Inspection·April 15, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete aware of Resident #2's labs and the daughter had reported she was coming in the evening and administering the levothyroxine. The facility had to educate the daughter against doing so as it could cause the resident to be overmedicated. Review of the facility policy Documentation of Medication Administration (revised November 2022; version 1.2) revealed that a medication administration record is used to document all medications administered. Administration of medication is documented immediately after it is given. Event ID: Facility ID: 105810 If continuation sheet Page 2 of 4 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 04/15/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, document review, and policy review, the facility failed to maintain a fully functional resident call system in 4 of 8 sampled facility bedrooms. (Rooms 11, 36, 18, and 48) Residents Affected - Some The findings include: An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:24 PM. The bedroom call light system was tested for both A and B bed and found to be not functional. An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:50 PM. The bedroom call light system was tested and found to be not functional. An observation of unoccupied resident bedroom [ROOM NUMBER] was conducted on 4/15/25 at 9:18 AM. Resident bedroom [ROOM NUMBER]'s call light system was not functional. An observation of unoccupied resident bedroom [ROOM NUMBER] was conducted on 4/15/25 at 9:22 AM. Both A and B bed were missing call lights cords rendering the call system for room [ROOM NUMBER] not functional. (Photographic evidence obtained.) An interview was conducted with the Administrator on 4/14/25 at 3:05 PM. When asked how the facility monitored the functionality of the resident call system, he stated a company comes in every 6 months to check the entire system. He stated they were in the facility about 2 weeks ago and identified they needed some replacement call light boxes. He acknowledged that the resident call system was old. The Administrator was asked if he had any evidence of the facility staff checking the call light system between the 6 months visits conducted by the company. The Administrator provided 2 service request documents from dated 3/4/25 indicating that the call system is obsolete and is working to quote a new system. Bad call stations were found in rooms [ROOM NUMBER]. Another invoice dated 3/28/25 indicated again they went over the nurse call system with customer. This invoice again stated that rooms [ROOM NUMBER] needed new call stations. The invoice stated, System is obsolete and cannot order new parts for repair. Customer is going to look for parts for repairs. A follow-up interview was conducted with the Administrator on 4/15/25 at 12:16 PM. He stated a company had to make parts for the resident call system and that was why it took so long to get parts for repairs. He was able to provide an audit from 3/11/25 for all call lights in facility, which indicated that the resident call system in room [ROOM NUMBER]B bed was not working and repaired on 3/12/25, the light for the 39B bed was not working and repaired 3/12/25, the lights for room [ROOM NUMBER] A and B were not working and repaired on 3/12/25, and 50 B bed not working and repaired on 3/12/25. He stated that was the only audit he could find. The facility policy for Residents Call System (revised September 2022; version 1.0) states, residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. The resident call system remains functional at all times. The resident call system is routinely maintained and tested by the maintenance department. Review of an additional undated facility policy for Maintaining Call Light System in Nursing Home indicated Miracle Hill Nursing and Rehabilitation Center is committed to maintaining a fully operational call light system that meets the needs of our residents. Regular monitoring, maintenance, and timely repairs are crucial to ensure compliance with federal and state regulations. The maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 3 of 4 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 04/15/2025 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 0919 Level of Harm - Minimal harm or potential for actual harm staff will routinely conduct an inspection of the call light system to ensure that all components are functioning properly. If the maintenance staff identified a problem that cannot be resolved during monthly monitoring, they will attempt to trouble shoot the issue using their training skills. If the issue remains unresolved, the maintenance staff will contact the outside contractor for immediate assistance. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105810 If continuation sheet Page 4 of 4