Inspection·January 29, 2026

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #8's care plan revealed Resident #8 has an impaired ability to self-feed related to rheumatoid arthritis and dementia as evidenced by dependence for personal care and functional limitations. A review of Resident #43's admission record revealed an admission date of 11/11/2022. A review of Resident #43's Minimum Data Set for functional abilities, dated 12/20/2025 revealed the resident is dependent, or requires the complete assistance of a helper, with eating. A review of Resident #43's care plan revealed the Resident #43 needs total care provided for all activities of daily living (ADL) needs. On 1/28/2026 at 1:20 pm, an interview was conducted with Staff G, CNA. Staff G, CNA stated food trays are passed out one by one. If a resident requires assistance the tray should be left on the cart until a staff member is available to assist the resident. Staff G, CNA said there are six residents in the 200 hall who need assistance with eating and there have been times when CNAs have to stand while assisting residents with eating because there are no additional chairs available. She stated the facility does not want CNAs to pull chairs from other rooms into resident rooms. If a chair is available, the CNAs will sit while helping. On 1/28/2026 at 1:29 pm, a follow up interview was conducted with Staff G, CNA. When asked if Resident #8 was assisted with eating, Staff G responded, the feeder?. Staff G stated she assisted Resident #8 with eating at the beginning of the meal service and forgot to remove the tray from the room. Staff G went into the resident's room at 1:30 pm and collected the tray. On 1/29/26 at 9:30 am, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation is for CNAs to be seated while assisting a resident with their meal. CNAs should never be standing over the resident. The DON stated staff should assist the resident at the time the tray is taken into the room, the tray should not be left in the resident's room. The DON stated residents should never be referred to as feeders and CNAs should always knock on the resident's door before entering their room with a food tray. Review of the facility's policy titled Resident Rights, revised October 2009, revealed employees shall treat all residents with kindness, respect, and dignity. Policy and Implementation . 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 2 of 13 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 01/29/2026 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 observations, record reviews, and interviews the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) were accurately completed and obtained prior to admission with mental health diagnoses and/or intellectual disorders for four (#5, #8, #9, and #33) of 15 sampled residents.Findings include: Residents Affected - Few Review of Resident #5s admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to generalized anxiety disorder (onset 12/12/25), unspecified depression (onset 12/12/25), unspecified anxiety disorder (onset 12/12/25), and unspecified psychosis not due to a substance or known physiological condition (onset 1/8/26). Review of Resident #5s PASRR dated 12/9/25 and completed at an acute care facility showed the resident had diagnoses of anxiety disorder and depressive disorder. The PASRR did not include the diagnosis of unspecified psychosis not due to a substance or known physiological condition (onset 1/8/26). Review of Resident #5s PASRR dated 12/23/25 and completed at an acute care facility showed the resident did not have a mental illness or suspected mental illness diagnosis. The PASRR showed the resident did not have any functional limitations, no difficulty with interpersonal functioning, concentration, persistence, or pace difficulties, and or any serious difficulty in adapting to typical changes. The screening revealed the resident had no diagnosis or suspicion of a serious mental illness or intellectual disability and a level 2 screening was not required. Review of Resident #5's psychiatric admission note, dated 1/14/26, showed Resident #5 did have a psychiatric history, continued to tolerate psychiatric medications without complications, voiced no concerns with depression or anxiety but did have poor sleep. The resident had reported having a history of psychosis, depression, anxiety, and reported taking the antipsychotic medication risperidone for the past year with good effect. The mood behavior score was 4 = mild/moderate depression. The resident reported insomnia with loss of energy and aggravating factors with being in the facility, ongoing medical problems, and life stressors. The assessment/plan included adjustment insomnia, chronic recurrent moderate major depressive disorder, unspecified psychosis due to a substance or known physiological condition, and generalized anxiety disorder. An interview was conducted on 