Inspection·September 20, 2023

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a day for dry eyes. The Order Summary did not include an order from the physician allowing the resident to self-administer any medication. A review of Resident #13's September Medication Administration Record (MAR) showed staff had administered the resident's Artificial Tears twice daily except for the refusal that was observed. The MAR showed the resident did not self-administer the ophthalmic solution every 4 hours as reported. Review of Resident #13's progress notes revealed the following: - 9/19/23 at 8:02 a.m., Resident declined for resident self-medicating self at bedside with own artificial tears. MD to be notified and resident need to be evaluated if resident can be administered correctly. Family member at bedside stated that family supplying medication. - 9/19/23 at 6:11 p.m., an Administration note for Artificial Tears identified supervised self-administration. - 9/19/23 at 7:55 p.m., the Director of Nursing (DON) noted Resident verbalized a desire to self-administer her eye drops earlier today during medication pass. Eye drops are an over-the counter (OTC) item, however, there is concern regarding (re:) resident's ability to properly store and access the medication as she is not able to independently retrieve items stored in her bedside table. Will collaborate with (w/) resident, physician, Interdisciplinary team (IDT) and request Occupational Therapy (OT) input. A review of Resident #13's New admission Data Collection and Observation, dated 9/14/22, showed the resident had not expressed a desire to self-administer medications. A review of Resident #13's care plan included a focus that showed the resident had a vision deficit and required glasses. The interventions associated with this focus instructed staff to Administer eye drops as ordered. The care plan did not show the resident had the ability to self-administer eye drops or any other medication. A review of Resident #13's evaluations revealed one Medication Self-Administration Safety Screen, dated 9/19/23, which was the initial screen, was not locked (completed), and had errors. The instructions for the Safety Screen instructed to Complete this assessment prior to resident initiating self administration of medication and with any medication order changes, change in function/condition that might affect the residents ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly. Use clinical judgment with section B to determine if or what level of self-administration will be allowed. The Self-Administration screen showed the resident was being considered for the self-administration of Artificial Tears Ophthalmic Solution and the medication would be kept at the residents bedside. The evaluation portion of the screening showed the resident required assistance with reading the label and/or identifying the medication, was unable to demonstrate secure storage of medications kept in room, and required assistance with correctly administer eye drops or eye ointments correctly. The approval portion of the evaluation was incomplete and did not identify if the physician order had been obtained for unsupervised administration, with supervision administration, or may not self-administer medications. On 9/19/23 at 9:30 a.m., the Director of Nursing (DON) reported that no resident had been evaluated for self-administration of medications, however; Resident #13 had asked to be evaluated this morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated on 9/20/23 during an interview that began at 2:22 p.m., leaving Resident #103's medication unattended at bedside was a big no no. The policy - Resident Self-Administration of Medication, implemented 10/24/22, revealed It is the policy of this facility to support each resident's right to self administer medication. A resident may only self administer medications after the facility's interdisciplinary team has determined which medications may be self administered safely. The policy explanation and compliance guidelines revealed that Each resident is offered the opportunity to self administer medications during the routine assessment by the facilities interdisciplinary team. The Residents preference will be documented on the appropriate form and placed in the medical record. Review of the explanation and guidelines revealed the following: 3. When determining if self administration is clinically appropriate for a resident the interdisciplinary team should at a minimum consider the following: - a. The medications appropriate and safe for self administration; - b. The residence physical capacity to swallow without difficulty, open medication bottles, (and) administer injections; - d. The residents capability to follow directions until time to know when medications need to be taken; - g. The residents ability to ensure that medication is stored safely and securely. 4. The results of the interdisciplinary team assessment are recorded on the medication self administration assessment form which is placed in the residence medical record. 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charged nurse for return to the family or responsible party. Families are responsible parties are reminded of the policy and procedures regarding resident submission when necessary. 