Inspection·October 4, 2023

F 0644 part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/03/23 at 3:30 p.m., the Director of Nursing (DON) stated, when a Resident gets a new psych diagnosis the Resident should be submitted for a level II PASRR review. The DON reviewed and confirmed the five PASRR's were not correct for Residents' #7, #16, #25, #40 and #41 and stated those Residents should have been submitted for a level II PASRR review upon being diagnosed with a new psych diagnosis. Residents Affected - Some Review of the facility's Policies and Procedures titled, Preadmission Screening and Resident Review (PASRR), dated 11/08/2021 showed 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical record and any recommendations for service will be followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 interviews and record review the facility failed to ensure five residents (Residents #10, #12, #18, #23 and #43) of 14 residents reviewed for Pre-admission Screening and Resident Review (PASRR) had a level I completed prior to admission and two residents (Residents #7 and #40) of 14 residents had a level I PASRR completed by an appropriate and authorized staff member. Residents Affected - Some Findings included: Review of Resident #10's admission record showed Resident #10 was admitted to the facility on [DATE] with diagnoses of displaced interochanteric fracture of right femur, subsequent for closed fracture with routine healing, Iron deficiency, lack of coordination and abnormalities of gait and mobility. There was no PASRR available to review in Resident #10's medical chart. Review of Resident #12's admission record showed Resident #12 was admitted to the facility on [DATE] with diagnoses of psychotic disorder with delusions due to know physiological condition, major depressive disorder, recurrent, unspecified, generalize anxiety disorder and post Traumatic Stress Disorder, chronic. There was no PASRR available to review in Resident #12's medical chart. Review of Resident #18's admission record showed Resident #18 was admitted to the facility on [DATE] and then re-admitted to the facility on [DATE] with diagnoses of anxiety disorder, unspecified, major depressive disorder, recurrent, moderate and unspecified dementia, severe without behavioral disturbance. There was no PASRR available to review in Resident #18's medical chart. Review of Resident #23's admission record showed Resident #23 was admitted to the facility on [DATE] and then re-admitted to the facility on [DATE] with diagnoses of anxiety disorder, unspecified and insomnia. There was no PASRR available to review in Resident #23's medical chart. Review of Resident #43's admission record showed Resident #43 was admitted to the facility on [DATE] with diagnoses of traumatic hemorrhage of the cerebrum, unspecified without loss of consciousness and bipolar disorder, unspecified. There was no PASRR available to review in Resident #43's medical chart. During an interview on 10/03/23 at 4:07 p.m., the Director of Nursing (DON) stated that if there was no PASRR in the hard copy medical chart then there was not a PASRR available. The DON reviewed Residents #10, #12, #18, #23 and #43 medical charts and confirmed there were no PASRRs available for review. Review of Resident #7's admission record showed Resident #7 was re-admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, recurrent, moderate. The level I PASRR dated 08/30/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Review of Resident #40's admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, recurrent, unspecified, Anxiety disorder, unspecified and Vascular Dementia, severe, with mood disturbances. The level I PASRR dated 07/21/23 showed in Section I part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 - Some During an interview on 10/03/23 at 3:30 p.m., the Director of Nursing (DON) stated when a Resident gets a new psych diagnosis the Resident should be submitted for a level II review. The DON stated that she had never completed a PASRR in the facility because she had never been given access to the system and allowed to complete PASRR. The DON stated the previous Nursing Home Administrator (pNHA) always completed them because the pNHA was the only person in the facility who had access to the PASRR system. The DON reviewed Resident #7's PASRR dated 08/30/23 and Resident #40's PASRR dated 07/21/23 and confirmed both were not correct and Resident #7 and #40 should have been submitted for a level II review. During the review of Resident #7 and #40's PASRRs the DON noticed the PASRRs were electronically signed with the DON's name and credentials. The DON shook her head no and again stated she never had access to the PASRR system and these PASRRs had been signed falsely. The DON stated she never discussed with anyone information about these two PASRRs and these PASRRs had been signed with her name and credentials without her permission and her knowledge. During an interview on 10/03/2023 at approximately 3:50 p.m., the DON called the Social Service Director (SSD) on the phone for a phone interview. While on speaker phone with the survey team the SSD stated the only person in the facility who had completed any PASRR was the previous NHA (pNHA) and no PASRR was needed to be