Inspection·October 22, 2021

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #33 related to missing items. The resolution revealed referred to H [hearing] aide on campus. The date complainant was notified was 09/07/21. A review of Resident #33's Complaint/Grievance Report, dated 8/31/21 revealed Resident #33's POA communicated a verbal concern to the Social Services Coordinator of . lost R [right] hearing aid + [plus] batteries in resident room. Bag is missing. Resident came in with L [left] hearing aid in ear + R [hearing aid] + batteries in a [plastic bag]. The findings of the investigation revealed the hearing aid was not found and actions taken to resolve the grievance were to refer Resident #33 for a hearing evaluation. On 9/10/21 the grievance was signed as being resolved to the complainant's satisfaction. An interview with Staff D, Certified Nursing Assistant (CNA) on 10/21/21 at 9:27 a.m. revealed when a resident is admitted , an admission person completes an inventory log with what personal items the resident was admitted with. All items a resident has must be documented on the form, including how many hearing aids a resident has. So, admitting staff would document if the resident had one or two hearing aids on admission. Staff D, CNA stated Resident #33 has hearing problems and uses a hearing aid. Staff D stated Resident #33's POA assists with putting in the hearing aids in the morning. A record review of Resident #33's Checklist for CNA's to complete for each admission, dated 8/25/21, revealed complete resident belongings sheet . DIRECTIONS: [NAME] and list items brought for the personal use of the resident/patient. Please bring additional items to the Nurse's Station for proper handling. Under the section assistive devices revealed no information listed related to Resident #33's right or left hearing aid. An interview with the Social Services Coordinator (SSC) on 10/21/21 at 1:01 p.m. revealed the facility process for family/resident concerns is to complete a grievance form for proper concern follow-up. The grievance is assigned to the appropriate department, such as nursing or housekeeping. The grievance follow-up timeframe is usually about three days. A grievance is addressed right away, however; the resolution may take longer depending on the type of grievance, such as missing items. A grievance is considered resolved once it is to the satisfaction of the person who made the grievance. The SSC stated she was familiar with Resident #33's grievance filed on 8/31/21 related to a missing hearing aid. The SSC stated according to Resident #33's grievance, the facility searched for the missing hearing aid but could not locate it. Resident #33 was referred to a hearing clinic and should have been seen on 09/10/21. This evaluation would have been completed in the facility. The SSC reviewed Resident #33's online medical chart but was unable to locate the hearing evaluation. The SSC stated she would review Resident #33's hard medical chart for the hearing evaluation and if unable to find it, she would contact the hearing clinic provider to get the record. The SSC stated Resident #33 was sent to the hospital around 9/10/21 but . regardless of that he should have been seen for a hearing evaluation and the grievance followed-up with. A follow-up interview on 10/21/21 at 2:18 p.m. with the SSC revealed she followed up with the provider who conducts the hearing evaluations. The provider stated he arrived at the building on 9/10/21, however, during that time the facility was having a COVID-19 outbreak and therefore appropriate hearing evaluations could not be done due to the personal protective equipment requirements. So, he did not complete Resident # 33's, or the other resident on schedule that day, hearing evaluation on 9/10/21. The SSC stated the expectation is that someone would have notified her that Resident #33 did not have a hearing evaluation completed on 9/10/21 so another hearing appointment could be set up and the evaluation submitted to the Nursing Home Administrator (NHA) for appropriate grievance resolution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 10/21/21 at 3:00 p.m. with the NHA revealed herself and the SSC meet weekly to discuss grievances and resolve them as timely as possible. Some grievances may take longer to resolve depending on their nature. The NHA stated she was familiar with Resident #33's grievance related to a missing hearing aid. She was under the impression, that the facility was just waiting for the hearing evaluation to be completed for Resident #33 for the grievance resolution. The NHA confirmed the expectation was that if Resident #33 was not seen for his hearing evaluation appointment on 9/10/21, a follow-up appointment would have been made. A policy review of the Grievance Procedure, not dated, revealed A resident, his/her representative, family member, visitor or advocate may file a verbal or written comment, grievance or complaint concerning resident rights, treatment, abuse, neglect, harassment, medical care, behavior or other residents, theft of property, etc. without fear of treat or reprisal in any manner. Such grievance or complaint may be made anonymously . The Administrator, the Provider's Grievance Official, will review the Grievance/Complaint Form or verbal Grievance/Complaint and will Forward to the respective department for investigation and the initiation of the corrective action, as necessary . Generally, within seven (7) working days, the Grievance Official or designee will contact you and will inform you of the outcome of the Grievance/Complaint . Should you disagree with the findings, recommendations, or actions taken, you may meet with the Administrator or designee or contact one of the Resident Advocacy Organization listed below . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure physician orders for the treatment and care of an indwelling catheter for one resident (#336) of five residents sampled were implemented within a timely manner. Findings included: An observation on 10/19/21 at 10:31 a.m. revealed Resident #336 lying under the bed covers. A catheter bag and catheter tubing were observed by the resident's bedside. Red coloring was observed inside of the catheter tubing. The resident was not responsive to an attempted interview. Resident #336's admission Record revealed an admission date of 10/12/21 with medical diagnoses of retention of urine, unspecified dementia, muscle weakness, and major depressive disorder. Resident #336's [Hospital Name] Discharge Summary report, dated 10/10/21, revealed on page 1 . Patient was stable for discharge however she has some urinary retention. She had 400 cc [cubic centimeters] in her bladder. She has a history of UTIs [urinary tract infections]. A [catheter] was placed Recommend . continuing the [catheter]. Page 9 of the report revealed under discharge instructions to . voiding trials at SNF [skilled nursing facility], continue [catheter]. Resident #336's Medical Certification for Medicaid Long-Term Services and Patient Transfer Form revealed a [catheter] was inserted on 10/9/21 for urinary retention due to an unknown cause. An attempt was made to remove the [catheter] in the hospital; the voiding trial to verify [catheter] removal was not successful. A record review of Resident #336's Order Summary Report on 10/19/21 and 10/20/21 revealed no active orders for [catheter] care and treatments. An observation with Staff D, Certified Nursing Assistant (CNA) on 10/21/21 at 11:13 a.m. confirmed the presence of Resident #336's indwelling catheter. During an interview on 10/21/21 at 11:17 a.m. Staff E, Registered Nurse (RN), who was also acting as a Unit Manager, stated when a resident was admitted with an indwelling catheter, the admitting nurse must enter physician orders into the online medical system. Usually, the resident will not come with orders related to catheter care when admitted from the hospital, so it is the facility's responsibility to input them. The following day, after a resident is admitted , an interdisciplinary team meeting is held to create a focus care plan for the resident with an indwelling catheter. Staff E, RN reviewed Resident #336's online medical chart and confirmed the lack of physician orders related to treatment and care of the indwelling catheter. Staff E, RN said, . this was missed. Staff E, RN stated the purpose of having physician orders is to ensure appropriate treatments are being provided to a resident. A physician progress note dated 10/18/21 revealed . [Resident #336] was also found to have a UTI [urinary tract infection] and started on Cipro [antibiotic] today as per primary team . A nursing progress note dated 10/18/21 revealed . order for ABT [antibiotic] for E. Coli in the urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0690 Level of Harm - Minimal harm or potential for actual harm An interview on 10/21/21 at 11:36 a.m. with the Director of Nursing revealed when a resident is admitted with an indwelling catheter, physician orders should be input into the online medical system for care of the catheter. The physician orders are verified and input upon the resident's admission. A review of the resident's online medical record confirmed physician orders related to Resident #336's catheter care and treatment was not input until 10/21/21. Residents Affected - Few A policy review of admission Criteria, revised March 2019, revealed Our facility admits only residents whose medical and nursing care needs can be met . Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least . routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. A policy review of Catheter Care, Urinary, revised September 2014, revealed The purpose of this procedure is to prevent catheter-associated urinary tract infections. Review the resident's care plan to assess for any special needs of the resident . Report other information in accordance with facility policy and professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview and observation on 10/19/21 at 1:17 p.m. with Resident #188, she stated nurses were not giving her cream on her legs at night even though she asks every day. The resident's legs were observed purple in color below the knees around the shin area. During a subsequent interview with Resident #188 on 10/21/21 at 9:00 a.m. she stated she still did not get any lotion applied to her legs and would really like it since the doctor ordered it. A Review of the October 