13. The care plan must reflect resident self administration and storage arrangements for such medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to protect the Private Healthcare Information and personal data for three (Residents #55, #46, and #54) of 28 sampled residents as evidence by conversations held at the receptionist desk with a visitor standing nearby and with resident documents left unattended at the receptionist desk. Residents Affected - Few Findings included: On 9/18/23 at 2:50 p.m., Staff D, Executive Assistant/Receptionist, was talking on the telephone at the reception desk making an appointment for a walker to be delivered to an unknown resident's home address. The name, date of birth , and home address of the resident was given to the recipient of the phone call. This information was overheard by this writer as well as other team members from the conference room across the hallway, approximately 12 feet, from the receptionist's desk. On 9/19/23 at 10:45 a.m., Staff D was sitting at the receptionist's desk while a female visitor was standing directly in front of the desk. The staff member was speaking to an unknown person on the telephone and provided the Medicare or Medicaid number of a resident to the recipient of the call. On 9/19/23 at 4:52 p.m., Staff D was sitting at the reception desk on the telephone making a follow up appointment for Resident #55. The staff member provided the recipient of the call with the name and date of birth of the resident, Medicare Part A number of the resident, and identified the secondary insurance held by the resident. This information was overheard while this writer was sitting in the conference room across from the reception desk. On 9/20/23 at 1:58 p.m., the Nursing Home Administrator reported that Staff D was at lunch. An observation at that time showed the reception desk in the front lobby of the facility was unoccupied and unattended. On 9/20/23 at 2:01 p.m., the reception desk was observed, still unoccupied. On top of the desk, in front of the computer keyboard was Resident #54's Photo and Other Media Release Form, dated 9/20/23 and signed by the resident's emergency contact. Next to Resident #54's form was a pad of paper listing several residents' names. On the other side of the form was a piece of yellow paper that showed Resident #46 had an appointment with a Primary Care Physician, date of the appointment, and specific information regarding the appointment. The observation revealed an open yellow binder with the Vaccine Consent Form for Resident #54 on top of contents. The consent was filled out and signed by the resident's representative on 9/20/23 and showed the vaccine consents for the Flu, Pneumonia, and COVID vaccines. (Photographic Evidence Obtained) An interview was conducted on 9/20/23 at 4:03 p.m. with Staff D. She stated the receptionist desk was her office. She reported receiving HIPAA (Health Insurance Portability Accountability Act) training upon hire, two (2) years ago. Staff D stated appointments and transportation needs were regularly made from the reception desk and when making an appointment the provider would ask for the resident's name and date of birth . Staff D reviewed the photographic evidence obtained and stated normally turns it over and said it was her fault. An interview was conducted on 9/20/23 at 4:24 p.m., with the Nursing Home Administrator (NHA). The NHA said HIPAA meant Privacy of Protected Information and included everything, name, medication information, date of birth , and Medicare/Medicaid numbers. The observation and overheard conversations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were reviewed and discussed with the NHA who stated that it was inappropriate (to be seen and overheard). The NHA agreed that visitors and other residents could hear Protected Health Information (PHI) from the reception desk. The admission Handbook, which the facility identified as being given to each resident at the time of his/her admission identified in the section - Confidentiality/HIPAA, All your healthcare information is considered protected healthcare information. To maintain continuity of care, it is only disclosed in the course of normal health care operations. Except for normal healthcare operations your healthcare information can only be assessed with your permission. The policy - HIPAA Security Measures, implemented 10/21/22 revealed, It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that are in electronic format. The policy did not address the protection of written Protected Health Information (PHI). The policy's Explanation and Compliance Guidelines included the following: - Facility leadership will ensure the implementation of policies and procedures to prevent, detect, contain, and correct any security violations. - Security measures will be implemented to manage risk and vulnerabilities as identified in the risk analysis. - Only appropriate employees will have access to electronic protected health information (EPHI). These employees will receive appropriate training related to the security of the information for which they have access. - The facility will perform a