1/29/26 at 10:30 a.m. with the Social Services Director (SSD). The SSD stated the currently dated PASRR trumps an older one and a level 2 was only done if the resident was exhibiting behaviors. The SSD reviewed Resident #5's diagnoses and stated she would have to look at the resident. The SSD reviewed the PASRR dated 12/23/25 and stated she didn't know why this one was uploaded because the resident hadn't been gone for 30 days. 2. A review of Resident #8's admission record revealed an admission date of 9/8/25, with diagnosis to include but not limited to: generalized anxiety disorder. A review of Resident #8's annual minimum data set (MDS) for medication, dated 12/13/25, revealed the following under high-risk drug classes: antianxiety usage. A review of Resident #8's care plan revealed the following focus areas to include: mood and behavioral status as evidenced by/ related to behavioral disturbance and generalized anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 3 of 13 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 01/29/2026 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 A review of Resident #8's physician orders dated January 2026 revealed the following: Level of Harm - Minimal harm or potential for actual harm -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth two times a day for mood disorder. Residents Affected - Few -Observe closely for significant side effects of anti-anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior. A review of Resident #8's PASRR, level 1 screen dated 9/2/25, revealed no diagnoses were marked under Section A-Mental Illness (MI) or suspected MI. On 1/29/26 at 10:25 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated when a resident is admitted to the facility with a PASRR, the admissions department is responsible for updating the document. The SSD stated admissions would either reach back out to the hospital to request an updated PASRR be sent to the facility or the facility would correct the PASRR. The SSD confirmed Resident #8 was admitted with a diagnosis of generalized anxiety disorder, and stated the diagnosis should have been marked on the PASRR. Review of Resident #9's admission Record revealed an admission date of 11/01/24. Resident #9 was admitted to the facility with diagnoses to include psychotic disorder with delusions due to known physiological condition (11/01/2024), insomnia (11/06/2024), depression (11/06/2024), mood disorder due to known physiological condition with mixed features (10/20/2025), and major depressive disorder, recurrent (10/25/2025). Review of Resident #9's Minimum Data Set (MDS), dated [DATE] for Medications revealed, Resident #9 received antipsychotic, antidepressant, and anticonvulsant, regularly. Review of the Level I PASRR, dated 1/23/2025, revealed: Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional Admission was marked. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During an interview on 01/27/26 at 3:46 p.m., the Regional Nurse Consultant stated we do not have any Residents in house with a Level II PASRR. During an interview on 01/29/26 10:25 a.m., the SSD, stated Resident #9 receives extra psychological services. Resident #9 is seen weekly by psychotherapist. The SSD stated since Resident #9 is not currently exhibiting any behavior, we do not answer the questions on section II. Question 2. A, B, and C as yes. The SSD stated if Resident #9 was not controlled/treated, then yes, Resident #9 would have issues with interpersonal functioning. If the questions were marked yes, then it would have triggered for a level II PASRR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 4 of 13 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 01/29/2026 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 4. Level of Harm - Minimal harm or potential for actual harm Review of Resident #33's admission record revealed an admission date of 12/24/25, with diagnoses to include by not limited to: depression (unspecified). Residents Affected - Few A review of Resident #33's MDS, dated [DATE] under Medications for high risk drug classes: revealed antianxiety and antidepressant medications, being recieved. A record review of Resident #33's physician orders showed the following: -Alprazolam oral tablet 0.5 milligram (mg) to give one tablet by mouth three times a day for anxiety/restlessness/agitation, ordered on 01/07/2026 -Duloxetine HCL (hydrochloride) oral capsule delayed release particles 60 mg to give one capsule by mouth two times a day for depression, ordered on 01/07/2026 -Hydroxyzine HCL oral tablet , give 50 mg by mouth at bedtime for anxiety, ordered on 12/24/2025. -Trazadone HCL oral tablet 50 mg, give 0.5 tablet by mouth at bedtime for depression. (0.5 tab=25 mg), ordered on 01/07/2026. A record review for Resident #33's medical record did not reveal a PASSR. On 01/29/26 at 10:40 a.m., an interview was conducted with the SSD. The SSD stated Hospice