completed since the pNHA left in September 2023. The SSD confirmed all PASRRs were completed in the state portal and that only the pNHA had ever had access to that portal. Review of the Kepro FL [Florida] PASRR Provider Portal Frequently Asked Questions (FAQ) website on 10/03/23 (https://floridapasarr.kepro.com) Level 1 Review showed Who is able to complete a Level I screening? Anyone who works for a hospital or nursing facility and holds the following credentials: Masters of Social Work, or license in the State of Florida as a Clinical Social Worker (LCSW), Mental Health Counselor (LMHC), Physician (MD/DO), Physician Assistant (PA), Registered Nurse (RN), or Psychologist. During an interview on 10/03/2023 at 4:20 p.m., the previous Nursing Home Administrator (pNHA) stated she had worked for the facility for two years prior to leaving on 09/08/2023. The pNHA stated most of the time PASRRs did not need to be completed at the facility as most residents came to the facility with the PASRRs completed by the hospital prior to admission to the facility. The pNHA stated she was the only staff member in the facility that had access to the PASRR portal in Kepro. The pNHA stated she only remembered a couple of PASRRs she had to complete because the Residents did not come with a PASARR. The pNHA stated she remembered both she and the DON sat down and completed the PASARR together but the pNHA had to submit the PASARR as the DON did not have access to the PASRR online system. The pNHA stated when signing the PASRR electronically it was submitted by just typing the name down and submitting the form. During an interview on 10/03/23 at 4:35 p.m., The DON stated,No, I never did any PASRRs with [name of previous Nursing Home Administrator] The DON stated I never talked about any PASRRs with the pNHA and never sat down with her. The pNHA was the only person with access to the PASRR system and the pNHA signed my name falsely without my permission and without my knowledge. Review of the facility's policy Preadmission Screening and Resident Review (PASRR) dated 11/08/2021 showed 1. It is the responsibility of the center to assess and assure the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain results. 5. Results of the screening evaluation will be placed in the appropriate section of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 individual's medical record and any recommendations for service will be followed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 - Many Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure interventions in the comprehensive care plan were implemented for eight residents (#27, #7, #8, #10, #29, #31, #37, and #41) out of nine residents sampled for anticoagulant medications. Findings included: Review of admission records showed Resident #27 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). The resident had a care plan in place for Anticoagulant Therapy, dated 2/16/21. Interaction/Approaches included Monitor labs as ordered, notify physician, and monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of orders for Resident #27 showed an order for Warfarin 6 milligram (mg) every evening for atrial fibrillation, with a start date of 6/12/23. Review of Resident #27's Medication Administration Record (MAR) showed the resident received Warfarin 6 mg every evening in September 2023 and October 2023 to date. Review of Resident #27's MAR and Treatment Administration (TAR) did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #7 was admitted on [DATE] with diagnoses including chronic atrial fibrillation. Review of orders showed Resident #7 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for atrial fibrillation. Start date 4/10/23. -Aspirin 81 mg. Give one tablet by mouth once daily for heart failure. Start date 4/10/23. Review of Resident #7's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 4/20/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #7's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #8 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 Review of orders showed Resident #8 had the following orders: Level of Harm - Minimal harm or potential for actual harm -Eliquis 2.5 mg. Give one tablet by via peg tube twice daily for atrial fibrillation. Start date 10/7/22. Residents Affected - Many Review of Resident #8's MAR showed the resident received Eliquis as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 11/25/19. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #8's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #10 was admitted on [DATE] with diagnoses including acute embolism and thrombosis of left popliteal vein and iron deficiency anemia secondary to blood loss. Review of orders showed Resident #10 had the following orders: -Eliquis 2.5 mg. Give one tablet by mouth twice daily for deep vein thrombosis prevention. Start date 10/7/22. Review of Resident #10's MAR showed the resident received Eliquis as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 1/27/22. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #10's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #29 was admitted on [DATE] with diagnoses including history of thrombophlebitis. Review of orders showed Resident #29 had the following orders: -Xarelto 20 mg. Give one tablet by mouth one daily for bilateral lower extremities thrombophlebitis. Start date: 12/26/22. Review of Resident #29's MAR showed the resident received Xarelto as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 1/4/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 Review of Resident #29's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #31 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). Residents Affected - Many Review of orders showed Resident #31 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for deep vein thrombosis. Start date 10/7/22. -Aspirin 81 mg. Give one tablet by mouth once daily for CAD clot prevention. Start date 11/19/21. Review of Resident #31's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 12/2/21. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #31's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #37 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and atherosclerotic heart disease of native coronary artery (CAD). Review of orders showed Resident #37 had the following orders: -Eliquis 5 mg. Give one tablet by mouth twice daily for deep vein thrombosis. Start date 5/3/23. Review of Resident #37's MAR showed the resident received Eliquis and Aspirin as ordered every day in September 2023 and October 2023 to date. The resident had a care plan in place for Anticoagulant Therapy, dated 5/17/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #37's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. Review of admission records showed Resident #41 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation. Review of orders showed Resident #41 had the following orders: -Xarelto 15 mg. Give one tablet by mouth once daily for atrial fibrillation. Start date: 7/6/23. Review of Resident #41's MAR showed the resident received Xarelto as ordered every day in September 2023 and October 2023 to date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 - Many The resident had a care plan in place for Anticoagulant Therapy, dated 7/18/23. Interaction/Approaches included monitor for signs of abnormal bleeding, bloody black stool, bruises, nose bleeds, blood urine and report to physician. Review of Resident #41's MAR and TAR did not reveal any documentation monitoring was in place for signs and symptoms of bleeding, bruising, bloody black stools, or blood in the urine. An interview was conducted on 10/3/23 with Staff A, Registered Nurse (RN.) Staff A, RN said they do not have side effect monitoring documentation for residents on anticoagulants. An interview was conducted on 10/4/23 at 10:01 a.m. with Staff B, RN. Staff B, RN said they do not have a flow sheet or monitoring to sign on specific to anticoagulant use or signs and symptoms of bleeding. An interview was conducted with the Director of Nursing (DON) on 10/4/23 at 9:57 a.m. The DON said there is not a flow sheet for nurses to monitor for signs and symptoms of bleeding for residents on anticoagulants. She confirmed there is no documentation for anticoagulants triggered on the MAR or TAR. The DON said she would have to check and see if it is noted on the right side of the order sheets. She was observed pulling out an order sheet and confirmed nothing is noted on the order sheet for the nurses to watch for signs and symptoms of bleeding related to anticoagulant use. The DON said there should be monitoring and documenting for signs and symptoms of bleeding for residents on anticoagulant therapy. Review of a facility policy titled Laboratory/Diagnostic Monitoring, dated 8/1/22, showed the following: Policy: Residents will have laboratory/diagnostic monitoring per physician order with documentation in the medical record. Procedure: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The licensed nurse will process test requisitions and arrange for tests per physician order. 3. The laboratory, diagnostic radiology provider, or other testing source will report will report test results to the facility. 4. The licensed nurse will notify the physician of abnormal and/or critical results with documentation in the medical record. 5. The licensed nurse will notify the resident and/or resident representative of abnormal and/or critical results with documentation in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a discharge care plan was in place, a discharge summary was completed, and post care discharge plans were documented for one resident (#45) out of 3 residents sampled for discharge. Findings Include: A review of the face sheet revealed Resident # 45 was admitted to the facility on [DATE], and was discharged on 7/14/2023, with diagnosis to include but not limited to Parkinson's disease, Alzheimer's disease, unspecified, Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified, chronic obstructive pulmonary disease, and major depressive disorder. A review of the medical record revealed no physician discharge order, no discharge summary, and no post care discharge plan was present for Resident #45's discharge on [DATE]. On 10/4/2023 at 3:22 PM., an interview was conducted with the Director of Nursing (DON). The DON said when she reviewed Resident #45 medical record, she found no discharge physician order and no documentation indicating a post-discharge plan, and discharge summary was completed. The DON