2021 physician orders revealed: -Ammonium lactate cream 12% apply to bilateral lower extremity topically at bedtime for rash started 10/7/21. -Triamcinolone Acetonide cream 0.1% apply to affected area topically every 12 hours as needed for itching dated 10/7/21. A review of the MDS assessment dated [DATE] revealed a BIMS score of 15, indicating she was cognitively intact. During an observation of the treatment and medication carts with Staff H, LPN on 10/21/21 at 9:57 a.m. she confirmed the prescription ordered Ammonium lactate 12% and Triamcinolone Acetonide cream were not in the carts and would need to call the pharmacy to see when they were ordered and received. During a phone interview with the Consultant Pharmacy Technician on 10/21/21 at 10:27 a.m. the pharmacy representative stated the facility ordered the cream, but it was not sent, and confirmed the facility did not receive the Ammonium Lactate 12% or Triamcinolone. A review of the MAR for October 2021 revealed Ammonium lactate 12% was documented as applied to bilateral lower extremities, every night at 9:00 p.m. from 10/7/21 to 10/21/21. In an interview with the wound care Nurse Practitioner on 10/21/21 at 10:40 a.m. she stated the Ammonium Lactate 12% was necessary and advised the facility to continue with the cream. The Nurse Practitioner confirmed if it is ordered it should be applied or the physician should be notified. During an interview with the DON on 10/21/21 at 10:46 a.m. she stated any prescription ordered should be ordered and applied according to the physician order. She stated any cream ordered and not applied but checked off as applied would be considered a medication error and she would need to contact the physician, family and speak to the resident. Review of the policy, 5.1 Delivery and Receipt of Routine Deliveries, revised 1/1/13, showed the following: Applicability: The policy 5.1 sets forth procedures relating to the delivery and receipt of routine deliveries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0755 Procedure: Level of Harm - Minimal harm or potential for actual harm 2. Upon delivery by pharmacy, facility nurse or other authorized designee on behalf of facility should: Residents Affected - Few 2.1 Sign the delivery manifest (may be electronic if permitted by applicable law), note the time of arrival, and take responsibility for the receipt, proper storage, and distribution of the delivered medications. Review of the policy, Charting Errors and/or Omissions, revised December 2006, revealed the following: Policy Statement Accurate medical records shall be maintained by this facility. Policy Interpretation and Implementation 2. If it is necessary to change or add information in the resident's medical record, it shall be completed by means of an addendum and signed and dated by the person making such change or addition. Review of the policy, Charting and Documentation, revised July 2017, reflected the following findings: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 2. The following information is to be documented in the resident medical record: e. events, incidents., or accidents involving the care plan goals and objectives. 7. Documentation of procedures and treatments will include care-specific details, including: c. the assessment data and/or any unusual findings obtained during the procedure/treatment; f. Notification of family, physician, other staff, if indicated. A review of the policy, Medication and Treatment Orders, revised July 2016, revealed the following: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0755 Policy Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure refills are readily available. Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure medications were available and provided for two residents (#11 and #188) of eight residents observed during medication administration. Findings included: 1. A review of the admission Record for Resident #11 reflected a diagnosis of COPD (chronic obstructive pulmonary disease). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #11's cognition was intact. On 10/22/21 at 9:28 a.m. during the medication administration observation, an interview was conducted with Resident #11. She stated she has not been getting her Singulair as the facility ran out. Resident #11 said, This happens all the time, and she further said she does not get her Prednisone neither. An interview was conducted at the same time with Staff G, Licensed Practical Nurse (LPN). Staff G said he informed the unit manager, and she thought the Prednisone was on order. A review of the October 2021 physician orders revealed the following: -8/13/21 Deltasone (prednisone) give 10 milligrams (mg) by mouth one time a day for inflammation, -8/16/21 Singulair (montelukast Sodium) give 1 tablet by mouth at bedtime for COPD. A review of the Medication Administration Record (MAR) for October 2021 reflected the following: -Deltasone was signed every day from October 1st to October 22nd, indicating the medication was administered. On October 17th code 5 was documented, and review of the code key showed, Hold,/see nurses notes. On October 20th code 9 was documented, and review of the code key showed, Other/see nurses notes. A review of