periodic technical and non-technical evaluation of its security plans and procedures to ensure it continued compliance in response to environmental or operational changes that affect the security of EPHI. - The facility will implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access EPHI. All workstations that access EPHI will have restricted access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 observation, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review and failed to correct the document for two (Residents #6, and #12) of twenty-eight sampled residents. Residents Affected - Some Findings Included: 1. A review of Resident #6's admission Record revealed the resident was admitted on [DATE] with unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and unspecified single episode major depressive disorder. The Preadmission Screening and Resident Review (PASRR), dated 8/3/23, for Resident #6 did not include any Mental Illness diagnoses. Section IV of the screening revealed that the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASRR evaluation was not required. A review of Resident #6's active Order Summary Report identified the resident received the antipsychotic medication of Aripiprazole daily for mood disorder with psychosis, Memantine twice daily for dementia, the antidepressant Trazodone for unspecified single episode of Major Depressive Disorder, and Venlafaxine (antidepressant) daily for depression. An interview was conducted on 9/20/23 at 2:22 p.m. with the Director of Nursing (DON). The DON reported that the residents' PASRR's are done in the hospital and when the resident was admitted , she scans through the PASRR to ensure if Level II had been done if indicated. The DON reviewed Resident #6's admission Record and PASRR and identified that the PASRR was incorrect. The Director stated she would have to look into having someone redo them, either a Registered Nurse or physician. 2. A review of Resident #12's admission Record revealed the resident was admitted on [DATE] and 6/10/21. The admission record included the principal diagnosis of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and secondary diagnoses of chronic Post-Traumatic Stress Disorder (PTSD), and unspecified recurrent major depressive disorder. The mental illness diagnoses, including dementia had an onset date of 2/25/21. A review of Resident #12's Preadmission Screening and Resident Review (PASRR), dated 12/20/20, did not identify the resident had any mental illness or suspected mental illness. The services section of the screening did list dementia as additional information. A further review of the PASRR revealed that it did not identify the residents dementia diagnosis as primary. The screening revealed No diagnosis or suspicion of Serious Mental Illness of Intellectual Disability indicated. Level II PASRR evaluation not required. During an interview on 9/20/23 at 2:27 p.m., the Director of Nursing reviewed Resident #12's PASRR and admission Record then confirmed the primary diagnosis of the resident was dementia and that the PASRR should identify PTSD and the dementia diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to assess and develop a comprehensive care plan related to side rails for two (Residents #12 and #18) out of twenty-eight sampled residents. Findings Included: 1. On 9/18/23 at 1:33 p.m., an observation was conducted of Resident #12's bed. The observation showed a mattress that was bolstered at the head of bed (HOB) and end of bed (EOB) with 1/4 rails lowered in a manner that produced a 1/2 rail covering the distance in between the two bolsters. A review of Resident #12's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Post-Traumatic Stress Disorder (PTSD), and Parkinson's Disease. A review of the annual comprehensive assessment, dated 7/22/23, showed Resident #12 had a Brief Interview of Mental Status score of 4, indicative of severe cognition impairment. A review of Resident #12's Side Rail Evaluation and Consent, dated 8/18/23, revealed the plan for 1/2 side rails was to enable positional changes and improve bed mobility and for use during resident care/mobility. The evaluation did not show a physician's order was obtained or the resident's representative signed the consent. Review of Resident #12's care plan identified the following: - was a fall risk related to requiring extensive to total assistance by staff, poor safety awareness, and poor balance. The interventions did not include the use of side rails. - very limited mobility with poor coordination and balance related to weakness and Parkinson's disease. The interventions associated with this focus did not include the use of side rails. - need for Activities of Daily Living (ADL) assist due to weakness and cognitive deficits. The interventions did not include the use of side rails for positioning assistance. 