said the normal process was a discharge summary should have been completed with all the Interdisciplinary Team, the nurse would write a discharge note and the physician would provide a discharge order to permit the resident to leave the facility. On 10/4/2023 at 3:43 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO said she do not have a discharge policy because she has not had a chance to update the policy for the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure laboratory results were completed as ordered and results were tracked for two residents (#27 and #9) out of 14 residents sampled. Residents Affected - Few Findings included: Review of orders for Resident #27 showed an order for Warfarin 6 milligram (mg) every evening for atrial fibrillation with a PT (Prothrombin time)/INR (International normalized ratio) lab to be drawn every Monday, with a start date of 6/12/23. PT measures how long it takes for a clot to form in a blood sample and INR is a calculation based on PT results. The PT/INR is used to monitor the effectiveness of the anticoagulant Warfarin. On 10/1/23 a review of Resident #27's lab results showed a PT/INR result dated 9/18/23 as high at 20.3 with a reference range of 9.6-12.2. The results for the next lab, due to be drawn on 9/25/23, could not be found. Review of admission records showed Resident #27 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery. The resident had a care plan in place for Anticoagulant Therapy, dated 2/16/21. Interaction/Approaches included Monitor labs as ordered and notify physician. Review of Resident #27's Medication Administration Record (MAR) showed the resident received Warfarin 6 mg every evening in September 2023 and October 2023 to date. Review of Resident #27's Treatment Administration Record (TAR) showed the PT/INR to be drawn on 9/25/23 was signed off as completed. Review of admission records showed Resident #9 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #9's orders showed the following: -Depakote Sprinkles 125 mg once a daily. 6/16/23 discharged [DATE]. -Depakote Sprinkles 125 mg three times a day. 9/22/23. -Depakote and Ammonia Levels every six months. September and March. 9/22/23 Review of Care plans for Resident #9 showed a plan in place for Seizure Disorder. Interactions/Approaches included monitor lab values per orders and report to physician. Review of the laboratory book showed the resident's Depakote level was drawn by the lab on 9/29/23. However, no results could be found in the medical record. An interview was conducted on 10/2/23 at 2:02 p.m. with the Director of Nursing (DON). The DON said she knows Resident #27's PT/INR was drawn on 9/25/23 because it was signed off in the lab book by the phlebotomist. (Lab book with phlebotomist initials observed). The DON reviewed the record as well (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 0770 Level of Harm - Minimal harm or potential for actual harm as several other locations and said she didn't know where the results were. She said she would contact the lab to get the results of the PT/INR. The DON was observed reviewing the medical record of Resident #9. She confirmed she could not find the results for the Depakote level drawn on 9/29/23. The DON said the lab book shows it was drawn but she doesn't know where the results are and confirmed she had not seen any results. Residents Affected - Few On 10/2/23 at 3:10 p.m. the DON provided a copy of the results of Resident #9's Depakote level drawn on 9/29/23. She said she had to call the lab and get them to send over the results. She stated the resident's Depakote level was low and she notified the doctor. Review of Resident #9's lab results showed the Depakote level (Valproic acid) was drawn on 9/29/23 and the results were reported on 9/29/23. The Valproic Acid level was low at 33.4 with a reference range of 50.0-100.0. The Valproic Acid lab measures the amount of anticonvulsant medication in the blood sample. On 10/2/23 at 3:50 p.m. the DON said she still did not have the results of Resident #27's PT/INR. She said the lab continues to only fax the results for her lab drawn on 9/18/23 and she didn't understand why. On 10/3/23 at 10:05 a.m. the DON confirmed she still does not have results for Resident #27's PT/INR from 9/25/23. A phone interview was conducted on 10/3/23 at 12:31 p.m. with the laboratory the facility uses for testing. The lab said all results are faxed to the facility since they do not use electronic charting. They said the PT/INR lab results are faxed first then all other labs follow. They also said the facility can login to the computer and see all lab results. The lab looked up Resident #27's record and said no lab was drawn on 9/25/23. An interview was conducted on 10/3/23 at 12:48 p.m. with the DON. When asked how the facility tracked labs to ensure they were completed and results returned she said they do not track that and added, we should. The DON said labs results are returned the same day they are drawn, typically on the 3:00-11:00 p.m. shift. The DON said if a nurse is administering Warfarin, they should make sure the lab results were ok. She confirmed the nurses continued to administer Warfarin to Resident #27 without having lab results to review. Staff A, Registered Nurse (RN) joined