mediation administration notes for October 2021 revealed there was no note for the 17th or 20th. Further review of the MAR revealed the Singulair was also documented as administered from October 1st to October 22nd. On 10/22/21 at 10:17 a.m. an interview was conducted with Staff G, LPN. She said she reordered the Prednisone because she did not find it. On 10/22/21 at 10:58 a.m., an interview was conducted with Staff G, LPN. She confirmed she had signed for the Deltasone after reviewing the MAR but had not given it. She said, Oh sorry. I will change it. On 10/22/21 at 11:22 a.m. a telephone interview was conducted with the Consultant Pharmacy Technician. She stated, Fifteen tablets of Singulair were sent out on 10/15, and thirty tablets of Prednisone on 10/21. It should be there. It was delivered at 6:57 p.m. and signed for by a staff member. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0755 Additionally, the technician said fifteen tablets of Prednisone had been sent to the facility on 9/28. Level of Harm - Minimal harm or potential for actual harm On 10/22/21 at 11:36 a.m. an observation was conducted with the Unit Manager Staff C, Registered Nurse (RN) of the Emergency Drug Kit (EDK). She pulled up the profile for Resident #11 and it revealed Singulair and Prednisone were not available. Residents Affected - Few On 10/22/21 at 11:40 a.m. an interview was conducted with the Director of Nursing (DON). She said they can reorder medications on the MAR. On 10/22/21 at 12:31 p.m. in a follow up interview with the DON, she revealed the Prednisone had been delivered to another nursing unit. She confirmed there were eight days the Prednisone was not given but had been signed (documented as administered) on the MAR. A review of the inventory list for the EDK dated 10/22/21 showed both medications were available in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure pharmacist recommendations for one resident (#2) of five residents sampled were reviewed and implemented, or if rejected the facility failed to ensure a rationale was provided by the physician, within a timely manner. Findings included: Resident #2's admission Record revealed an initial admission date of 12/24/19, and an admission date of 10/18/21 with medical diagnoses of chronic atrial fibrillation, adult failure to thrive, acute respiratory failure, history of falling, and Alzheimer's disease. Resident #2's care plan revealed a focus area, revised on 01/15/21, of [Resident #2] has altered cardiovascular status. Interventions for this focus area included administering medications as ordered by the physician, monitor, document, and report signs/symptoms of anti-arrhythmia complications such as chest pain, vital signs as ordered and notify physician of any abnormal readings. A review of the Consultation Report, recommendation date of 09/01/21, revealed Comment: [Resident #2's] medication administration record (MAR) or prescriber order sheets (POS) includes items that need clarification . Please clarify the following items . 1. New Digoxin order needs a pulse prompt . Response Requested . The document did not have a physician response nor was the document signed or dated by the physician. Resident #2's MAR report for September 2021 revealed, Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure . Start Date 08/31/2021 0900 . D/C (Discontinue) Date 10/15/2021. Further review revealed from 09/01/21 to 09/30/21 no pulse at the time of medication administration was recorded. The Order Summary Report as of 10/22/21 revealed Resident #2 was prescribed one daily Digoxin 125 MCG (microgram) tablet to be provided by mouth for dysrhythmia. This was ordered on 10/18/21. A review of the Consultation Report, recommendation date of 10/08/21, revealed Comment: [Resident #2's] medication administration record (MAR) or prescriber order sheets (POS) includes items that need clarification . Please clarify the following items . 1. New Digoxin order needs a pulse prompt . Response Requested . The document did not have a physician response. The document was had an illegible signature on the Unit Manager line with a date of 10/12/21. Resident #2's MAR report for September 2021 revealed Digoxin Tablet 125 MCG . Start Date 08/31/2021 0900 . D/C (Discontinue) Date 10/15/2021. Resident #2's pulse was recorded at the time of medication administration on 10/14/21 and 10/15/21. Further review revealed Digoxin Tablet 125 MCG . Start Date 10/19/021 0900. No pulse was recorded at the time of medication administration from 10/19/21 to 10/22/21. An interview on 10/22/21 at 9:36 a.m. with the Director of Nursing (DON) revealed recommendations from the pharmacist are reviewed immediately. The requests are either discussed with the doctor over the phone, or they are placed into their files for review once they come to the facility. The DON reviewed Resident #2's online medical record and confirmed a pulse was not recorded at the time of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0756 Level of Harm - Minimal harm or potential for actual harm administration for Digoxin until 10/14/21. Resident #2 was sent to the hospital on [DATE] (for an unrelated event) and returned on 10/18/21. When a resident goes out to the hospital and