Health inspection·December 1, 2022

F 0552 Level of Harm - Minimal harm or potential for actual harm RN indicated there was a nurse that worked in another part of the facility that spoke Spanish. They were asked if there was an interpreter service available at the facility for times when family might not be available or if they knew how to utilize an interpreter service. Each of the staff members indicated that they did not know if an interpreter service was available and that they had not been trained how to use one if it was available. Residents Affected - Few 11/30/22 at approximately 11:00 AM, an interview was conducted with the Social Services Director. She was asked to explain how they communicate with Resident #61. The Social Services Director indicated that she utilizes the resident's daughter and son to translate when needed. The Social Services Director mentioned communication words posed on the wall above the bed and indicated that the resident she can point to specific things to communicate. The director indicated that an interpreter service was previously available through the previous management company but she did not have information on what interpreter service was currently available. 1/30/22 at approximately 10:30 AM, an interview was conducted with the Director of Nursing (DON). She was asked to explain how staff adequately communicate with Resident #61. She explained that there is a communication board posted in the room. She also indicated that there had previously been a Spanish speaking nurse who worked with the resident. She explained that staff members utilize the Residents' family members to interpret. The surveyor notified the DON that observations revealed concerns in how some of the staff were communicating with the resident. Several nurses and staff had been asked how to communicate with Resident #61 if family members were not available. All of the staff members except social services were unable to explain the process for contacting or utilizing an interpreter service. The DON indicated that she would obtain the number for the interpreter service, get it posted and complete in-services for the nurses. A review of the facility's policy titled Translation and or Interpretation was conducted. The policy states when a staff member fluent in the patient's language is not available. Written and verbal translation is available 24 hours an day 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105727 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 105727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Rehabilitation and Nursing Center 879 Usery Road Chipley, FL 32428 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, staff interviews and record review, the facility failed to provide a palatable diet that took resident preferences and feedback into consideration for 9 of 20 residents sampled who consume meals from the facility (#s 6, 7, 8, 10, 27, 34, 55, 66, and 109). Residents Affected - Some The findings include: On 11/28/22 at approximately 12:01 PM, an interview was conducted with Resident #7 who stated, the food is horrible. An observation was made of the resident eating beans and macaroni and cheese from a plastic container. Resident #7 revealed her family brings food to her because the food at the facility is so horrible. On 11/29/22 at approximately 11:44 AM, Resident #7 revealed to the surveyor that she went to the kitchen and ordered a salad for lunch and further stated the salad consists of lettuce and tomatoes. On 11/29/22 at approximately 12:34 PM an observation was made of Staff B, Registered Nurse (RN) supervisor serve resident #7 lunch tray. The tray included the regular menu of meat balls and noodles. The resident refused the lunch tray and stated, I went to the kitchen and told the kitchen staff I wanted a salad for lunch. Observed Staff B remove the meal ticket from the tray and notified Resident #7 she would go to the kitchen to get her a salad, after she finished serving the trays to the other residents. On 11/28/22 at approximately 2:26 PM, resident #6 was interviewed regarding requesting alternate food choices. He indicated sometimes when he asks for an alternate the kitchen staff have an attitude. On 11/29/22 at approximately 8:44 AM, an interview was conducted with Resident #109 who stated, the food is horrible, it's like prison food. On 11/29/22 at approximately 12:22 PM, an observation was made of staff B, RN Supervisor, serving Resident #109 lunch tray. The resident stated when asked if that was what he wanted for lunch, there's nothing I can do about it. Staff B offered to get Resident #109 an alternative food choice, the resident stated, it doesn't matter. On 11/30/22 at approximately 9:21 AM, an follow-up interview was conducted with Resident #109 who stated breakfast was the same as always, with powdered eggs and blah. Resident #109 stated the staff do not offer him a choice of meals before the meal is served, and then stated he did not know there was an option for an alternate meal choice. Resident #109 then stated the food is not fit to eat, but he has to eat it. A review of Resident #109 record revealed the resident has a medical diagnosis to include Type II diabetes with an order for carbohydrate-controlled diet. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status, (BIMS) score of 10 which indicates moderate impairment. The care plan, with a problem start date of 7/1/22 indicated the resident is at risk for malnutrition related to the resident's disease processes. On 11/28/22 at approximately 3:28 PM, an interview was conducted with resident #10 who stated the food is not good. On 11/29/22 at approximately 12:28 PM an observation was made of Resident #10 sitting in her wheelchair in her room who stated she did not want to eat her lunch. The lunch tray was observed to be meatballs with noodles and carrots. On 11/30/22 at approximately 9:33 AM an observation was made of Resident #10 breakfast tray which was partially eaten. Resident #10 stated the food is not fit to eat and stated the staff do not offer an alternate meal. A review of Resident #10 record revealed the annual MDS dated [DATE] with a BIMS of 08 which indicates moderate impairment. The Care plan with a problem start date of 4/16/19 indicated the resident is at risk of malnutrition related to intake of less than 75% for most meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105727 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 105727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Rehabilitation