Inspection·May 12, 2023

F 0604 Level of Harm - Actual harm Residents Affected - Few (ARNP) was made aware and recommended a psych consult/follow-up visit. The UM stated the resident was not placed on any additional medication, since he was already on psychotropic medication, Trazadone at nights. Trazadone: This medication is used to treat depression. It may help to . Decrease anxiety. (Retrieved on 5/22/23 from www.WebMD.com) On 5/11/23 at 11:27 AM, LPN A confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. She recalled she made rounds with the off going nurse LPN D. She recalled the resident was in a low bed, with his legs coming off the bed. LPN A stated she removed the blanket from the bottom of the resident's legs and placed them back in the bed and covered him. She verbalized she did not notice any sheet tied across the resident. LPN A recalled she was in another hallway caring for residents, and the resident's assigned Certified Nursing Assistant (CNA) B came to get her and showed her the resident had a sheet around his mid-section tied to both sides of the resident's bed frame. LPN A recalled they tried to remove the sheet, but could not get it untied, and she had to cut the knot with her scissors. She explained the resident was lying with his arms at his side, and he would not be able to turn, get up, or sit up with the sheet tied around him, and attached to both sides of the bed. She recalled the restraint was noted between 1:30 AM and 2:00 AM, and she did not know who tied the resident with the sheet. She said the only staff on the shift along with her were two other CNAs. She said the resident's assigned CNA alerted her to the incident, and said she did not know who did it, and the other CNAs also denied any knowledge of the incident. LPN A stated she cared for the resident prior to the incident of 5/06/23, and the resident was confused, and was not able to make his needs known. She stated he was at risk for falls, was not resistant to care, and did not exhibit any aggressive behavior. On 5/11/23 at 12:26 PM, the Administrator stated he received a phone call on 5/06/23 from 7 AM to 3 PM CNA C who informed him that she received report from the off going CNA B that she discovered a sheet tied across the resident's mid abdomen attached to the bed frame. CNA C reported that CNA B said she went into the resident's room to provide care when she made the discovery. The Administrator recalled he contacted the staff who worked on the 3 PM to-11 PM shift on 5/05/23, and LPN D denied any knowledge of the resident being tied down with a sheet. He stated the Weekend Supervisor who informed him was made aware of the incident by LPN A. The Administrator stated he arrived at the facility around 8:40 AM on 5/06/23 and reviewed the video surveillance footage which showed CNA E entering and exiting the resident's room a lot. At 9:47 AM the Administrator recalled he went to talk with the resident who had a BIMS of 08/15 and his roommate who had a BIMS of 12/15, and both residents denied having knowledge of the incident. At 12:55 PM he called Law enforcement, and a deputy visited forty-five minutes later, and asked for resident #1's medical record and the names and phone numbers of all staff who cared for the resident. He noted LPN A was interviewed by the deputy at that time. He said the deputy assessed the resident's room, took pictures, and prior to his exit, he informed the facility they would be investigating abuse. The Administrator indicated he called CNA E who was the resident's assigned CNA on the 3 PM to 11 PM shift on 5/05/23, and she denied having any knowledge of a sheet tied across the resident. On 5/08/23 he reviewed the video surveillance in depth, and the video footage revealed that on 5/05/23 at 9:08 PM, CNA E went into the resident's room with a sheet and emerged five minutes later empty handed, without the sheet. At 9:36 PM, LPN D went into the resident's room, came out at 9:38 PM and talked and gestured to CNA E in the hallway. The Administrator verbalized he spoke to both LPN D and CNA E on 5/08/23, and both denied being aware of the sheet tied across the resident. He said he reviewed the surveillance video footage with them, and they still denied they knew there was a sheet tied across the resident and tied to both sides of the bed frame. He stated video footage showed both LPN D and CNA E in the resident's room several times during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 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 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 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 0604 their shift. Level of Harm - Actual harm On 5/11/23 at 1:12 PM, the Director of Nursing (DON) stated she was notified by the Administrator on 5/06/23, that LPN A, and CNA B discovered resident #1 had a sheet over him that was tied to the bed