Inspection·February 8, 2024

F 0550 Policy Interpretation and Implementation: Level of Harm - Minimal harm or potential for actual harm 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Residents Affected - Few U. Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; V. have the facility respond to his or her grievances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 2 of 13 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 02/08/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to accurately document for one resident (#107) on a discharge Minimum Data Set (MDS) out of five residents reviewed for transfer and discharge. Residents Affected - Few Findings included: A review of Resident #107's admission Record showed Resident #107 was admitted to the facility with diagnoses including pneumonia, low back pain, muscle weakness, and anxiety. A review of Resident #107's Physician order, dated 1/6/24, showed: Ok [okay] to discharge home on 1/6/24 with remaining medications and home health services. A review of a Care Plan Note, dated 10/26/23, showed the following: Focus: Resident #107 wishes to return home with spouse Goal: Discharge goals are to return home when therapy goals are met/medically appropriate for discharge. Interventions: Establish a pre-discharge plan with [Resident #107]/family/caregivers and evaluate progress and revise plan; Make arrangements with required community resources to support independence post discharge home care, PT (physical therapy), OT (occupational therapy), MD (medical doctor), wound nurse; Provide discharge teaching. A review of Resident #107's Transition of Care and Discharge summary, dated [DATE], showed the following: Section A, discharge to Home/ Community, and the reason for discharge, condition improved is selected. Section C, Contacts and Follow-up revealed Home Health Nursing and Therapy services have been arranged for Resident #107. During an interview on 2/8/24 at 10:49 a.m. the Social Services Director (SSD) said on 1/6/24 Resident #107 was discharged from the facility. During an interview on 2/8/24 at 12:17 p.m. the Minimum Data Set Director (MDSD) stated Resident #107 was discharged home. The MDSD reviewed Resident # 107's MDS, Discharge Return Not Anticipated, dated 1/6/24 and stated section A 2105 showed the resident was discharged to a Short-term General Hospital was incorrect. She stated the record would need to be amended. A review of the facility's policy, titled, Certifying Accuracy of Resident Assessment, version 1.1 showed the following: Policy Statement All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 3 of 13 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 02/08/2024 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 0641 Policy Interpretation and Implementation: Level of Harm - Minimal harm or potential for actual harm Section #2 All personnel who complete any portion of the MDS assessment, tracking form, or correction request form must sign a hard copy of such assessment certifying the accuracy of the portion of the assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 4 of 13 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 02/08/2024 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 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 interviews, observations, and record review the facility did not ensure pressure relieving interventions were ordered and implemented for one resident (#67) out of three sampled residents. Residents Affected - Few Findings included: A review of Resident #67's admission record showed the resident was admitted on [DATE] with diagnoses to include Fournier Gangrene, abscess of the penis, Diabetes Type II, Alzheimer's disease, and peripheral vascular disease. On 2/6/24 at 2:16 p.m. Resident #67 was observed lying on an air flowing parameter mattress, wearing a hospital gown and non-skid socks. A review of the Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) was not assessed, Short term memory OK revealed a score of 1, Cognitive Skills for Daily Decision Making score of 1 indicating Resident #67 had modified independence. A review of the care plan, dated 12/4/2023, revealed the following: Focus: Resident #67 had actual impairment to skin integrity r/t (related to) diabetic ulcer (wound) to left heel and left medial foot. Goal: Resident #67 will have no worsening skin alteration through review date. Interventions: (dated 12/4/24) to provide treatment per physician order; and follow up interventions; (dated 2/1/24) Resident # 67 to wear [heel protection boot] and to lay on a pressure reduction mattress. A review of Resident #67's Order Summary Report, dated 12/4/23, showed [sic] wound consult and for a pressure redistribution mattress. An order, dated 12/11/23, showed [pressure always relieving boot] on as tolerated every shift. A review of Resident #67's Medication Administration Record (MAR) for January 2024 revealed the use of pressure relieving boots were documented daily while the resident was in the facility. For 2/2/24-2/6/24 there was no documentation indicating pressure relieving boots were worn or refused by Resident #67. A review of Resident #67's wound evaluation and management summary, dated 1/23/24, revealed the following: At the request of Resident #67's doctor, a thorough wound assessment and evaluation was performed. Resident #67's review of systems (ROS) revealed skin support surfaces in use included Group 2 bed mattress (a type of pressure-reducing support surface used to treat or prevent skin tissue breakdown) and pressure relieving boot on the feet. A review of Resident #67's wound evaluation and management summary, dated 2/6/24, revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 5 of 13 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 02/08/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #67's review of systems (ROS) showed support surfaces of Group 2 bed mattress and pressure relieving boot. A review of a focused wound exam of the