the interview. Staff A, RN said labs are drawn in the morning and it is usually passed down during nurse-to-nurse report at shift change since results typically come back on the 3:00-11:00 p.m. shift. The DON and Staff A, RN reviewed Resident #27's medical record and confirmed there was no documentation the resident had refused for the lab to be drawn. Neither the DON or Staff A, RN were aware no results had come back and agreed no one followed up with the lab to check on them. An interview was conducted on 10/3/23 at 12:52 p.m. with the Chief Nursing Officer (CNO). The CNO was notified of labs not being tracked to see if they were completed or if results came back. She stated, We will have to fix this. The CNO said the DON should take the lab book with her to every morning meeting to review what should have been completed the day prior. An interview was conducted on 10/3/23 at 3:56 p.m. with Resident #27's primary physician. He said he would have expected to have been notified if a lab had been missed and of abnormal lab results. Review of a facility policy titled Laboratory/Diagnostic Monitoring, dated 8/1/22, showed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 0770 following: Level of Harm - Minimal harm or potential for actual harm Policy: Residents Affected - Few Residents will have laboratory/diagnostic monitoring per physician order with documentation in the medical record. Procedure: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The licensed nurse will process test requisitions and arrange for tests per physician order. 3. The laboratory, diagnostic radiology provider, or other testing source will report will report test results to the facility. 4. The licensed nurse will notify the physician of abnormal and/or critical results with documentation in the medical record. 5. The licensed nurse will notify the resident and/or resident representative of abnormal and/or critical results with documentation in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure proper infection control practices related to handwashing, cleaning of reusable equipment, and washing of reusable water pitches in two of two resident halls. Residents Affected - Some Findings included: An observation was made on 10/1/23 at 9:18 a.m. of a bedpan sitting in a basket in the bathroom of Resident #7. The bedpan was uncovered, and wet washcloths were in the basket with it. Resident #7 said the bedpan had been sitting in her bathroom like that since she had to give a urine sample several days ago. (Photographic evidence obtained.) Review of admission records showed Resident #7 was admitted on [DATE] with diagnoses including urinary tract infection (UTI). Review of Resident #7's quarterly Minimum Data Set (MDS,) dated 7/14/23, Section C, Cognitive Patterns showed her Brief Interview for Mental Status (BIMS) score was 12, indicating she had moderately impaired cognition. Review of Resident #7's laboratory documents showed she had a urinalysis collected on 9/25/23. An interview was conducted on 10/4/23 at 3:25 p.m. with Staff A, Registered Nurse (RN.) She said Resident #7 uses the toilet in her room and she didn't know why the bedpan was there. She said it is possible the resident uses it at night. An interview was conducted on 10/4/23 at 2:22 p.m. with the Director of Nursing (DON.) She reviewed the photo of the bedpan in the bathroom of Resident #7. The DON confirmed the bedpan and used washcloths should not have been left in the bathroom. She said a straight catheter should have been used for the urine sample. An observation was made on 10/3/23 at 9:01 a.m. of Staff A, RN using a blood pressure cuff on two different residents during medication pass without cleaning the blood pressure cuff between residents. The blood pressure cuff was observed to be a wrist cuff that was made of a cloth material. The cloth was observed to have soiled spots on it. (Photographic evidence obtained.) During this same medication pass, Staff A, RN took a resident's blood pressure, returned to the cart without performing hand hygiene, gathered medications, realized a medication was not in the cart, called a provider from her cell phone, went to the medication room to access the emergency drug kit, signed out the medication, returned to the cart, then went to the resident room to administer medications. Throughout this process no hand hygiene was performed. An interview was conducted on 10/4/23 at 2:20 p.m. with Staff A, RN. Staff A, RN said the blood pressure cuff should be cleaned between each resident. She said she usually wipes it with the cleaning wipes in her cart. Staff A, RN confirmed the blood pressure cuff was cloth on the inside portion that touches the residents. She said you can't use sanitizer or anything liquid because the cuff will stay wet. She said the wipes work ok. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 An interview was conducted on 10/4/23 at 2:22 p.m. with the DON. The DON said the blood pressure cuffs should be cleaned between every resident. When asked about the wrist cuffs being used, she said those are the nurses' personal blood pressure cuffs, they do not belong to the facility. The DON looked at the blood pressure cuff and acknowledged the cloth could not be sanitized. The DON also confirmed staff should be performing proper hand hygiene every time they go in and out of a resident room. Residents Affected - Some An observation was made on 10/2/23 at 10:55 a.m. of a Certified Nursing Assistant (CNA) refilling resident's pink plastic water pitchers for the morning. The CNA was observed picking up a water pitcher from a resident's bedside table, dumping the water in the sink, taking it to a cooler in the hallway, filling it with ice and water, and she then returned it to the resident's tray table. The CNA did not wash the pitcher prior to refilling. The pitcher did not have a date or label on it. The CNA finished in one resident's room and proceeded to another resident's room to repeat the process without completing any hand hygiene. On 10/01/23 during an interview Resident #12 said the facility no longer uses Styrofoam cups and pointed to a pink plastic water pitcher on her bedside table, labeled with her room number and bed assigned. (Photographic evidence obtained) On 10/01/23 a Certified Nurse Assistant (CNA) was observed refilling pink plastic hydration pitchers and returning them to residents. On 10/02/23 CNAs were observed removing, sometimes rinsing in the bathroom sink, refilling, and returning pink plastic hydration pitcher to residents. On 10/03/23 during a random interview a CNA said that she rinses out the pink plastic hydration pitchers, refills and returns them to the residents. During an interview on 10/03/23 at 10:20 a.m., the Dietary Manager said most residents use Styrofoam cups and We do not have to wash for hydration the pink plastic hydration pitcher should be washed in the Dietary department after every use. During an interview on 10/03/23 at 10:25 a.m., Staff A, Dietary Assistant said, No, we don't wash those pink pitchers, I haven't seen them. During an interview on 10/03/23 at 10:30 a.m. with Staff C, CNA , about the pink plastic hydration pitcher said, When I fill them, I usually wash the pitcher out myself first and then refill. On 10/04/23 during a tour of the Laundry Department (LD) clean linen was observed in a room between the washing machines and the maintenance and housekeeping hallway with two doors propped open. (Photographic evidence obtained) On 10/04/23 at 02:38 p.m., during an interview the DON stated the process to wash the pink plastic hydration pitchers had not been determined prior to distributing to each resident and she had not observed the clean linen storage in the LD. A review of the facility's policy titled, Cleaning and Disinfecting of Resident Care Items and Equipment, dated 12/2008, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 Policy statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations, for disinfection and OSHA Bloodborne Pathogen Standard. Procedures to include: Residents Affected - Some 2) Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) use 3) Durable Medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4) Equipment that is designated reusable shall be used by more than one resident A review of the facility's policy titled Handwashing/ Hand Hygiene policy, revised April 2012, revealed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Procedures: 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact; i. Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse of blood pressure); v. After completing duty. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations: a. Before and after direct contact with residents; d. Before preparing or handling medications; g. After contact with a resident's intact skin; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to ensure the residents' medical records included documentation 1)indicating the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, and 2) the resident had received or had not received the immunization due to medical contraindications or refusal for five (# 7, #12, #37, #246 and #296) out of five resident for immunizations. Residents Affected - Some Findings included: A review of the facility's admission forms, provided to all new admissions, did not reveal influenza and pneumococcal immunization education, or consents related to vaccines. A review of the medical records for Residents #7, #12, #37, #246, and #296 revealed no documentation indicating 1) the resident or the resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, or 2) the resident had received or had not received the immunizations due to medical contraindications or refusal were located in the medical records. On 10/03/23 at 2:36 p.m. an interview was conducted with the Director of Nursing (DON), she stated vaccine status can be found in the admission section of the medical record. During a review of Resident # 12's medical record with the DON, she verified vaccine information was missing. The DON said she would check the Online Immunization Information System for documentation regarding immunizations for Residents #7, #12, #37, #246, and #296. On 10/04/23 at 1:00 p.m. the DON confirmed she did not find 2022 influenza vaccine or pneumonia vaccine documentation for Residents #7, #12, #37, #246, and #296. The facility did not provide a requested policy related to resident vaccines by the exit of the survey team on 10/4/23 at 4:45 p.m. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 17 of 17