frame. The DON stated she was told the resident was checked, assessed, and had no adverse effect. She recalled she came to the facility on 5/06/23, and spoke with the resident, along with the deputy who spoke Spanish, and the resident did not remember the event. She spoke with the resident's roommate, and he did not notice anything out of the ordinary. The DON stated the facility was a restraint free facility. Residents Affected - Few On 5/11/23 at 1:37 PM, CNA B confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. She recalled she was told by off going CNA E that the resident was trying to get out of bed. CNA B verbalized she started making rounds about 1 AM and got to resident #1's room about 2 AM. She recalled that when she went into the resident's room, he was in bed with his blanket across him. She recalled she pulled the blanket back to provide care for the resident, and noted he had a top sheet tied across his abdomen, which was attached to both sides of his bed frame. CNA B stated she tugged on the knot to remove the sheet the sheet but it was tight. She said she then went to get his assigned nurse, LPN A. She recalled the LPN was caring for another resident, so she had to wait, and they got back to resident #1's room around 3 AM. She explained to the LPN what she discovered. The CNA said she and LPN A attempted to remove the sheet, but it was tied tightly and the knot was tied to the frame. She explained the more they tried to move the bed to loosen the knot, the more it was stuck in the frame. She reported that LPN A ended up cutting the sheet off the resident with her scissors, and they threw the sheet in the thrash. The CNA stated LPN A said she would take care of it and would talk with the two CNAs and the nurse from the previous shift. CNA B reported that in the morning she waited to be relieved, and when CNA C came, she told her about the incident, and immediately CNA C called the Administrator. She informed him of the incident, and she reported her discovery to both the oncoming weekend supervisor and the Administrator. CNA B said usually when she had the resident, he would place his leg over the side of the bed, and when she instructed him to put his leg back in bed he would laugh and then do as asked. She stated the resident did not refuse care, and him being tied to the bed was a form of abuse. On 5/11/23 at 2:08 PM, LPN D recalled that on 5/05/23 around 7:30 PM to 8:00 PM, she did a dressing to resident #1's left heel and spoke to him in Spanish. LPN D said sometimes the resident was confused and did not comprehend what was said. The LPN stated that when she went down the hallway, she glanced into the resident's room, and he had his legs over the side of his bed, and his cover sheet was up to his chest. LPN D recalled she said, what are you doing, she lifted the cover, and placed his legs back in the bed. She verbalized that around 9:30 to 10:00 PM, CNA E was sitting in the hallway doing her charting. She recalled she told the CNA to keep an eye on the resident, because he kept trying to get out of bed. She told the CNA that the resident was a fall risk, he could fall, and she did not want any falls to occur on her shift. LPN D recalled she told CNA E that if the resident continued to attempt to get out of bed, she should inform her, so that they could get him up in his wheelchair, and place him at the nurses' station. LPN D stated that when LPN A came in, they did walking rounds starting from the back of the hall to the front. When they went into resident #1's room, he had his legs over the side of the bed, and his sheet was below his waist. The LPN stated she placed his feet back in bed and continued giving report to LPN A. She stated she did not see any sheet tied across the resident and tied to both sides of the bed frame, and verbalized she heard about the incident on 5/06/23 when the Administrator called her. She said she was shocked, and had no idea why someone would do that, verbalizing that (action) was against the law. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 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 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 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 0604 Level of Harm - Actual harm Residents Affected - Few On 5/11/23 at 2:53 PM, CNA E confirmed she was assigned to resident #1 on the 3 PM to 11 PM shift on 5/05/23. She recalled that when she came to work, the resident was sitting in his wheelchair at the nurses' station. He went to the dining room for supper, and then he was sitting in the hallway, and was placed to bed probably around 8 PM. CNA E said she checked on the resident, because lately he had been falling from his low bed. She said that during the shift, the resident would often have his legs over the side of his bed. She would place his legs back in bed, and a couple minutes later he would