and Nursing Center 879 Usery Road Chipley, FL 32428 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/28/22 at approximately 11:59 AM, an interview was conducted with Resident #8 who stated the food is terrible, but she just accepts the meals and either eats it or leaves it. On 11/30/22 at approximately 9:17 AM, a follow-up interview was conducted with Resident #8 who stated the staff do not ask for meal preference prior to serving the meal, they just bring the meal in. Resident #8 stated if she doesn't like the meal, she will pick what she can tolerate and leave the rest. The resident revealed the meals are getting worse and provided an example of Thanksgiving Day meal. The resident stated the lima beans were so hard she could not eat them. Resident #8 stated she has a refrigerator in her room, so she can keep food, condiments, etc. On 11/28/22 at approximately 2:00 PM, an interview was conducted with Resident #34, who's roommate stated the food is not very good. Resident #34 was asked if she liked the food, and the resident shook her head no. Review of the resident's medical record revealed the resident was non-verbal, but communicated by shaking her head yes or no. On 11/28/22 at approximately 10:16 AM, an observation was made of the menus posted on 3 North nursing unit, located across from the nurse's station. The menus posted were for Sunday breakfast, lunch, and dinner. An additional observation was made on 11/29/22 at approximately 11:44 AM, the menus posted were for Sunday breakfast, lunch, and dinner. Photographic evidence obtained. On 11/28/22 at approximately 03:27 PM, Resident #55 indicated that she was unsatisfied with the food served at the facility. She explained that residents had met and repeatedly requested fried chicken, they have not been served fried chicken. She explained that for the Thanksgiving meal they were served turkey with lima beans. She described the lima beans as being undercooked and hard. She also said that vegetables served were often either undercooked and hard or overcooked and mushy. She indicated that alternates served were often left overs from the last meal. She explained the residents have met and complained on numerous occasions; but have seen no improvement in food quality. On 11/29/22 at approximately 11:55 AM, an interview was conducted with Resident #66. He said: The food is never palatable. The food is either over cooked or under cooked. He had a case of canned food and a refrigerator in his room. He said: I have to stay stocked with my own food because I cannot eat the food here. It has gotten worse in recent months. We have complained but the food does not get any better. He was asked to specifically describe the issues with the food. He said: The food has a poor consistency and a poor temperature. On 11/29/22 at approximately 11:55 AM, Resident #27 said he also wanted to talk about the food. He had eaten cheerios, milk, and a banana provided by the facility for lunch. He said: I ask for cheerios all the time because I do not like the food here. I can eat cheerios. He was asked if he has requested food choices from the alternate menu. Resident #27 explained that the problem with the food is the way that it is cooked. He explained that alternate food choices were just as poorly cooked as the main menu items . On 11/29/22 at approximately 12:22 PM, an interview was conducted with Staff B, RN Supervisor who stated residents who get up can review the posted menus and then request an alternate food choice. She stated if the residents do not get up or go outside of their room the staff will review what is on the menu and will then notify the kitchen of the request. She confirmed she gets a lot of complaints related to food and stated she tells the dietary department when a resident complains or will notify the administrator depending on the complaints. She stated she was not aware the menus had not been changed since Sunday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105727 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 105727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Rehabilitation and Nursing Center 879 Usery Road Chipley, FL 32428 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/30/22 at approximately 9:00 AM, an interview was conducted with Staff A, CNA who stated residents who get up can review the menus and tell the staff what they want for lunch. Staff A revealed the requests must be to the dietary department by 10:00 AM so the dietary department can prepare the appropriate tray. She stated for the residents that do not get up, or leave their rooms, the staff will go to the resident and let them know what is on the menu, then will submit the request to the kitchen. Staff A, CNA stated, the kitchen does not always respond, and the residents don't always get the requested tray. Staff A, CNA revealed the kitchen staff is usually the problem with getting the correct trays to the resident. A follow up interview was conducted on 11/30/22 at approximately 12:48 PM, with Staff A who stated, the kitchen sucks, and stated the kitchen staff are rude and get mad if the CNA's go to the kitchen for alternates. Staff A, CNA stated residents don't always get silverware or the right specialized plates, such as a lip plate. Staff A revealed there are a lot of food complaints and stated, the food is so bad, I wouldn't feed it to a dog. On 11/30/22 at approximately 11:29 AM, an interview was conducted with the Registered Dietician, (RD) who revealed she splits management of the kitchen with the Certified Dietary Manager (CDM). She revealed she is typically at the facility 3 days per week, and the CDM comes in 2 days per week. The RD stated the menus are on a 4-week rotation cycle and the menu is changed every 6 months. The RD revealed the facility has a resident food council, and the residents voice what they like and don't like. The RD stated meal preferences are obtained on admission and quarterly and are entered in the meal tracker system and further stated preferences change more frequently for residents who are alert and oriented. The RD stated the process for the residents to get an alternate meal is for the resident to tell the CNA and the CNA would go to the kitchen and ask for a tray. She stated the kitchen staff may need to finish a tray line prior to fixing the requested tray, and then the dietary staff would send it to the floor. The RD stated the kitchen manager and herself follow up on the grievances, and indicated if the resident grievance is not specific, such as a complaint