did not fill out a PASSR on the resident but agreed the PASSR would fall onto the facility to update a PASSR on the resident to capture Mental Illnesses and behaviors. During an interview on 01/29/26 at 10:55 a.m., the SSD stated we do not have a policy for PASRR we use the regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 5 of 13 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 01/29/2026 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 - 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 observations, interviews and record review, the facility failed to develop a care plan related to antipsychotic medications for one (#8) of five residents reviewed for unnecessary mediations and failed to update a care plan for wound management for one (#46) of one resident reviewed for wound care.Findings include: On 01/26/2026 at 11:28 a.m., Resident #46 was in his room asleep with a dressing noted to his foot dated 01/25/2026. A record review of Resident #46's physician orders showed the following: -Wound consult ordered on 01/07/2026 -Wound care: left medial toe cleanse with normal saline, apply Calcium Alginate with bordered dressing everyday shift for arterial wound, ordered on 01/14/2026. -Wound care: cleanse left lateral foot with normal saline, apply medicinal honey cover with dry dressing every evening shift every other day for unable to stage (UTS), ordered on 01/27/2026. -Wound care: cleanse right heel with normal saline; paint with betadine cover with border dressing and rolled gauze every evening shift every other day for UTS, ordered on 01/27/2026. A record review of Resident #46's care plan showed a focus of potential/actual impairment to skin integrity related to (r/t) abrasion initiated on 11/06/2025. On 01/29/2026 at 11:16 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident #46 has a wound and this current wound should have a care plann. The DON reviewed Resident #46's medical record and confirmed there was not a care plan for the wound to the foot. On 01/29/2026 at 11:33 a.m., the DON stated she contacted the MDS (Minimum Data Set) coordinator who stated Resident #46 was care planned for a wound. The DON reviewed the care plan again and stated the wound was imputed as an abrasion. The DON stated the wound should be marked appropriately as a pressure wound with an updated revision date. 2. A review of Resident #8's admission record revealed an admission date of 9/8/2025, with diagnosis to include but not limited to: Dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, and generalized anxiety disorder. A review of Resident #8's annual minimum data set (MDS) for medication, dated 12/13/2025, revealed the following under high-risk drug classes: antianxiety usage. A review of Resident #8's physician orders dated January 2026 revealed the following: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth two times a day for mood disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 6 of 13 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 01/29/2026 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 -Observe closely for significant side effects of anti-anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior. A Resident #8's care plan revealed there were no focus areas or interventions related to the medication administered daily for anxiety and mood disorder. Residents Affected - Few An interview was conducted on 1/29/2026 at 9:52 a.m. with the MDS Corporate Director. The MDS director reviewed Resident #8's care plan and confirmed not seeing an active care plan for high-risk medication use. The MDS director said because of Resident #8's diagnosis and related medication use, Resident #8 should have care plan for high-risk medication use. A review of the facility's policy titled Care Plan- Comprehensive with an effective date of 9/01/2022, revealed the following: POLICY: Our facility .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. PROCEDURE: 2. Each resident's comprehensive care plan is deigned to: a. incorporate identified problem areas; b. Incorporate risk factors associated with identified problem; e. Reflect treatment goals, timetables, and objectives in measurable outcomes; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels .4. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are developed through an interdisciplinary process .6. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change; 7. The Care Planning/ Interdisciplinary Team is responsible for the review and updating of care plans: a. when there has been a significant change in the resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 7 of 13 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 01/29/2026 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 0825 Provide or get specialized rehabilitative services as required for a resident. 