2. On 9/18/23 at 9:30 AM, Resident #18, was observed in bed with a side rail up on each side of bed. Resident #18 was asking for help in a low voice, stating she wanted to go home because she must take care of her bills. The resident was neatly groomed, she was clothed in day attire, her hair was brushed, her glasses were on, and a lift sling was underneath her. A review of the electronic medical record) revealed Resident #18 was admitted to the facility with an initial admit date of 11/16/2015 with diagnoses to include essential hypertension, atrial fibrillation, major depressive disorder, and chronic renal disease, stage three. Resident #18 had a readmit date of 8/31/2021 with additional diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, malignant neoplasm of the cecum (anatomically part of the gastrointestinal system assisting in digestion), and anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 A record review of Resident #18's Minimum Data Set (MDS), dated [DATE], showed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of four which indicated severe impaired cognition. Upon further review of the MDS, Section E -(Behavior) showed no potential indicators for psychosis, wandering, or rejection of care. Review of Section G -(Functional Status) had Resident #18 as requiring total assistance (two + persons physical assist) for bed mobility, transfers, dressing, toilet use, personal hygiene and locomotion on unit and set up (help only) for eating. The answer was not used for the MDS Section P - (Restraints and Alarms) for P0100, Bed Rails. An observation on 9/19/23 at 11:30 a.m. of Resident #18's room revealed the right side rail in an upright vertical position and the left side rail in a horizontal position parallel to the bed in the upright position (Photographic Evidence Obtained.) Resident was not present. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 9/19/23 at 9:44 a.m. Staff C confirmed Resident #18 required total care related to toileting, bathing, transferring and required some assistance with eating and minor ADLs (Activities of Daily Living). She was verbal and could ask for things usually by a one-word request. Staff C stated Resident #18 might have mild verbal outbursts but was cooperative with bathing and transfers to her wheelchair. Staff C stated Resident #18 had a [spouse] who was a resident here at some point in time but stated she had never seen him come to visit the resident. Staff C stated the resident had a [family member] who would visit. Staff C stated Resident #18 had not tried to get out of bed on her own. A record review of Resident #18's physician orders for the month of September showed no current orders for side rails. A review of the most recent care plan, dated 8/31/23, showed no care plan areas identified for utilization of side rails. A record review of Nursing Side Rail Evaluation and Consent in Resident #18's electronic medical records, dated 8/11/23, documented side rails (enablers) were indicated to enable positional changes and improve bed mobility and for use during resident care/mobility. There was no resident or resident representative documented as being involved in the consenting process. An interview with the Director of Nursing (DON) was conducted on 9/19/23 at 3:00 p.m. The DON stated residents should have a care plan for side rails. The DON stated the residents should be evaluated, consented to and care planned for the side rails. The DON agreed Resident #18 was not properly care planned for the use of siderails. A review of the facility's policy titled, Comprehensive Care Plans, implemented on 10/17/2018 and revised on 01/23/2021, documented, It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, includes measurable objectives and timeframes to meet our resident's medical, nursing, and mental and psychosocial needs are identified and the resident's comprehensive assessment. Policy explanation and compliance guidelines included the following items: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the residents [sic] personal and cultural preferences in developing goals of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma induced . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Residents Affected - Few 6. The comprehensive care plan will include measurable objectives and time frames to meet the residents' needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor their resident's progress. Alternative interventions will be documented, as needed. 7. The physician, other practitioner or professional will inform the resident and/ or resident's representative of the risks and benefits of proposed care, of treatment, and treatment alternatives options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record including discussions with the resident and or resident representative. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to revise the care plan with appropriate interventions following a fall on 04/20/23 for one resident (Resident #37) out of the sampled twenty-eight residents. The resident had a second fall on 04/23/23 in the same location and around the same time. Resident #37 was discharged to the hospital on [DATE] and was found to have a fractured cervical spine (C1). Findings included: On 09/18/23 at 11:43 a.m., Resident #37 was observed sitting in the main dining room in a wheelchair and wearing a neck brace. On 09/19/23 at 10:27 a.m., Resident #37 was observed sitting in the dining room in a wheelchair and wearing a neck brace. The admission Record showed Resident #37 was admitted to the facility on [DATE] with diagnoses to include progressive supranuclear ophthalmoplegia, unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and history of falling. Section C (Cognitive Patterns) of the Minimum Data Set (MDS) dated [DATE] showed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderately impaired cognition. Section G (Functional Status) showed Resident #37 required extensive assistance with two plus persons physical assist for bed mobility and transfers. He needed extensive assistance with one-person physical assist for walk in the room, walk in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident #37 needed limited assistance with one person physical assist with eating. Section J Health Conditions showed Resident #37 has had a fall with a major and minor injury. A review of the progress notes showed the following: 04/20/23 (no time) - Staff heard a thud in the large dining room and saw Resident #37 on the floor on his knees with his head on the floor. The resident leaned forward and fell out of the wheelchair. He was assessed and found to have a complaint of pain to the head, a hematoma to the forehead, and a skin tear to the dorsal right hand between the first finger and thumb. 04/20/23 at 14:04 (2:04 p.m.) - The Advanced Registered Nurse Practitioner (ARNP) was notified of the fall with no new orders. The family was contacted. 04/20/23 at 22:37 (10:37 p.m.) - Resident #37 was doing well post fall from this afternoon. He had a bump on the right side of his forehead and an ice pack has been placed on and off as he will allow. His vital signs improved throughout the evening and were all within normal limits at 2200. He tore (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the first bandage off the right hand but was replaced with an allevyn. He denied any pain or discomfort other than the soreness of the bump on his head. Post fall monitoring continued for 72 hours total and is on the 24-hour report sheet. 04/23/23 (illegible time) - Resident #37 experienced a ground level unwitnessed fall. He was found on the floor of the main dining room next to a wheelchair on the left side. The resident was assessed, and a laceration was noted on the right side of the forehead accompanied by swelling. Resident #37 complained of pain to the head/headache with no other injuries or complaint of pain or discomfort. His vitals were within normal limits. He was returned to wheelchair, placed in an environment for additional monitoring, and administered as needed (PRN) pain medication. Resident #37 was able to answer yes or no questions and agree with statements when interviewed for root cause. He agreed that he was trying to put his shoe back on. He was alert and oriented to baseline. Neuro checks were initiated. An attempt to contact the family was made. The on-call physician was contacted. The on-call physician agreed with the plan of care and asked to be notified of any change in condition. 04/24/23 at 21:12 (9:12 p.m.) - Resident continues 72-hour post fall monitoring. He had bruising on the right side of his forehead. He complained of pain in his head and was given acetaminophen at dinner time to good effect. Neuro checks were within normal limits at this time. Monitoring will continue. 04/25/23 at 22:09 (10:09 p.m.) - Resident continues 72-hour post fall monitoring. He had new bruising developed on bilateral eyes from fall which happened Sunday afternoon. His family member pointed out that he had bruising around both eyes. He denied any facial pain and had not complained of pain during this shift. He was taking scheduled acetaminophen to good effect every 6 hours. 04/26/23 at 22:20 (10:20 p.m.) - Resident #37 continues 72-hour post fall monitoring. He had facial bruising around both eyes and bruising on his forehead, he denied any pain. Neuro checks were within normal limits. 04/28/23 at 21:07 (10:07 p.m.) - Resident #37 returned from the hospital. His family member and hospital staff reported the resident had a fracture of cervical spine (C1) and will require cervical collar to be worn at all times for 2 months at least. The Fall Scale with an effective date of 04/20/23 showed Resident #37 had intermittent confusion. He had fallen before and had 1-2 falls in the past 3 months. His vision was poor. Resident #37 overestimates or forgets the limits of his ability to ambulate safely. He had a score of 18 which indicated a low risk of falls. This form was dated 05/15/23 and signed by the Risk Manager. The Fall Scale with an effective date of 04/23/23 showed Resident #37 was disoriented. He had fallen before, and he had 3 or more falls in the past 3 months. His vision was poor, and his gait was weak. Resident #37 overestimates or forgets the limits of his ability to ambulate safely. He had a score of 21 which indicated a moderate risk of falls. This form was dated 04/23/23 and signed by Staff B, Licensed Practical Nurse (LPN). The Nursing Home Transfer and Discharge Notice dated 04/28/23 showed the resident was transferred to a local hospital due to increased confusion. The care plan with a focus area related to falls showed Resident #37 had multiple falls and continues to be a fall risk related to having poor safety awareness due to impaired cognition and