Inspection·August 15, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm sure, and confirmed that the resident and staff were not interviewed. When asked if there were any injuries to the resident, he again said that he was not sure and added that he would ask the ADON. When asked about the facility's abuse and neglect investigation and reporting policy, he stated that any allegation of abuse should be reported immediately within 2 hours. When asked if the allegation met the reporting requirements. He said that he would have to investigate. Residents Affected - Few On 8/15/23 at 12:50 pm, the Administrator returned and stated he had interviewed the staff that was assigned to the resident, and she confirmed that she did not change Resident #6 per facility protocol. The administrator confirmed that a thorough investigation was not conducted and mentioned that he had not filed an immediate report. On 8/15/23 at 1:00 pm, Residents #5 and #6 were observed in room [ROOM NUMBER]. They were both seated in a wheelchair. An interview was attempted with Resident #6, however; she could not answer any questions. A green Hoyer lift pad was observed behind her back. Her roommate (Resident #5) said, that is my sister and I watch out for her. She is [AGE] years older than me. When asked about the care, she stated that 90% of the time the care was good. She added that sometimes the call light response was not the best and she has to wait 45 min - 1 hour. She added that about a month or so ago she turned the light on about 3:00 pm and it was not answered until 3:30 pm. She mentioned that on that day, she had not seen her sister from 6:30 am to 3:30 pm. She stated that her sister goes to the dining area for all her meals, and she required assistance and therefore the night shift staff normally dress her and get her up by 7:00 am. She said that when the restorative CNA brought her sister back to the room she was soaking wet. She added that she made a grievance to the social services. She was informed that staff had been educated to check and change the resident's every 2 hours. On 8/15/23 at 1:12 pm, an interview was conducted with CNA A. She stated that she has been in the facility for about a year and works as a restorative aide, but assists the staff as needed. When asked if she provided care to Resident #6, she said, yes, then continued to state that the resident was on restorative program for range of motion and assistance with meal. She added that resident attended dining for all meals. When asked who provided care to residents on restorative program, she said that the CNAs are assigned to the residents and are responsible for the care but could assist as needed. Normally those that attend dining for all meals are supposed to be dressed and ready to go to the dining room by 7:30 am for breakfast, therefore the night shift staff normally get them up. When asked if Resident #6 had any concerns with getting up early, she said the resident normally does not talk much, she will only answer yes or no questions. She added that her roommate/sister is her advocate. She confirmed that she had answered a call light for Resident 5 (Resident's #6 roommate/ sister). She was very upset because the call light had been on for a while and was concerned because Resident #6 had not been changed from 6:30 am - 3:30 pm. She explained that she went and got Resident #6 from the nurses station. She then assisted the resident to bed with the assigned 3-11 CNA and the resident was soaking wet, urine had penetrated through her brief to her pant and the Hoyer lift pad that was under her had made an imprint to her buttocks. After cleaning the resident, she notified the social worker. She stated that the CNA who was assigned to the resident during the day (7:00 am -3:00 pm) had already left for day. On 8/15/23 at 1:35 pm, an interview was conducted with CNA B. When asked how she was made aware of the residents functional status, she said, at the beginning of each shift the off going staff give a report about the residents, and if something is not shared then I would check the resident's chart or ask the nurse. When asked if she was familiar with Resident #6's functional needs she said, yes, she is total dependent, requires a Hoyer lift with two staff assist for transfer and was incontinent for bowel and bladder. When asked about the incident reported on 6/13/23 related to Resident #6, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105756 If continuation sheet Page 2 of 5 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 105756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Hilliard 3756 W Third St Hilliard, FL 32046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm she stated that the resident was already up for the day when she got to the facility on that day. She added that the resident was also assigned to receive a shower and therefore she assumed that the shower team would change her. She confirmed that she did not check and change the resident during her shift. She said, I did not follow the facility protocol to check and change every 2 hours and I take accountability for not changing the resident and it will not happen again. Residents Affected - Few A review of the facility's policy and procedures tilted, Abuse & Neglect, reviewed on 11/21/22 revealed: Reporting Allegations: In response to allegations of abuse, neglect exploitation, or mistreatment the facility must: Ensure that all alleged violations involving abuse or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made. Report the result of the investigation to the administrator or his or her designated representative and to other officials in accordance with State Law, including to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105756 If continuation sheet Page 3 of 5 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 105756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Hilliard 3756 W Third St Hilliard, FL 32046 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 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and policy and procedure review, the facility failed to ensure that all alleged violations of neglect were thoroughly investigated. The facility failed to investigate staff failure to provide assistance with activities of daily living (ADL) for more than 8 hours for one (Resident #6) of three residents whose