that the food sucks she can't do much with the complaint and stated, I eat the food and it doesn't suck. She stated if the grievance can be fixed, it will be fixed on the spot. She stated if it is fixed immediately, she does not complete a grievance or document the complaint and stated if it is a complaint such as I always get what is on my dislike list, she will write a grievance and will work to resolve the complaint. The RD stated the dialysis patients have a liberalized diet which is supported by the literature for residents in a long-term setting, and she tries to teach them it is ok to eat the diet provided. She stated she coordinates with the dietician at the dialysis center. The RD was told the residents had complaints of food not cooked well, and she stated, I don't doubt there are complaints of food. She was told the beans were hard, and not fully cooked on Thanksgiving and the biscuit was so hard the resident could not eat it. She stated when there is a complaint of how the food is cooked if it is reported when it happens, she would look at trays and remove items that were not good and substitute for something else and stated they would just fix it on the spot and keep the line moving. She stated they do try to accommodate the requests and stated the kitchen staff try to accommodate the residents and stated she really advocates for the kitchen staff because they try hard. She confirmed the menus on the units are changed daily and confirmed the menus on 3 North were not changed. A follow up interview was conducted with the RD on 12/1/22 at approximately 10:13 AM who stated she is at the facility most of the time and primarily runs the kitchen and indicated the CDM is at the facility 1-2 days per week. The RD stated she is part of the QAPI team and discusses weights primarily and confirmed she follows up with each complaint. The RD stated the facility has had a hard time getting a CDM and stated they have had 3 in the last year. The RD stated the kitchen staff can be gruff with the staff and stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105727 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 105727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Rehabilitation and Nursing Center 879 Usery Road Chipley, FL 32428 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 0804 she might be gruff sometimes as well. Level of Harm - Minimal harm or potential for actual harm On 11/30/22 at approximately 10:45 AM, staff member C, LPN, was interviewed. She indicated nursing staff advocate for the residents and their choices of alternate meals, however the dietary staff can be difficult to deal with. Residents Affected - Some On 12/1/22 at approximately 10:26 AM, a telephone interview was conducted with the facility CDM who confirmed he is at the facility 2 times per week and stated he covers 4 other facilities. The CDM confirmed the RD focuses more on clinical issues and the CDM is more operational and confirmed the facility has a dietary manager. The CDM revealed the residents give suggestions for menu items, but the kitchen staff follow the agreed upon 4-week menu cycle and stated they will work to give what the residents want as long as the RD signs off and it meets nutritional standards. The CDM revealed the residents prefer fried chicken over baked and stated fried chicken was on the menu for today. The CDM stated the residents will notify the CNA's when they want the alternate meal, the CNA would then go to the kitchen to get the meal. The CDM stated the dietary manager follows up on the food/dietary grievances and will then give the completed grievance to social services. The CDM confirmed that the dietary department does not track or trend grievances. On 12/1/22 at approximately 10:46 AM, an interview was conducted with Staff H, dietary manager who stated she is required to follow the menus and must stick to the budget and can only use the substitute menu if items do not come in on the truck. She stated the residents like fried chicken, but baked chicken is usually on the menu. She revealed she has discussed with the RD and CDM the requests made by the residents, but she is told she must follow the menus and confirmed the residents are not happy, but she must go by the menus. The dietary manager confirmed she follows up on the grievances by talking with the residents, then discusses with the social worker, who completes the grievance form, she then signs the form. A review of the Resident Council Minutes was completed, for the time period of January 2022 to October 2022, which revealed complaints related to food on 1/11/22, 2/3/22, 3/3/22, 4/7/22, 6/7/22, 8/4/22, and 10/16/22. A review of grievances from January 2022 to November 2022 revealed continued food complaints throughout the period. Two grievances were generated through the resident Council meeting on 1/11/22 and 8/4/22. Resident #79 filed a grievance related to food on 1/17/22, 5/2/22, 6/6/22. Resident #46 filed a grievance related to food on 5/2/22. Resident # 6 filed a grievance related to food on 5/2/22 and on 10/26/22. Resident #55 filed a grievance on 11/6/22. Additional grievances related to food were completed on 2/3/22, 4/7/22, 3 additional grievances on 5/2/22, 6/6/22, 6/7/22, 8/16/22, 8/29/22. All of the grievances reviewed were documented as resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105727 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 105727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Rehabilitation and Nursing Center 879 Usery Road Chipley, FL 32428 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 recorded review the facility failed to comply with the facility's infection control policy and procedure for instilling eye medications for 1 of 1 sampled residents. (Resident # 89) Residents Affected - Few The findings include: On 11/30/22 at approximately 2:11 PM, staff member D, Licensed Practical Nurse (LPN) was observed administering medications to resident # 89. The staff member proceeded to instill 1 drop of Prednisolone AC 1% eye medication into the resident's right and left eyes without wearing gloves. On 11/30/22 at approximately 4:00 PM, an interview was conducted with staff member D, LPN. She indicated she was aware she was to put on gloves before instilling eye drops but just forgot. A review of the facility's policy and procedure for Eye Drops dated 11/2001 revealed staff were to put on gloves prior to instilling eye drop medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105727 If continuation sheet Page 7 of 7