Inspection·March 14, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at the facility completing the MDS assessments during her 4 weeks of absence. She admitted that she is still very behind on the MDS assessments and is doing her best to catch them up. Review of the facility policy for Care Plans, Comprehensive Person-Centered revealed 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Event ID: Facility ID: 105810 If continuation sheet Page 2 of 9 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 105810 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Hill Nursing & Rehabilitation Center, Inc 1329 Abraham Street Tallahassee, FL 32304 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 3/14/24, Resident # 68's Quarterly MDS, dated [DATE], showed in progress, to be completed by 1/1/24, resulting in the plan being 73 days overdue at the time of review. Residents Affected - Some On 3/14/24, Resident # 53's Quarterly MDS, dated [DATE] showed in progress, to be completed by 2/27/24, resulting in the plan being 16 days overdue. An interview was conducted with the MDS Licensed Practical Nurse on 3/13/24 at 4:05 PM concerning all of the above issues. She confirmed the quarterly MDS reviews were not completed. She stated she was the only full-time employee completing MDS and care plans. A review of the undated facility policy for Care Plans revealed the resident assessment must be reviewed no less than once every 3 months. Resident #20 had a quarterly assessment initiated on 12/16/23 that was not completed by survey exit date on 3/14/24. Resident #26 had a quarterly assessment initiated on 3/1/24 that was not completed by survey exit date on 3/14/24. Resident #37 had a quarterly assessment initiated on 12/16/23 that was not completed by survey exit date on 3/14/24. Resident #75 had a quarterly assessment initiated on 2/28/24 that was not completed by exit from the survey on 3/14/24. Resident #94 had a quarterly assessment initiated on 2/17/24 that was not completed by exit from the survey on 3/14/24. A record review of the electronic medical record for Resident #18 revealed the resident was admitted on [DATE]. A review of the MDS list for Resident #18 revealed the last quarterly MDS assessment was completed on 10/16/23. As of 3/12/24, the quarterly assessment dated [DATE] is still listed as In Progress. On 03/12/24 at 3:48 PM a record review of the care plan for Resident #18 revealed the goals were dated through 3/3/24 . The care plan has not been updated due to the quarterly assessment not being completed. Based on record review, staff interview, and policy review, the facility failed to ensure quarterly review assessments (minimum data sets) were completed at least once every 3 months for 9 of 29 sampled residents. (Resident #18, #20, #26, #37, #53, #55, #68, #75, and #94) The findings include: A review of Resident #55's electronic medical record revealed a quarterly minimum data set (MDS) dated [DATE] as in progress but not complete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 3 of 9 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 105810 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Hill Nursing & Rehabilitation Center, Inc 1329 Abraham Street Tallahassee, FL 32304 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure each resident assessment (minimum data set) accurately reflected the resident's status for 2 of 29 sampled residents. (resident numbers 30 and 55) Residents Affected - Few The findings include: A review of Resident #30's electronic medical record revealed a quarterly minimum data set (MDS) dated [DATE], which indicated the resident was taking an anticoagulant. A review of the current and past physician orders revealed the resident had never received an anticoagulant. An interview was conducted with Employee A (licensed practical nurse MDS) on 3/14/24 at 10:06 AM. Employee A stated Resident #30 had not received an anticoagulant and the MDS was not correct. A review of Resident #50's electronic medical record revealed an admission MDS dated [DATE], which indicated the resident was taking an anticoagulant. A review of the current and past physician orders revealed the resident had never received an anticoagulant. An interview was conducted with Employee B (licensed practical nurse) on 3/13/24 at 4:14 PM. Employee B stated the resident had not received an anticoagulant and the MDS was not correct. A review of the facility policy for Comprehensive Assessments (revised March 2022) revealed that comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual and states that the assessment must accurately reflects the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 4 of 9 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 105810 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Hill Nursing & Rehabilitation Center, Inc 1329 Abraham Street Tallahassee, FL 32304 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. Resident #149 A review of Resident #149's electronic medical record revealed the resident had a suprapubic urinary catheter. The record revealed an incomplete care plan for the catheter with a target date of 6/9/24. The care plan listed no interventions for care of the catheter. An interview was conducted with Staff A on 3/13/24 at 4:21 PM. She stated the care plan was not complete and should include interventions for the care of the catheter. A review of the undated facility policy for Care Plans revealed, .the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. Based on record review and interview, the facility failed to