have his legs over the side of the bed again. She said every twenty minutes she observed him with his legs over the side of his bed. CNA E said LPN D told her that she found the resident with no gown on. She said the LPN told her she placed a gown on him and repositioned him. The CNA said she went to check on the resident and his sheet, and blanket were on the floor, and his legs were out of the bed. She said she told the 11 PM to 7 AM CNA to be sure to keep an eye on the resident because he was trying to get out of bed. CNA E stated she did not place a sheet across the resident and tied it to the bed frame. She verbalized that on 5/06/23 she saw a text on her phone from the Administrator instructing her to come to the facility. She reported she was interviewed by the Administrator, he documented the interview, and she signed the statement. The CNA denied tying a sheet across the resident, and said she observed the resident every thirty minutes, and would have seen if he was tied down with a sheet. On 5/11/23 at 3:38 PM, in a telephone interview CNA C stated she worked from 6:45 AM to 11:00 PM on the weekends. She explained when she came to work on 5/06/23, she was informed by CNA B that resident #1 was tied to the bed frame so tightly, they had to cut him out. CNA C stated she was in disbelief. She recalled CNA B said she told LPN A who wanted to talk to the evening nurse about it. CNA C recalled she told CNA B, we have to tell someone important. She said she called the Administrator and left a voice message. When the Administrator called back, she told him about the incident, and what CNA B told her. The Administrator then spoke with CNA B. On 5/11/23 at 4:07 PM, the video recording for 5/05/23 was reviewed with the Administrator. The recording noted that at 6:59 PM CNA E rolled the mechanical lift to resident #1's room door. At 7:00 PM, she transferred the resident via wheelchair from the nurse station to his room. At 7:03 PM, CNA E came out of the resident's room, retrieved the mechanical lift, and re-entered the resident's room. CNA E remained in the resident's room for approximately eleven minutes. At 7:14 PM, she placed the mechanical lift in the hallway. At 9:08 PM, CNA E walked from the clean linen room with a sheet into resident #1's room. At 9:14 PM, the CNA exited the resident's room empty handed. On 5/11/23 at 4:40 PM, in a telephone interview, Registered Nurse (RN) Weekend Supervisor stated that on 5/06/23 at 7 AM, she was met by CNAs B and C in the hallway, who told her they wanted to talk to her regarding an incident that happened overnight. She explained CNA B told her she found the resident with a sheet across his chest, and the sheet was tied on both sides to the frame of his bed. She stated she spoke with the Administrator and was directed to do a full head to toe skin assessment on the resident. The Weekend Supervisor stated the resident was asleep when they walked into the room, and when she started to evaluate him, he woke up. She verbalized he had no injury, red areas, or bruising, and exhibited no behavior. On 5/12/23 at 10:55 AM, in a telephone interview, resident #1's daughter said the facility informed her of the incident of 5/06/23 and she was very surprised that someone would do that. She recalled she was told by various staff members the facility did not use restraints, and she never expected that would be done to her father. She explained her father was forgetful and his logic was not there. The resident's daughter indicated she would have been very upset if he had sustained any skin issues or was hurt in any way. She said she would not want it to happen again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 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 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 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 0604 Level of Harm - Actual harm Residents Affected - Few On 5/12/23 at 12:47 PM, in a telephone interview, the Psych ARNP said she saw resident #1 on 5/08/23. She recalled she was told the resident's blanket was tight over him. She said she assessed him and he had no issues and his affect was good. She explained the resident was not able to voice his concerns or recall the incident due to confusion. The ARNP stated she was not aware the sheet was tied to the bedframe, and scissors had to be used to cut and release the sheet. 