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 provide rehabilitative therapy services in a timely manner for two (#17 and #46) out of two residents. Findings include: On 01/27/2026 at 9:57 a.m., a telephone interview was conducted with the resident representative (RR) for Resident #46. The RR stated being happy with the care provided by the facility but stated Resident #46 has not had therapy. The RR stated Resident #46 is always in bed, when he comes to visit every day. The RR stated the staff are scared to get Resident #46 out of bed because of past seizures. The RR stated Resident #46 had a swallow study during his last hospitalization and was supposed to have the swallow test repeated. The RR states not knowing the status of this repeat swallow study. The RR stated Resident #46 speaks to him and ate yogurt yesterday. The RR stated when Resident #46 originally arrived at the facility, he was talking and walking. The RR stated he knows Resident #46 can get back to his previous status. A record review of Resident #46's physician orders showed on 01/07/2026 an order for PT (physical therapy) to eval (evaluate) and treat as indicated. PT treatment by 5 x/wk (week) for 4 wks. PT treatment by thera ex (therapeutic exercise), thera act (therapeutic activities), NMR (neuromuscular re-education), group therapy, gait training and AD (assistive device). PT/Cg (physical therapy contact guard assist) safety education fall prevention/precautions. Pt (patient) discharge planning with recommendations for follow up care.A physician order, dated 01/07/2026, for Occupational Therapy Clarification order- Skilled Occupational Therapy 5 times a week for 4 weeks to include therapeutic exercise, self-care, neuromuscular reeducation, therapeutic activities, wheelchair management, safety awareness , diathermy (high frequency electromagnetic currents or ultrasound waves to generate deep heat within body tissue mobility), and ultrasound.On 01/27/2026 at 1:29 p.m., an interview was conducted with Staff K, Physical Therapist (PT). Staff K, PT stated Resident #46 was not on caseload. Staff K, PT reviewed physician orders and verified the orders, dated 01/07/2026, for physical therapy to evaluate and treat. Staff K, PT stated his director would be the one to view the order to then place the resident on a therapists calendar for evaluation or treatment. Staff K, PT showed his calendar for the day of 01/07/2026 and the day after and stated Resident #46 was not on his calendar for evaluation. Staff K, PT stated the calendar would be his only way of seeing his workload. On 01/27/2026 at 2:56 p.m., an interview was conducted with Staff L, Occupational Therapist (OT). Staff L, OT stated after looking at her documentation for Resident #46, she had completed an evaluation on 01/07/2026 but was told to discharge him off service from the administrative staff on 01/07/2026. Staff L, OT confirmed physical therapy had not seen the resident on 01/07/2026. On 01/27/2026 at 3:07 p.m., an observation was made during of the former nursing home administrator walking into the rehab gym and told Staff L, OT to, put [Resident #46] on your work order today.On 01/27/2026 at 3:28 p.m., an interview was conducted with Staff O, Interim Director of Rehabilitation(iDOR). The iDOR stated Resident #46 had an order for PT/OT evaluation and treat dated 01/07/2026 but stated she could not see any emails indicating reason to remove from the list of residents for therapy. The iDOR stated if the physician orders therapy then the facility should provide. On 01/27/2026 at 6:07 p.m., the iDOR called and stated she could not find in any of her email correspondence why Resident #46 was removed from therapy. A review of Resident #46's admission Record showed an original admit date of 11/06/2025 with a recent readmission of 01/06/2026 and diagnoses to include but not limited to:Traumatic hemorrhage of cerebrum, unspecified with loss of consciousness of unspecified duration , subsequent encounter.Epilepsy, unspecified, intractable , without status epilepticusMuscle weakness (generalized)Need for assistance with personal careDifficulty in walking, not elsewhere classifiedPost traumatic seizures. A record Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 8 of 13 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 01/29/2026 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review of Resident #46's Minimum Data Set (MDS) admission dated 11/10/2025 showed a Brief Interview for Mental Status (BIMS) score of 12, which showed moderate cognitive impairment. Functional Abilities showed Resident #46 as independent from sit to stand, lying to sitting on side of bed, sit to lying on the side of the bed, chair/bed to chair transfer supervision or touching assistance with the ability to toilet transfer. A record review of Resident #46's MDS dated [DATE] showed a BIMS score of 99, which showed the resident was unable to complete or was not attempted. Functional Abilities showed Resident #46 showed supervision or touching