returns, the medications and physician orders are reconciled to make ensure the continuality of care. Usually, the follow-up time frame for the recommendations is within 2 weeks. The DON confirmed it is the nursing standard of practice to measure a resident's pulse prior to administrating Digoxin. Residents Affected - Few An interview on 10/22/21 at 9:54 a.m. with Staff A, Licensed Practical Nurse (LPN) revealed that prior to administering medication, a resident's vitals are taken including the pulse. Related to Digoxin, Staff A stated currently Resident #2 did not have pulse parameter physician orders for Digoxin administration. Staff A, LPN said, I would withhold it [Digoxin] if her pulse was below 50, or is it 60? Honestly, I would not give it if her pulse was below 50. A follow-up interview on 10/22/21 at 12:58 p.m. with the DON revealed the standard of practice is that Digoxin is not administered if a resident's pulse is less than 60. If the medication is administered with a pulse level less than 60, it can slow the heart further and cause complications. The DON confirmed the lack of pulse monitoring logged at the time of Digoxin medication administration and implementation of the pharmacist recommendation. A policy review of Medication Regimen Review [MRR], effective 12/01/07, revealed . The consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement . Facility should independently review each resident's medication regimen directly from the resident's medical chart and with the Interdisciplinary Care Team members, resident or Responsible Party, as needed . Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR Facility should encourage Physician/Prescriber to either (a) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected . Facility should provide the Medical Director with a copy of the MRRs and should alert the Medical Director where MRRs require follow-up . Facility should maintain copies of MRRs on file in Facility, either as part of the resident's permanent medical record or in a special file, in accordance with Applicable Law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 behavior and side effect monitoring for psychotropic medication was conducted for one resident (#29) of five residents sampled. Residents Affected - Few Findings included: An observation on 10/20/21 at 3:13 p.m. revealed Resident #29 in bed in her night gown and stated she fell from bed the previous night as she attempted to go the restroom herself without waiting for staff to assist her. An additional observation on 10/21/21 at 12:38 p.m. revealed Resident #29 laying down in bed facing the window with the lunch tray untouched. An interview was attempted and Resident #29 did not respond. Review of Resident #29's admission Record revealed that Resident #29 was readmitted to the facility on [DATE] and with an original admission date of 8/4/21. Review of a 5-day Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the physician orders as of 10/21/21 showed Resident #29 had an active order, with a start date of 08/23/21, for Mirtazapine 7.5 mg (milligrams.) Give 2 tablets by mouth at bedtime for depression. The orders did not include behavior and side effect monitoring for the anti- depressant. Review of the October 2021 Medication Administration Record (MAR) showed Mirtazapine 7.5 mg was administered as ordered and the facility was not monitoring behavior and side effects for the use of the anti-depressant. A psychological evaluation for Resident #29 dated 09/08/21showed Resident #29 was seen for adjustment disorder with depressed mood, other recurrent depressive disorders. The primary goal of the visit indicated Resident #29 has been sleeping more and is less talkative the last several visits. Review of a psychological note dated 10/04/21 showed Resident #29 was seen for a follow-up and psychotropic medication evaluation. Resident #29 had a history of depression and insomnia. The note revealed a care plan with recommendations to continue Mirtazapine 15mg at HS (hours of sleep) and to continue to monitor for mood, sedation, medication side effects and behaviors. A psychological progress note dated 10/06/21 identified a goal to continue follow-up on a bi-weekly basis to address treatment goals of reduced depressive and anxious symptoms and improve coping and interpersonal strategies through the use of motivational enhancement and cognitive behavioral therapies. On 10/22/21 at 9:56 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation is for behavior and side effects monitoring to be completed for anti-depressant and anti-psychotic medications. The DON reviewed Resident #29's MAR for October 2021 and stated it [the monitoring] should have been put in. The DON said, There is no reason why we are not monitoring. The DON further stated they were monitoring before the resident went to the hospital and provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the MAR dated 08/01/21 - 08/31/21 showing monitoring stopped on 08/12/21. The DON said, When she returned on 08/16/21 orders were not restarted and no one caught it. We will start the orders today. The MAR dated 08/01/21 - 08/31/21 showed that Resident #29 was being monitored for depression with difficulty sleeping every