weakness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with decreased mobility and balance (falls may be unavoidable due to multiple risk factors). The intervention initiated after the fall on 04/20/23 was the care plan to discuss the resident's progression of disease and safety. The intervention initiated after the fall on 04/23/23 was a lap buddy should be placed on his wheelchair when in his chair. Resident #37 was preoccupied with anything on the floor. An appropriate intervention to prevent Resident #37 from falling was not implemented after the fall on 04/20/23. On 09/19/23 at 1:50 p.m., Staff B, LPN, reported on the day of the fall, the resident was trying to stand. His head was observed on the floor. He assessed him. He was not complaining of pain at the time. No one witnessed the fall. The resident could not what happened. He did not go out to the hospital on that day. On 09/20/23 at 9:09 a.m., the Assistant Director of Nursing (ADON) reported they have a post fall monitoring sheet that was utilized to monitor the resident for 72 hours. They reviewed falls in morning meetings and discuss interventions to put in place. Sometimes they would put the new intervention in the Certified Nursing Assistant (CNA) task, if it looked like an infection they would do labs, and therapy was involved. They would send a resident out to the hospital depending on the situation. Resident #37 looked like he had a headache because he was holding his forehead. One time he said he was trying to pick up a shoe. He liked to be to himself. In an emergency, they must contact the doctor to get further directions about sending a resident out to the hospital. The doctor was notified of the fall. He was continuing to have headaches prior to being sent out to the hospital. He was later discharged to the hospital and was found to have a C1 fracture. The fall was unwitnessed, and his head was on the floor. On 09/20/23 at 9:25 a.m., the Director of Nursing (DON) stated they did an interdisciplinary review with the team. Resident #37 spent much of his day in the dining room because he had a significant history of falls. One of the falls happened after lunch while staff were prepping, and one was after lunch while staff was doing their after-lunch routine. They generally lay him down after lunch and get him back up for dinner. Staff heard a sound that was suspicious, and Resident #37 was found on the floor. He was responsive, alert, and wanted to get up. He was assessed and a hematoma was observed on his head and ice was applied to it. Staff notified the physician. Resident #37 was not on any blood thinners. If he was on blood thinners, they would have sent him out immediately. No post fall huddle form, Situation Background Assessment Recommendation (SBAR), or Change in Condition (CIC) form was completed. The DON stated they generally just chart in the chart and notify family. If there was loss of consciousness or an obvious injury, they would send a resident out to the hospital. With a head injury, they don't automatically send them out and the doctor made that determination unless the family or the resident said they want to go out to the hospital. Resident #37 had a fall on 04/20 and a second fall on 04/23. He did not have a head injury on the second fall. While monitoring him, he was holding his head and they became concerned. He was not as active as he normally was, and they wanted to have him evaluated due to the back-to-back falls. The DON stated he just was not acting himself. They did not send a resident out to the hospital unless there were neurological changes. He only complained that his head hurts which she would expect. The resident required three people to get him up. They always talk to staff to get statements and follow up after a fall. The root cause was he was probably trying to go back to bed after lunch. The second fall was three days later just before lunch. The fall was unwitnessed, and they really did not know what happened. When asked what kind of intervention was put in place after the first fall, the DON stated she believed they had a care plan meeting and tried to figure out other things from an Interdisciplinary Team (IDT) standpoint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0657 Level of Harm - Minimal harm or potential for actual harm They were questioning if they should put a helmet on him because they were starting to see more of him coming forward when falling. Having an IDT meeting was standard stated the DON. This meeting was held with a family member. Prior to these two falls, they moved him to the dining setting to have more opportunities to see him. Residents Affected - Few The procedure provided by the facility Prevention of Falls Program revised 06/09/22 revealed the following: Intent Care plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. II. Quality Assurance/Risk Management Guidelines A. Responsibility of Risk Manager/Designee Care plan is to be updated with any new interventions. B. The Interdisciplinary Plan of Care (IPOC) team will meet within the same period of time and discuss the causative factors, interventions to prevent another fall, make therapy referral as necessary and revise the care plan if necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure one (Resident #14) of twenty-eight sampled residents received on-going nursing assessments following a change in condition during 2 of 3 days of survey. Residents Affected - Few Findings included: Review of an undated facility policy titled, Resident Right-Notification of Change, showed it is the policy of the facility to inform the resident and or their legal representative of changes in the resident's condition or plan of care in such a manner to acknowledge and respect resident rights. A need to alter treatment significantly means a need to stop a form of treatment . or commence a new form of treatment to deal with a problem. On 09/18/23 at 12:30 p.m., Resident #14 was observed sleeping in her bed all morning. The resident did not eat lunch. The resident did not respond to the interview. A review of an admission record for Resident #14 showed she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. On 09/18/23 at 12:34 p.m., an interview was conducted with Staff L, Certified Nursing Assistant (CNA). She stated Resident #14 did not look well. She said, it looks like she is not feeling well. Staff L stated she would notify the nurse. On 09/19/23 9:22 a.m. an interview was conducted with Staff M, Licensed Practical Nurse (LPN). She stated the resident was sick. She said, the resident has had a lingering cough for quite some time. She stated the resident had been tested for Covid twice and the results came back negative. Staff M stated the resident had a negative chest x-ray on 09/17/23, but her condition had not improved. Staff M stated she normally worked in this hall, and she thought the ARNP (Advanced Registered Nurse Practitioner) had seen the resident the day before. Staff M reviewed the resident's record with the surveyor and confirmed there had been no current notes or nursing progress notes indicating the resident's condition. A review of Resident #14's EMR (electronic Medical Record) revealed the resident did not have any notes from 08/22/23 to 09/19/23. A review of physician orders for Resident #14 revealed no new orders. A review of Evaluations conducted on Resident #14 showed no health assessments/ evaluations documented. On 09/19/23 at 2:40 p.m., an interview was conducted with Staff L, CNA. She stated Resident #1 was about the same. Staff L said, there has been no change. She is not eating. Staff L confirmed Resident #14 had not been feeling well for some time and that she was not herself. Staff L stated the nurses knew and she did not need to notify anyone. On 09/19/23 at 2:45 p.m., an interview was conducted with Staff K, LPN. She stated Resident #14 was still not feeling well. She stated the resident had had some lingering cough and sore throat. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few K stated she had texted the doctor. She said, I don't know the last time she was seen. I'm waiting for notification that the doctor has received the message. Staff K confirmed resident #14 had not been feeling well for at least a couple weeks. Staff K stated there should have been nursing notes showing the resident's progress. A review of Resident #14's weight and vitals summary log dated 09/01/23 to 09/19/23 showed the resident's temperature was checked on 09/3/23 and 09/19/23. The reading on 09/19/23 showed 97.2, with a notation low of 97.8 exceeded The resident's blood pressure was obtain one time during this period on 09/19/23, with a reading of 102/69. The record revealed no further evaluation and monitoring. On 09/19/23 at 02:48 p.m., an interview was conducted with Staff N, CNA. She stated the resident had not been feeling well for at least 2 days. She stated the resident ate a little that morning but had not eaten lunch. Staff N stated she worked with this resident almost daily. She stated if a resident was unwell, they notify the nurse or the DON. On 09/19/23 at 02:50 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was not feeling well, she would expect nursing staff to complete a 24-hour report. She stated a CNA can initiate a Stop and Watch program when they note a change in condition (CIC) such as a resident not eating or if they had increased pain. She stated nursing staff including CNA's can initiate an alert. The DON stated she had not received a 24-hour report or any alerts on Resident #14. She stated the resident had a chronic cough and swallowing problems, but she was not aware she had not been eating or that her condition had changed. The DON said, I'd expect a nurse to put in a note regarding the resident's health care status and note if there was a CIC. The DON stated vitals should be taken regularly to monitor the resident's progress. 