assistance for walking 50 feet with two turns: the ability to walk at least 50 feet and make two turns, and not attempted due to medical condition or safety concerns; for walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. A record review of Resident #46's care plan showed: -Focus of alteration/at risk for alteration in functional performance as evidenced by: weakness and debilitation related to recent illness/hospitalization., medical condition/s limit activity tolerance, date initiated: 11/16/2025. The Goal for focus area: will achieve highest practical functional level by next review with target date of 04/09/2026. Interventions to include but not limited to:PT referral/eval/treat as indicated/ordered, date initiated 11/16/2025.Ot referral/eval/treat as indicated/ordered, date initiated 11/16/2025.Provide assist of 2 helpers with: toileting hygiene, toileting transfers, bed mobility, eating mobility dressing/grooming, date initiated 01/15/2026Report changes in functional performance, dated initiated 11/16/2025 -Focus of limited physical mobility, eval for PT OT and ST, date initiated 11/06/2025. The Goal: will increase level of mobility through the review date with target date of 04/09/2026.Interventions to include but not limited to:Provide supportive care, assistance with mobility as needed. Document assistance as needed, date initiated 11/06/2025PT, OT referrals as ordered, PRN, date initiated 11/07/2026 On 01/27/2026 at 4:07 p.m., an interview was conducted with Staff M, Registered Nurse (RN)/Supervisor. Staff M, RN, stated being told Resident #46 was custodial upon last admission by the Admissions department. Staff M, RN stated Resident #46 will lift his leg up for assistance with staff during wound dressing changes and can sit on the edge of the bed. On 01/28/2026 at 12:03 p.m., Staff K, PT stated evaluated Resident #46 yesterday (1/27/2026) and stated the resident is cognitively intact and answers questions appropriately. Staff K, PT stated Resident #46 has lost weight and would be a good candidate for therapy. Staff K, PT stated being surprised how weak Resident #46 has gotten. On 01/28/2026 at 4:23 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). Both had stated being unfamiliar with Resident #46 because of their new tenure at the facility. Both agreed there was an order for PT and OT and the resident should have received therapy despite payor source. On 01/26/2026 at 2:21 p.m., an interview was conducted with Resident #17. Resident #17 stated she was still waiting for the physical therapy department to order her a new roller but has not received it. Resident #17 stated having the equipment at home and stated being ready for discharge. Resident #17 stated I will order the roller myself to be delivered here if that is what needs to be done. A record review of Resident #17's progress notes showed the following entry on 01/19/2026 13:27 (1:27 p.m.): Patient returned from [spine and pain outpatient appointment]. New orders for Eval and PT for 10 visits. Therapy notified. A record review of Resident #17's current physician orders did not show an order for physical therapy. On 01/27/2026 at 1:29 p.m., an interview was conducted with Staff K, PT. Staff K, PT stated Resident #17 was not on case load. Staff K, PT reviewed the calendar for 01/19-01/20/2026 but was unable to state if Resident #17 had been evaluated. Staff K, PT stated not having documentation to show Resident #17 had been seen by therapy. Staff K, PT stated being aware of the order for Resident #17 but was not able to follow the order without approval from administration. Staff K, PT stated the DOR will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 9 of 13 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 01/29/2026 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete place the resident(s) on the calendar. A record review of Resident #17's care plan showed:-Focus of alteration in functional performance as evidenced by : weakness and debilitation related to recent illness/hospitalization., medical condition/s limit activity tolerance, date initiated: 8/12/2025. The Goal- [#17] will achieve highest practical functional level by next review, target date: 04/29/2026. Interventions to include but not limited to:PT referral/eval/treat as indicate/ordered, date initiated: 08/12/2025OT referral/eval/treat as indicate/ordered, date initiated: 08/12/2025A record review of Resident #17's admission Record showed an admit date of 8/04/2025 with diagnoses included but not limited to:Chronic obstructive pulmonary disease with (acute) exacerbationMuscle weakness (generalized)Unspecified abnormalities of gait and mobilityOn 01/28/2026 at 4:23 p.m., an interview was conducted with the NHA and the Director of Nursing (DON). The DON stated the progress note written should have been placed in as an order. The DON stated it was a lack of communication. The facility stated there was