diabetic wound of the left heel, full thickness, dated 1/23/24, showed the wound size 0.3 cm Length (L), 0.5 cm Width (W), 0.1 cm Depth (D) and the wound surface area of 0.15 cm2. A review of a focused wound exam of the diabetic wound of the left heel, full thickness, dated 2/6/24, showed the wound size 0.6 cm Length, 0.4 cm Width, 0.1 cm Depth and the wound surface area of 0.16 cm2. Recommendations included an off-load boot for Resident #67. During an interview on 2/7/24 at 8:20 a.m. Staff E, Licensed Practical Nurse (LPN) said he had just change the dressing on Resident #67's left heel and confirmed the resident was not wearing a heel protection boot. Staff E was unable to locate a heel protection boot in Resident' 67's room and said he would check for orders regarding the heel protector. On 2/7/24 at 11:21 a.m. Resident # 67 was observed lying in bed with a heel protection boot on his left heel and a second boot was on top of the dresser at the foot of the resident's bed. On 2/7/24 at 3:49 p.m. an interview was conducted with Staff G, Licensed Practical Nurse, Unit Manager (LPN, UM). She said orders for a pressure reduction mattress and heel protection boots were ordered today (2/7/24). Staff G said staff is expected to document on Resident #67's Treatment Administration Record (TAR) when heel protection devices and the pressure reduction mattress are in use. A review of the facility policy titled Prevention of Pressure Ulcers, dated May 2018, reviewed and revised October 2019, revealed the following: -Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factor and interventions for specific risk factors. -Preparation: Review the resident's care plan to assess any special needs of the resident. - interventions and Preventative Measures, General: For a person in bed determine if the resident needs a special mattress. -Risk Factor-Immobility: When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from the knee to ankle or with other devices as recommended by clinical staff or by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 6 of 13 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 02/08/2024 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure one resident (#41) out of thirty-four sampled residents, was provided with ordered psychiatric services; during two of three visits (11/30/2023 and 12/21/2023). Findings included: On 2/5/2024 at 10:03 a.m. Resident #41's room was observed to be on isolation precautions, with signage on the door and Personal Protective Equipment at door side. Resident #41 was overheard calling out multiple times, help, help. Staff responded to the resident and were able to calm the resident. The resident was overheard crying softly at 11:35 a.m. and 2:00 p.m. Staff responded to the room and intervened. On 2/6/2024 at 8:30 a.m. Resident #41 was observed in her room. The resident was overheard crying softly while lying in bed. Staff responded and intervened. This behavior was again overheard at 11:23 a.m. On 2/7/2024 at 7:50 a.m. Resident #41 was observed in her room and lying in bed. She was noted crying softly and calling out help. Staff were observed to respond and intervene. A review of the medical record revealed Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #41 had a Power of Attorney in place to make her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dementia, and altered mental status. A review of the Minimum Data Set assessment (Medicare 5 day), dated 1/10/2024, revealed; Cognition: Brief Interview Mental Status score 3 of 15, indicating Resident #41 would not be able to be interviewed related to her care and services. A review of the Physician's order, dated 11/29/2023, revealed psychology services to eval and treat resident for placement in new environment. A review of the Symptom Checklist referral page to psychiatric services, dated 11/30/2023, revealed Resident #41 is to be seen for adjustment to new environment. A review of the Physician's order, dated 12/21/2023, revealed psychology service for sadness. A review of the Symptom Checklist referral page to psychology services, dated 12/21/2023, revealed Resident #41 to be seen for depressive symptoms to include sadness. A review of the nursing progress notes, revealed the following; (a.) 11/30/2023 13:01 Social Service note - Referral sent to [Psychiatric services provider] services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 7 of 13 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 02/08/2024 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 0742 (b.) 12/9/2023 Nursing note - Increased confusion. Level of Harm - Minimal harm or potential for actual harm (c.) 12/9/2023 Nurse narrative change of condition seems different than usual tired, weak confused, drowsy. Send to ER [Emergency Room] per MD [Medical Doctor]. Residents Affected - Few (d.) 12/13/2023 Nurse Note 18:50 - Upon admission while attempting to examine skin for any abnormalities or open areas resident refused to let me assess back or buttocks for open areas. Resident smacked my arm x2 and kept screaming, 'no I don't want you to, when attempting to assess back and buttocks, was not able to see if there was any open areas due to this. Reattempted 2 hours later with different CNA [Certified Nursing Assistant], resident apologized upon entering room but when asked if we could look at buttocks, resident answer still no she stated the reason for being , they just did this (most likely referring to hospital skin check). Will attempt later in night. (e.) 12/13/2023 Nurse note 22:20 - Reattempted to assess residents skin on back and buttocks for the third time, resident still refused to let us look at skin. Resident kept shaking head and repeatedly saying NO when attempting. (f.) 12/14/2023 Nurse note 22:23 - Pt is considerably more confused than before she went to the hospital. Frequently calling out, patient is lonely. (g.) 12/15/2023 Nurse Note 09:20 - NP [Nurse Practitioner] and POA [Power of Attorney] notified related