, pat dry, apply Santyl and medihoney and cover/wrap with kerlix daily every evening shift for wound healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 16 of 17 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/3/2023 at 8:55 AM, the Director of Nursing (DON) stated, The staff should not have placed clean foot back down on the barrier. They should have washed their hands in between wound care steps. Review of the facility policy and procedures titled Wound Care with the last review date of 1/17/2023 reads, Procedure . 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. Review of document presented by the facility titled Non-Sterile Dressing Change Aduit reads, Procedure . Preform Treatment According to Orders: Put on clean gloves, Remove dirty dressing and place in plastic bag (unless infection is present or saturated w/ [with] blood then place in red bag), Place dirty scissors on established barrier separate from existing clean field, Remove gloves, Place soiled gloves in plastic bag, Wash hands, Prepare supplies (open dressing, etc.), Put on clean gloves, Measure wound, Clean from inner edge to outer, Remove gloves, Place soiled gloves in plastic bag, Wash hands, Put on clean gloves, Apply medication and dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105621 If continuation sheet Page 17 of 17