not a facility policy for Rehabilitative services. Event ID: Facility ID: 105777 If continuation sheet Page 10 of 13 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 01/29/2026 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, record reviews, and interviews the facility failed to ensure transmission-based precautions were adhered to for one (#7) of one resident, failed to ensure staff completed hand hygiene appropriately while delivering meal trays and assisting residents with meals, and staff failed to manage laundry in a manner preventing cross contamination.Findings include: Residents Affected - Many An observation was made on 1/26/26 at 9:52 a.m. of two signs posted on the door to Resident #7's room. The signs showed staff and visitors of Enhanced Barrier Precautions and Contact precautions were to be utilized with the residents of the room. The sign for Contact precautions instructed for all family and visitors to report to the nursing station or see staff before entering the room. The sign detailed that Everyone MUST perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting. Wear gown before entering and remove upon exiting. Wear gloves before entering and remove upon exiting. Review of Resident #7s physician orders revealed an order dated 1/9/26 for Contact Precautions. An order was written on 1/25/26 at 12:54 p.m. for the resident showing Contact precautions every shift until 03/03/26 23:59. Review of the resident's orders revealed the resident was to receive the antiviral medication valacyclovir three times a day for shingles for two weeks (1/20/26) and erythromycin ophthalmic ointment three times a day for shingles until 2/18/26 (1/20/26). An observation was made on 1/26/26 at 12:52 p.m. of Staff E, previous Nursing Home Administrator (NHA) entering Resident #7's room, without donning any Personal Protective Equipment (PPE) and sat on the resident's bed. Staff E, previous NHA stood up walked to the roommate's side of room and spoke with them before returning to Resident #7. Staff E, left the room. Staff E, stated knowing the contact precautions were for Resident #7's roommate (indicated by bed letter) but did not know the reason. Staff E reported on 1/26/26 at 12:55 p.m. of speaking out of turn, that it was Resident #7 (indicated by bed letter) on contact precautions due to shingles and put hand up to eye area. Staff E, stated but I didn't touch her. An observation on 1/26/26 at 1:02 p.m. occurred of Staff F, Registered Nurse (RN) removing the contact precaution sign from the Resident's #7's door. Staff F, RN stated staff still have to honor the sign that is posted. Review of the policy – Infection Control Guidelines for All Nursing Procedures, revised April 2013, revealed Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. An observation was made on 1/26/26 at 12:20 p.m. of Staff A, Certified Nursing Assistant (CNA) delivering meal trays to resident rooms. The staff member came out of the resident room, moved the meal cart in front of room [ROOM NUMBER], took tray from cart and delivered it to resident in the window bed, exited the room, took another meal tray from the top of the cart and delivered it to the first bed of room [ROOM NUMBER]. The staff member took a tray from the bottom of the cart and delivered it to the second bed of room [ROOM NUMBER]. The staff member removed a meal tray from the cart and delivered it to the second bed of room [ROOM NUMBER], asking another CNA to assist in repositioning the resident. The observation showed Staff A did not perform hand hygiene while delivering and setting up residents for dining. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 11 of 13 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 01/29/2026 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 Residents Affected - Many Review of the policy – Hand Hygiene, effective 5/2025, revealed The organization considers hand hygiene the primary means to prevent the spread of infection. The policy described the process of hand hygiene using soap and water and alcohol-based hand rub. The policy did not show when hand hygiene should be performed. On 1/28/26 at 12:20 p.m., an observation of Staff E, former NHA did not perform hand hygiene prior to handling food trays On 1/28/26 p.m. at 12:20 p.m. an observation of Staff R, Business Office Manager (BOM) did not perform hand hygiene prior to handling food trays. On 1/28/26 at 12:35 p.m. an observation occurred that no hand sanitizers or hand hygiene was offered to residents prior to meal service. On 1/28/26 at 12:43 p.m. Staff B, CNA was observed exiting resident room [ROOM NUMBER]. Staff B walked to a plastic container in the hallway, took a PPE gown and gloves and re-entered resident room [ROOM NUMBER]. Staff B, pulled the privacy curtain closed and donned the gown and gloves. An interview was conducted with Staff R, BOM on 1/29/26 at 11:09 a.m. who confirmed passing out meal trays