5/12/23 1:18 PM, the DON stated the facility did not have a policy pertaining to physical restraints since the facility was a restraint free facility. She said the policy for Abuse, Neglect and Exploitation covered seclusion. The facility's learning module Protecting Resident Rights in Nursing Facilities copyright 2017 Relias Learning, Section 2: Resident Rights read, Freedom from restraints All residents have the right to be free from restraints, both chemical and physical, used for the purposes of discipline or convenience AND not used to treat a resident's medical symptoms . Restraints must only be used as a last resort or when medically necessary for the treatment of a medical condition. The facility's policy Abuse &Neglect Prohibition with effective date of 10/24/2022 documented that Involuntary seclusion was the separation of a resident from other residents or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 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 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report an alleged violation of abuse within the regulatory guidelines for 1 of 1 resident reviewed for restraint and seclusion of a total sample of 5 residents, (#1). Findings: Resident #1, a 95- year-old male, was admitted to the facility on [DATE]. His diagnoses included generalized anxiety disorder, major depressive disorder, cerebral infarction, cardiac pacemaker, history of falls, and malignant neoplasm of prostate. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/22/23, revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, dressing, and personal hygiene, and was dependent on staff for transfers, and toilet use. Section P indicated restraint was not used for the resident. On 5/11/23 at 11:27 AM, Licensed Practical Nurse (LPN) A confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. LPN A recalled she was in another hallway caring for residents when the resident's assigned Certified Nursing Assistant (CNA) B came to get her. She said they proceeded to resident #1's room and the resident had a sheet around his mid-section tied to both sides of the resident's bed frame. LPN A recalled they tried to remove the sheet, but could not get it untied. She said she had to cut the knot with her scissors. She said the resident was lying with his arms at his side, could not turn, get up or sit up. She recalled the restraint was noted by CNA B between 1:30 AM to 2:00 AM. LPN A said she did not report the finding to anyone since the resident did not have any injuries and added she was going to report it later in the morning. LPN A acknowledged the restraint was discovered between 1:30 AM to 2:00 AM and was not reported until approximately 7:15 AM to the oncoming supervisor. She verbalized she should have documented the incident, and initiated an incident report, but she did not. The LPN did not give a reason for the omission. On 5/11/23 at 12:26 PM, the Administrator stated he received a phone call on 5/06/23 from 7 AM to 3 PM shift CNA C who informed him that she received report from off going CNA B of a sheet tied across the resident's mid abdomen attached to the bed frame. CNA C reported that CNA B said she went in to provide care for the resident when she made the discovery. The Administrator stated he did not know why the incident was not reported to him immediately. He said it was discovered on the 11 PM to 7 AM shift, and the expectation was that staff would notify the Administrator, Director of Nursing (DON), and Abuse Coordinator immediately of any unusual occurrence or event. He confirmed the incident was not submitted to the relevant State agencies in the required regulatory timeframe. On 5/11/23 at 1:12 PM, the DON explained she was notified by the Administrator on 5/06/23, that LPN A, and CNA B discovered resident #1 had a sheet over him that was tied to the bed frame. She conveyed the incident should have been reported immediately. She noted all staff had education abuse abuse and neglect, and that any suspicion of abuse was to be reported immediately. On 5/11/23 at 1:37 PM, CNA B confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. She recalled at about 2 AM, the resident was in bed with his blanket across him. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 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 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she pulled the blanket back to provide care for the resident, and noted a top sheet tied across his abdomen that was tied to both sides of the bedframe. CNA B said she tried to remove the sheet but it was tight and she called for the assigned nurse, LPN A. She recalled the LPN was caring for another resident, so she had to wait, and they got back to resident #1's room around 3 AM. She said the knot was tied to the frame where the bed moved up and down, and the more they tried to move the bed to loosen the knot, the more it stuck in the frame. She said LPN A ended up cutting the sheet off the resident with her scissors, and they threw the sheet in the thrash. The CNA stated LPN A said she would take care of it and would talk with the two CNAs and nurse from the previous shift. The facility's policy Abuse & Neglect Prohibition with effective date of 10/24/2022 read, the center will investigate any alleged abuse/neglect . in accordance with state or federal law. The center will report such allegations