shift for depression with insomnia. Monitor side effects to include 0=none, 1=nausea/vomiting, 2=constipation, 3=confusion, 4=anxiety, 5=diarrhea, 6=hypotension, 7=tremors, 10=weight loss /gain, 11=dry mouth, 12=blurred vision and 13=urinary retention. Start date 05/04/21 and D/C (discharge) date 08/12/21. An interview was conducted on 10/22/21 at 11:31a.m. with the facility's pharmacist. The Pharmacist stated she would expect monitoring for a resident taking any anti-depressant. The Pharmacist stated they should be monitoring for set parameters related to dose tolerance and effectiveness. On 10/22/21 at 1:58 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A stated they conduct behavior monitoring, side effects monitoring and pain monitoring for all residents taking antipsychotic and antidepressant medications. Staff A stated the monitoring should be in the orders. Staff A said, [Resident #29] is on anti-depressant so we should be monitoring. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, reviewed and revised in May 2018, Policy Statement #4 showed, The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Under the Monitoring section it showed: 1. If the resident is being treated for altered behavior or mood, the IDT (interdisciplinary team) will seek and document any improvements or worsening in the individual's behavior, mood and function. 2. The IDT will monitor progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. 4. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications, for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. 5. (a) The IDT will monitor side effects and complications related psychoactive medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility did not ensure medications were secured for two residents (#47 and #48) out of 29 residents. Findings included: 1. During a facility tour on 10/19/21 at 10:20 a.m., Resident #47 was observed sitting in her wheelchair positioned by her bedside. Resident #47 was noted sleeping and did not respond to the request for interview. An empty medicine cup and a yellow powdered substance were observed spilled on the floor to the left of Resident #47's bed. (Photographic Evidence Obtained) On 10/19/21 at 11:03 a.m., a second observation revealed the yellow powdered substance on the floor. An immediate interview was conducted on 10/19/21 at 11:03 a.m., with Staff B, Registered Nurse (RN). Staff B stated Resident #47 takes her medications crushed. Staff B stated that she had crushed Resident #47's medications and put them in apple sauce that morning. Staff B made the observation of the yellow powdered substance on the floor and said, It looks like medicine to me. It is not from this morning. It maybe 3:00 (p.m.) -11 (p.m.) shift. Staff B stated the only thing she could think of is the yellow powder was crushed baby aspirin which the resident takes. On 10/21/21 at 10:31 a.m., a brown pill was found on the floor inside the doorway of Resident #47's room. (Photographic Evidence Obtained) A review of the admission Record for Resident #47 revealed she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, other seizures, cerebral infarction, unspecified chronic obstructive pulmonary disease, type 2 diabetes, atrial fibrillation, essential (primary) hypertension, hypertensive heart and chronic kidney disease, and dementia without behavioral disturbance. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section C - Cognitive Patterns, showed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognition impairment. 2. During a tour of Resident #48's room on 10/21/21 at 10:45 a.m., an observation was made of a small, round peach-colored pill on the floor. The pill was underneath a wheelchair positioned in the corner of the room to the left of the bed. (Photographic Evidence Obtained) On 10/21/21 at 11:19 a.m., the Director of Nursing (DON) conducted a tour of the rooms for Residents #47 and #48. The DON saw the pills on the floor and asked Staff C, RN to identify them. Staff C stated the small peach colored pill was Hydralazine for Resident #48. The DON stated the brown one was an over the counter (OTC) Senokot. The DON stated that it is a laxative and multiple residents take it as needed. The DON stated the crushed pills in Resident #47's room could not be immediately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few identified. The DON stated it might be a baby aspirin. Staff C said, She [Resident #47] does not take any yellow pills. The DON said, This is concerning. We will conduct further investigation. A review of the admission Record for Resident #48 revealed that she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease unspecified, paroxysmal atrial fibrillation, and essential hypertension, Review of the Quarterly MDS dated [DATE] Section C - Cognitive Patterns, showed Resident #48 had a BIMS score of 10, indicating moderate cognition impairment. A review of physician's order for Resident #48 dated 10/21/21 confirmed an active order for Hydralazine HCL tablet 10 mg (milligrams), give one tablet by mouth every 8 hours for HTN (hypertension). On 10/21/21 at 1:08 p.m., an interview was conducted with Staff C, RN. Staff C stated that pills should not be found loose on the floor