on 1/28/26. Staff R stated the process for hand hygiene is after every tray passed, hand hygiene should occur. An interview conducted on 1/29/26 at 11:23 a.m. with Staff I, CNA who confirmed assisting with meal tray service yesterday. Staff I stated the process for hand hygiene when passing meal trays is to thoroughly wash hands and use hand sanitizers before entering a resident room and sanitize hands after exiting the resident room. An interview conducted on 1/29/26 at 11:34 a.m. with Staff J, CNA . Staff J, CNA confirmed passing meal trays on 1/28/26. Staff J, CNA stated completing hand hygiene with friction and in between each finger and counts 30 seconds to a minute because staff J does not like hand sanitizers. Staff J uses paper towels to touch the knobs at the sink before staff J attends the patients. Staff J repeats handwashing when attending the next resident because staff J does not like hand sanitizers. On 1/28/26 at 10:40 a.m., an observation and interview occurred with Staff P, laundry aid (LA) with the Maintenance Supervisor interpreting. Staff P, LA was observed at the nurses' station pushing a large gray bin on wheels with clear bags of laundry. Staff P, LA acknowledged the laundry was dirty and was on the way to the laundry room. Staff P was not wearing gloves. Staff P, LA entered the dirty laundry room. Staff P, LA demonstrated how she would take dirty linen into the wash area. Staff P stated she would put on gloves and retrieve the dirty clothes and place them into the washing machine. Staff P stated next would remove the gloves along with the large plastic bag in the garbage container between the two washing machines, and dispose. When the laundry cycle was complete, Staff P stated she would grab a clean cart from the dryer area. Put on gloves and transport the clean clothes from the washer via cart to the dryer area. At no time did Staff P, LA utilize the PPE (apron and elbow high gloves) hanging on the wall, nor mention using the PPE. On 01/29/2028 at 8:18 a.m., an interview with the Director of Nursing (DON). The DON stated she had heard about the incident yesterday in the laundry room and stated when handling soiled linen, the staff should wear the apron and utilize the rubber gloves provided followed by washing hands. The DON stated she knew the rubber gloves and apron were located and provided in the laundry area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 12 of 13 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 01/29/2026 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 Residents Affected - Many During an observation on 1/28/2026 at 12:25 p.m. Staff E, Previous NHA, walked into a resident room passed a food tray, exited the room, no hand hygiene was performed. Staff E proceeded back to the meal delivery cart, removed another tray, walked to another room and set the tray on top of a PPE caddy. Staff E, donned PPE and delivered the food tray to a resident. No handy hygiene was observed. During a observation on 1/28/2026 at 12:41 p.m. in the dining room, Staff M, Registered Nurse Supervisor (RNS), moved glasses from her head to her face, removed a meal tray from the meal cart and delivered the tray to a resident at a table. Staff M, RNS removed a phone from her pocket, put the phone back in her pocket, and proceeded to re-arrange the meal trays on the cart. Staff M pulled up her pants and removed a meal tray from the cart and delivered the tray to the dining room. No hand hygiene was observed. During an observation on 01/28/2026 at 12:44 p.m. in the dining room, Staff Q, Licensed Practical Nurse (LPN), passed a meal tray to a resident proceeded back to the food cart. Removed another meal tray, set the tray on a table in front of the resident. By touching the residents' wheelchair via the handlebars, readjusted the resident to the table. Proceeded back to meal cart, rearranged the meal trays on the cart. No hand hygiene was observed. During an interview on 01/28/2026 at 1:03 p.m., Staff M, RNS stated assisting with the meal service with residents. During this process, I pass trays, observe residents to ensure they are not having any issues with eating and ensure they have the correct meals. We do hand hygiene in between each resident. I don't remember if I did hand hygiene during meal service today. During an interview on 01/29/2026 at 9:44 a.m., the Director of Nursing (DON), stated we should do hand hygiene in-between residents or when we are touching other surfaces. We should not put meal trays on PPE caddy. Review of the policy – Hand Hygiene, effective 5/2025, revealed The organization considers hand hygiene the primary means to prevent the spread of infection. The policy described the process of hand hygiene using soap and water and alcohol-based hand rub. The policy did not show when hand hygiene should be performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105777 If continuation sheet Page 13 of 13