to the state, .The center will report immediately but no later than 2 hours after forming the suspicion if the events that caused the allegation involve abuse. The facility's policy Incident Reporting for Residents or Visitors revised on 1/13/2017 directs that All incidents and unusual occurrences involving a resident will be documented and reported so as to meet all regulatory (state, and federal) requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 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 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 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 interview, record review, and surveillance video recording, the facility failed to consistently implement care plan interventions for transfers with a mechanical lift for 2 of 2 residents of a total sample of 5 residents, (#1, #2). Findings 1. Resident #1, a 95- year-old male, was admitted to the facility on [DATE]. His diagnoses included generalized anxiety disorder, major depressive disorder, cerebral infarction, cardiac pacemaker, low back pain, history of falls, and malignant neoplasm of prostate. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/22/23, revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, dressing, and personal hygiene, and was dependent on staff for transfers, and toilet use. On 5/11/23 at 2:53 PM, Certified Nursing Assistant (CNA) E confirmed she was assigned to resident #1 on the 3 PM to 11 PM shift on 5/05/23. She recalled that when she came to work, the resident was sitting in his wheelchair at the nurses' station. He went to the dining room for supper, and then he was sitting in the hallway, and was transferred to bed probably around 8 PM. CNA E stated the resident required a mechanical lift for transfers. She acknowledged she transferred the resident from his wheelchair to his bed with the mechanical lift by herself. She said she knew that two persons were required to transfer residents with mechanical lift, but when there were three CNAs on the unit, they were busy. She stated she transferred the resident by herself as the other CNAs were busy. She said she did not ask the nurse to help her. She verified the resident's care plan/[NAME] indicated he required two persons for transfer with a mechanical lift. On 5/11/23 at 3:49 PM, CNA F stated he was assigned to resident #1 on prior shifts. He stated the resident was a fall risk and required transfer with a mechanical lift with two persons. On 5/11/23 at 4:07 PM, video recording for 5/05/23 was reviewed with the Administrator. The recording showed at 6:59 PM, CNA E rolled the mechanical lift to resident #1's room door. At 7:00 PM, she transferred the resident via wheelchair from the nurses' station to his room. At 7:08 PM, CNA E came out of the resident's room, retrieved the mechanical lift, and re-entered the resident's room and remained there for eleven minutes. At 7:14 PM she placed the mechanical lift in the hallway. On 5/12/23 at 1:06 PM, the Director of Nursing (DON) stated staff were educated on hire, annually, and as needed regarding mechanical lift, and following the resident's care plan. She stated CNA E told them she did not request assistance from anyone to transfer resident #1 who required a mechanical lift for transfers. An intervention on the resident's care plan for ADL (Activities of Daily Living) self-care performance initiated/created on 3/18/23 and revised on 3/20/23, noted Transfers:2 person assist with (mechanical) lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 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 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 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 2. Resident #2 was admitted to the facility on [DATE] with diagnoses including ataxia, fibromyalgia,, muscle weakness, and Parkinson's disease. The resident's quarterly MDS assessment with ARD of 4/23/23 revealed the resident's cognition was intact with a BIMS score of 13 out of 15. The assessment noted resident #2 required extensive assistance of two staff persons for bed mobility and was totally dependent on staff for transfers. On 5/12/23 at 2:46 PM, resident #2 stated she was bed ridden and staff transferred her from bed to chair twice a week with a mechanical lift for showers. She said sometimes the transfer was done by one staff person but there should be two staff. The resident's ADL self-care performance care plan initiated 10/14/22 with revision on 5/03/23 indicated Transfers were via mechanical lift with two persons assist. The facility's policy Resident Transfer: Mechanical Lift revised on 8/29/2017 read, A mechanical lift is used to safely facilitate transfers of residents whose functional ability .requires use of a lift. Mechanical lifts requires a 2- person assist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105872 If continuation sheet Page 9 of 9