09/19/23 at 3:42 p.m., a follow -up was conducted with the DON. She stated she assessed the resident herself and put in a note. The DON read the progress note revealing the resident was, tired, weak, confused, and drowsy. Resident care of intermittent sore throat with dry cough . lung sounds clear but diminished on auscultation . Follow-up call placed today as resident's symptoms persist and intake is decreased. The DON stated she would expect staff to notify the physician and family if a resident was not feeling well. She stated she would expect the resident to be closely monitored. She said, This would include vitals, frequent checks and pushing fluids. Review of an undated facility policy titled, Notification of Change in Condition, showed the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notify, consistent with his or her authority, the resident's representative when there's a change in the resident's condition requiring notification. Under procedure, the facility will inform the resident, consult with the resident's physician and/ or notify the resident's family member or legal representative when there's a change requiring such notification. This process is reinforced as part of the facility QAPI (quality assurance and performance improvement) program through communication systems and processes such as walking rounds, shift hurdles, Stop and Watch and use of predictive data. Situations requiring notification include: 1 (b.) potential to require physician intervention. (2.) A significant change in resident's physical mental or psychosocial status that is a deterioration in health mental all psychosocial status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety related to labeling and dating foods, discarding expired foods, and using appropriate hand hygiene. Findings included: On 09/18/23 at 9:58 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The following concerns were observed: the wall in the kitchen was ripped and missing tiles; a box of bruised, cut, and sprouted potatoes; two opened bags of blueberries, one opened bag of strawberries, one opened bag of pineapple chunks, one opened bag of cauliflower florets, one opened bag of broccoli, and one opened bag of egg patties was observed in the reach in freezer undated; an opened bag of hotdog buns and one opened container of garlic parmesan wing sauce was observed in the dry storage room undated; one opened 16 oz bottle of water was observed in the dry storage room; two bottles of heavy-duty degreaser and two containers of sanitizers were observed sitting on the top of boxes of water with water damage in the outside storage area outside of the walk in freezer; an opened bag of unknown food was observed in the walk-in freezer without a label and date; spillage, 16 oz white Styrofoam cup with an unknown frozen substance, small frozen substance in a fast-food cup was observed in the freezer of the homestyle refrigerator without a label and date; and one unknown container of food, an opened stick of butter, a small container of corn and spaghetti, and food in a fast-food wrapper was observed in the bottom of the homestyle refrigerator without a label and date (photographic evidence obtained). The CDM confirmed that this refrigerator was for residents only. On 09/19/23 at 11:40 a.m., Staff H, Dietary Aide, took the temperature of the foods for lunch. She took the temperature of a milk and walked towards the trash can, removed the lid from the trash can, discarded the milk, and proceeded to finish taking the temperatures. She was wearing gloves, did not perform hand hygiene, or change gloves after touching the lid of the trash can. On 09/19/23 at 11:55 a.m., the CDM reported all foods should be labeled and dated. He stated he had explained hand washing to staff this morning. The CDM stated the water damage on the boxes of water was probably from a roof leak. The policy and procedure provided by the facility Maintenance Log with an effective date of 09/01/14 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 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 105849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wrights Healthcare and Rehabilitation Center 11300 110th Ave N Seminole, FL 33778 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 0812 Policy Statement Level of Harm - Minimal harm or potential for actual harm Our facility shall strive to ensure that the facility systems and building will be in good repair and free of potential hazards. Residents Affected - Some The one-on-one in-service record provided by the facility Labeling and Dating Foods undated revealed the following: Why Label? Foods are labeled for food safety. Information on the label tells staff when food is approaching dates from when it would be removed from service. Labels include the name of the item, date it was prepared or opened and a date the time should be used by. General Labeling Items are labeled when opened with opening date. Use By Details All foods placed in the refrigerator are to be labeled with name of item, date item is placed and date it is to be used. The in-service manual provided by the facility Hand Washing and Glove Usage dated 2019 revealed the following: Learning Objectives 1. The Employee will be aware of requirements for frequency of hand washing. 2. The Employee will be able to identify situations in which hands require washing. Hands should be washed when contaminated and after handling soiled dishes and trash. Always change gloves if the gloves get ripped, torn, or contaminated. Contamination can occur after touching a nonfood item such as the door or trash can. Hands should be washed when contaminated and after handling soiled dishes or trash. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105849 If continuation sheet Page 17 of 17