because another resident could take them. Staff C stated the pills could fall maybe when they [nurses] are popping from the blister. Staff C said, Either way they should find the pill that falls and dispose per protocol. Residents should be supervised during med administration. On 10/22/21 11:27 a.m., a follow - up interview was conducted with the DON. The DON said, Pills should not be on floor. The expectation is to supervise resident's during medication administration. Review of a facility policy titled, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 01/01/13, showed: 3.3 Facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet / cart or locked medication room that is inaccessible to residents and visitors. A facility policy titled, 6.0 General Dose Preparation and Medication Administration, revision date 01/01/23, showed: 3.9 Facility should not leave medications or chemicals unattended. 5.9 Observe the resident's consumption of the medication(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility did not ensure dental services for treatment were provided to one resident (#20) of twenty-five sampled residents. Residents Affected - Few Findings included: Resident #20 was originally admitted to the facility on [DATE] with diagnoses to include cerebral infarction, according to the admission Record. On 10/19/21 at 10:36 a.m. an interview and an observation were conducted with Resident #20. She had eight teeth that needed to be fixed; seven on the right and one on the left. Resident #20 had some missing teeth noted on the right upper side of her mouth. She stated she had never seen a dentist. On 10/20/21 at 3:45 p.m. an interview was conducted with Staff F, Social Services Coordinator. She said that usually the nurse, CNA (certified nursing assistant) or herself is informed of dental issues and she makes a referral unless it's an emergency. Dental services comes once a month. The facility just changed companies. Once a year they do an annual check. There is the standard cleaning and checkups. If they are not on the main list, and if they need service, we make a referral. We switched dental service companies in August (2021). On 10/20/21 at 3:58 p.m. a follow up interview was conducted with Staff F, Social Services Coordinator. Staff F said Resident #20 had a yearly assessment on February 24th (2021). She had a denture follow-up on March 23rd. She had partial dental impressions done on May 21st. She may have a partial. On 10/20/21 at 4:09 p.m. a follow up interview was conducted with Resident #20. She said she needed the hole on the right side of her upper mouth where she was missing some teeth, addressed. On 10/20/21 at 4:17 p.m. an interview was conducted with Staff J, CNA. Staff J said Resident #20 doesn't have dentures. A review of the dental visit made by the dental assistant dated 2/12/21 reflected an upper denture was recommended. A review of the dental visit made by the registered dental hygienist on 2/24/21 revealed Resident #20 had 6 missing maxillary teeth and 2 missing mandibular teeth and that Resident #20 had natural teeth without dentures. A review of the 5/21/21 dental services visit made by the dental assistant indicated Resident #20 was scheduled for impressions but complained of dental pain. Will need X-rays next visit and plan for symptomatic teeth. Review of the 6/24/21 dental services visit made by the dental assistant revealed Resident #20 wants extractions and partials made. Today is our last visit. Will need to seek treatment with a new dentist. Review of notice of termination with dental services provider reflected a termination date of 7/31/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0791 Level of Harm - Minimal harm or potential for actual harm A review of the contract for the new dental services provider reflected a contract signature date of 5/27/21 by the facility representative. Review of the consent for services, including impressions and dentures, signed by Resident #20 revealed a date of 8/30/21. Residents Affected - Few On 10/21/21 at 10:09 a.m. another interview was conducted with Staff F, Social Services Coordinator. Staff F said they changed companies. The new company just started coming. They had to get all the consents for the residents first. On 10/21/21 at 10:11 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She said she thinks the new company has been coming out. They came out and were getting everybody signed up and ready to go. Resident #20 was signed up in August (2021). On 10/21/21 at 12:19 p.m. a follow up interview was conducted with the NHA. She said Resident #20 told the previous unit manager about her dental concerns and she didn't follow up. That unit manager is no longer here. We dropped the ball. We contacted the dental company already and they will be coming out to see her. Review of the policy, Dental Services, revised December 2016, revealed the following information: Policy Statement Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation 1. Routine and 24-hour emergency dental services are provided to our residents through: a. a contract agreement with a licensed dentist that comes to the facility monthly. 6. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 17 of 17