develop a comprehensive care plan for 2 of 23 residents sampled. (Resident #32 and #49) The findings include: Resident #32 A review of Resident # 32's medical records was conducted. The physician's orders and Treatment Administration Record revealed the resident was receiving the following wound care treatments: On Left Calf: clean area with normal saline, apply calcium alginate to open area, apply unna boot, after wrap with kerilex and finish with coban, change dressing every Monday and Thursday, and as needed if soiled, start date 1/25/24. On right heel: clean area with normal saline, apply calcium alginate to open area, apply unna boot, after wrap with kerilex and finish with coban, change dressing every Monday and Thursday, and as needed if soiled, start date 1/25/24. However, Resident #32's plan of care did not include any goals and interventions for wound care treatments. On 3/13/24 at 3:30 PM, an interview was conducted with Staff A, the facility's MDS coordinator. She stated she was aware the wound care treatments had not been included and that the care plan was incomplete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 5 of 9 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 105810 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Hill Nursing & Rehabilitation Center, Inc 1329 Abraham Street Tallahassee, FL 32304 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and policy review, the facility failed to develop and implement an effective discharge plan that includes care giver support and referrals to local contact agencies in a timely manner for 1 of 1 residents sampled for discharge planning. (Resident #20) Residents Affected - Few The findings include: On 3/12/24 at approximately 10:00 AM, an interview was conducted with resident #20. He stated the he has lived at the facility for a year. The resident indicated he has been asking to be discharged or go somewhere else the entire time he has been living at the facility. He explained that he used to live with his mother. He indicated that he would like to live with his sister and, if that is not possible, to go to a group home. Resident #20 explained that his sister has been trying for the past year to help him find another place such as a group home. He does not feel at home living in a nursing home at his age. He explained that he goes home with his sister all the time but must be back at the nursing home at night. He always comes back but does not like living there. He wears an elopement bracelet and indicated that he would like assistance getting the bracelet removed as well. Resident #20 explained that he is not sure why it has taken so long to help him. On 3/14/24 at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON). She said the facility is trying to find the best placement for Resident #20. She was asked to provide documentation of what the facility has done to assist in placement of the resident. The DON explained that his sister is trying to assist the resident with placement. On 3/14/24 at approximately 9:45 AM, an interview was conducted with Resident #20's sister. She explained that she has been trying for a long time to help her brother find a placement other than the nursing home and is desperate to get him some help. She explained that, at one time, he had medically complex needs but he is doing much better. She believes that he would really benefit from a different setting. She stated that he does not want to live in a nursing home and would prefer a group home or any facility type that would assist with his intellectual disability more effectively. The surveyor asked her if they had considered a group home or facility that specializes in assistance for individuals with intellectual disabilities. Resident #20's sister explained that she did not know that such facilities existed. She said she has tried to do what she knows to do to help him but does not know what else to do. Resident #20's sister explained that the facility has not offered any assistance with placement or information regarding available options for placement since his admission to the facility a year ago. She indicated that he comes to spend time with her during the day, often to help him get out of the nursing home and give him a break from the environment. On 3/13/24 at approximately 11:31 AM, an interview was conducted with the Social Services Director about Resident #20. She understands that he wants to go home. His sister has been trying to find a placement for him. The resident thinks he can survive in the community. She explained that he can have an explosive temper and starts yelling sometimes but does calm down. The Social Services Director was asked to provide documentation of attempts to assist the family or the resident with placement into another facility. She explained that the resident's sister was taking care of placement and that assistance would be available if needed. The Social Services Director was asked if she has made any attempts to contact the sister since the initial Discharge Plan was initiated on 11/18/23 to see if she might need assistance. The Social Services Director indicated that she has not made contact with the sister. She mentioned that the Medicaid Case Manager has come out to the facility to meet with Resident #20 several times but was unable to provide documentation of the dates that the Medicaid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 6 of 9 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 105810 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Hill Nursing & Rehabilitation Center, Inc 1329 Abraham Street Tallahassee, FL 32304 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Case Manager came to visit or plans that were in place to assist with placement into another facility. A copy of Resident #20's discharge plan was requested along with contact information for the Medicaid Case Manager. A review of the discharge plan provided by the Social Services Director was conducted. The plan was dated 11/18/2023. The discharge plan indicated that the case manager would be assisting with the resident to live elsewhere. The Social Services Director was asked if 11/18/23 was last date any documentation was completed regarding discharge planning for Resident #20. The Social Services Director indicated that that was the last time that discharge planning was completed for Resident #20 since admission. On 3/13/24 at approximately 11:55 AM, an interview was conducted with Resident #20's Medicaid Case Manager. She explained that she had been working on getting the resident out to a group home. She was asked to provide dates that she has met with the resident. She did not have that information available but indicated she has been working on his case for quite some time and hoped to make progress with finding placement for him soon. A review of the care plan was conducted the care plan noted that Resident #20 desires to live elsewhere. A goal written by the Social Services Director stated that Resident #20 would adjust to this facility by next review. One of the interventions was to assist Resident #20's desire to live elsewhere. A review of the Transfer Discharge Policy (dated 10/2022) was conducted. The policy stated, .resident would remain in the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs can not be met by the facility. The safety of individuals in the facility is endangered due the clinical or behavioral status of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 7 of 9 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 105810 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Hill Nursing & Rehabilitation Center, Inc 1329 Abraham Street Tallahassee, FL 32304 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to store all drugs and biologicals in locked compartments for 2 of 27 observations of medication pass and storage conducted during the survey. The findings include: On 3/13/24 at approximately 8:30 AM, an observation was made of 5 blister cards left unattended on top of a medication cart that was in the hallway near room [ROOM NUMBER]. The medication cart was locked and there was no nurse or other staff members nearby. (photographic evidence obtained) At approximately 8:40 AM. Nurse B, a Licensed Practical Nurse (LPN), came out of the resident room and back to the medication cart. Nurse B quickly picked up the medication blister cards that were on top of the cart. She explained that the medication had been discontinued and she would return the medication cards to the locked medication room now. When asked if the medications should be on top of the cart where any resident has access to them, Nurse B indicated that the medications should be secured in the cart. The 5 cards were inspected. Three cards contained medication but the other two cards no longer contained pills. On 3/13/24 at approximately 3:34 PM, an interview was conducted with the Director of Nursing (DON). She was shown images of the medications left unsecured on top of the medication cart. The DON explained that medications should not be left unsupervised on top of the medication cart. She explained that education will be completed with the nurses regarding medication storage. Resident #12 On 3/11/24 at 10:38 AM, during the initial tour of the facility, a clear medication cup was observed unattended on Resident #12's overhead table. The medication cup contained two pills. Resident #12 was in bed and her eyes were closed. There was another medication cup observed left unattended on top of Resident #12's night stand. (Photographic evidence was obtained) As this observation was happening, Resident #55 was observed entering the room. Resident # 55's medical record was reviewed. The resident's care plan indicated wandering behaviors and a diagnosis of Alzheimer's dementia. Resident #12's medical record was reviewed. Physician's orders indicated that these 2 pills were a multivitamin-multimineral oral tablet and amlodipine besylate 10 mg (a medication commonly used to treat high blood pressure). On 3/11/24 at 10:41 AM, an interview was conducted with Staff C, a registered nurse (RN). She was asked about the medications cups left unattended. She stated the medication cup at the bedside table was left there by her because she got distracted, but the medication cup left at the night stand was not left there by her. On 3/13/24 at 2:16 PM, an interview was conducted with Director of Nursing (DON), she was made aware of the medications left unattended and stated should not have happened and further stated it went against facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 8 of 9 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 105810 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miracle Hill Nursing & Rehabilitation Center, Inc 1329 Abraham Street Tallahassee, FL 32304 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 A review of the facility's medication storage policy (last revised February 2023) was conducted. The policy stated medications were always to be stored in a secured location. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 9 of 9