grievances were reviewed, from a resident sample of eight. Residents Affected - Few The findings include: A review of the facility's grievance log revealed a grievance dated 6/13/23 from Resident #5. Resident complained that her sister who was also her roommate (Resident #6) had not been checked and changed for over 8 hours from 6:30 am - 3:30 pm. On 6/14/23, the Assistant Director of Nursing (ADON) was assigned to investigate the concern. The investigation findings read, verified certified nursing Assistant (CNA) for that resident. The action taken included education for CNAs to check and change resident's every two hours. The grievance indicated that education was provided. (Photographic copy obtained) A review of the medical record for Resident #6 revealed an admission date of 4/12/21 with re-entry date of 6/22/23. Her diagnoses included metabolic encephalopathy, muscle weakness, difficulty walking, dementia, and adult failure to thrive. A review of Resident #6's Modification of Medicare 5-day minimum data set (MDS) assessment dated [DATE] revealed she had a brief interview for mental status (BIMS) score of 1 out of 15 points, indicating severe cognitive impairment. The resident required extensive assistance with one staff for bed mobility, eating and toileting and extensive assistance with two people for transfer. The assessment also indicated that the resident was at risk for skin breakdown. A review of Resident #6's care plan with a review date of 5/26/23, indicated that the resident had an ADL self-care performance deficit related to muscle weakness and difficulty walking, back pain due to L1 compression fracture, frequent falls, and failure to thrive. Interventions included total transfer assistance of two persons using a Hoyer lift, and extensive to total assistance with toilet use, restorative dining for all meals. (Copy obtained) On 8/15/23 at 10:45 am, an interview was conducted with the Social Services Assistant. She was asked about the facility's grievance investigation procedure. She said, anyone can complete a grievance for the resident. There are blue cards at all nursing stations. Once I receive the grievance, they are assigned to the department heads for investigation. The department heads are required to return the grievance form with the resolution within 72 hour (most of the times it less than that) to social services. Once the grievance has been resolved, she then verifies with the residents if they are contented with the resolution, then I take the card to the administrator to sign. When asked about the grievance for Resident #5, she said she was notified by the restorative aide that the resident was very upset because her roommate who was also her sister had not been changed and had been up in her wheelchair from 6:30 am to 3:30 pm. She explained that the ADON was assigned to investigate the allegation, it was verified, and staff education was conducted. When asked if an abuse/neglect report was conducted, she stated that the administrator was responsible for reporting. When asked about the condition of Resident #6 and other resident that were taken care of by the staff involved. She said, I'm not sure, will ask the ADON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105756 If continuation sheet Page 4 of 5 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 105756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Hilliard 3756 W Third St Hilliard, FL 32046 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/15/23 at 12:47 pm, an interview was conducted with the Administrator. He was asked about the grievance related to Resident #6. He stated the grievance was closed on 6/22/23. When asked about the findings, he said, staff were educated on check and change every 2 hours. He provided the in-service sign in sheet dated 6/16/23. When asked if the allegations were founded, he said that he was not sure, and confirmed that the resident and staff were not interviewed. When asked if there were any injuries to the resident, he again said that he was not sure and added that he would ask the ADON. When asked about the facility's abuse and neglect investigation and reporting policy, he stated that any allegation of abuse should be reported immediately within 2 hours. When asked if the allegation met the reporting requirements. He said that he would have to investigate. On 8/15/23 at 12:50 pm, the Administrator returned and stated he had interviewed the staff that was assigned to the resident, and she confirmed that she did not change Resident #6 per facility protocol. The administrator confirmed that a thorough investigation was not conducted and mentioned that he had not filed an immediate report. On 8/15/23 at 2:30 pm, a joint interview was conducted with the ADON and the administrator. The ADON confirmed that she was normally assigned to investigate grievances related to nursing services. When asked about the grievance on 6/13/23 related to Resident #6, she said that she conducted an in-service with staff on 6/16/23. When asked if she educated all the staff she said, no, only the staff that were on duty at that time. When asked if the resident had any injuries pertaining to the incident, she said that she did not conduct any skin assessment. She was then asked if there were any other residents that were affected, she said that she did not check or interview other residents assigned to the staff. The Administrator stated that the facility had initiated a PIP and all the grievances from June-August would be reviewed again to ensure that they were appropriately investigated/reported. A review of the facility's policy and procedures titled, Abuse - Conducting an Investigation, reviewed on 7/18/23 revealed: It is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. The facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in process; and take appropriate corrective action as a result of the investigation findings. Complaints and grievances will be investigated as outlined in the Concern & Comment (Grievance) program policy and will be reported immediately if the investigation reveals any alleged violation involving neglect, abuse (including injuries of unknown source) and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider, and as required by State Law. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105756 If continuation sheet Page 5 of 5