to increased confusion. Labs ordered. (h.) 12/21/2023 Social Services - Referral sent to [Psychiatric services provider] Services for sadness. (i.) 12/29/2023 SBAR Change in Condition, MD notified and ok to send to ER. (j.) 1/6/2024 Nurse note - RETURN FROM HOSPITAL. (k.) 1/9/2024 00:00 Encounter note/assessment - Psych note/visit. Assessment completed and notes indicated to follow up within one week or sooner if clinically indicated to evaluate mood and medication efficacy as pt. adjusts to loss of independence. (l.) 1/12/2024 11:15 Social Service note - Referral sent to [Psychiatric services provider] Services. (m.) 2/3/2024 20:44 Nursing Note - Went to retake BS [blood sugar] at 8pm resident refused and was combative, supervisor provided accu check. Resident refused to eat or drink dinner. MD made aware and unsuccessful attempt to call POA. (n.) 2/3/2024 22:01 SBAR - Change of Condition r/t Behavioral symptoms e.g. agitation, psychosis). (o.) 2/4/2024 07:40 Nurse note - Left message with psych to see resident for behaviors. On 2/8/2024 at 9:10 a.m. an interview with the Director Of Nursing (DON) and the Nursing Home Administrator (NHA) was conducted. The DON confirmed Resident #41 had several psychiatric referrals during her admission to include on 11/30/2023, 12/21/2023, and 1/12/2024. The DON explained if the referral is psychology or psychiatry, the timeframes for actual visits are a little different. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 8 of 13 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 02/08/2024 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the 11/30/2024 referral was for a psychiatry visit and the visit actually happened on 12/6/2024. The DON stated the visit should have been conducted more timely than seven days. She was not sure as to why it took so long for the visit/assessment to be conducted. The DON verified a nurse progress note, dated 12/21/2023, was a psychiatric (psych) referral related to depressive symptoms of sadness. The DON provided the Symptom Checklist referral sheet, dated 12/21/2023, which was sent to psych. services. The DON could not confirm the referral was acted upon and completed from psych services. The DON stated per the psych services referral, dated 12/21/2023, the visit from psych services should have been conducted and completed prior to Resident #41's hospitalization on 12/29/2023. The DON and the NHA stated the visit had never been completed by psych services after the 12/21/2023 referral. The DON stated Resident #41 was again referred to psych services on 1/12/2024 with a visit from psych services conducted on 1/16/2024. On 2/8/2024 at 10:05 a.m. a follow up interview with the NHA was conducted. She stated she had reviewed Resident #41's medical record and found a referral for psych services, dated 12/21/2023. She stated the referral was sent to psych services but a visit to Resident #41 never occurred. The NHA stated she called psych services with reference to the referral and asked why this visit did not occur. The NHA stated she was told they received the referral but felt there was not criteria to meet a visit. The NHA stated they did not give her any further information as to why the psych visit was not conducted. She stated psych services did not communicate their decision back to the facility administration. She stated based on review of the medical record and the referral criteria; Resident #41 was presenting with behaviors of sadness, which would benefit from a psych service visit. On 2/8/2024 at 10:40 a.m. an interview with the Social Services Director (SSD) revealed when a resident is admitted , they will do a mini mental health evaluation, as well as look for behaviors and indicators that might require a psychiatric or psychological service visit. She stated once a resident is admitted , the resident is observed and evaluated daily, and if a resident presents with any behaviors that may require a psychiatry or psychological service visit she (social service department), or a unit nurse manager will evaluate the behaviors and then notify the resident's primary physician of the behaviors. She stated the primary physician will then order a referral to psych services, and have them come out for a visit/assessment. The SSD stated after psych services obtains the referral, it will generally take a couple days until the visit. The SSD confirmed she had put in to get an order and referral to Resident #41's primary care physician and psych services on 11/30/2023. She stated the referral and order was placed and sent to psych services, and the visit did not happen until 12/6/2023. The SSD did not know why it took a week to conduct the visit, but agreed a week was not considered a timely visit. The SSD confirmed she had put in to get an order and referral to Resident #41's primary care physician and psych services on 12/21/2023, with relation to increased sadness. She confirmed there had been progress notes, dated 12/13/2023, that identified Resident #41 screaming at and smacking staff, showing behaviors other than sadness. The SSD stated psych services did not come out, nor communicated to them the reason for the missed visit/evaluation. The SSD stated she did not follow up with psych services after the referral was sent to them on 12/21/2023, and she did not follow up with psych services as to why the visit did not occur. A review of the facility policy titled Telephone Orders, revised February 2014, revealed the following: Policy: Verbal telephone orders may be accepted from each resident's attending physician. 1. Verbal telephone orders may only be received by licensed personnel. Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 9 of 13 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 02/08/2024 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information; 3. Telephone orders must be countersigned by the physician during his or her next visit; 4. Unless otherwise prohibited by law, verbal telephone orders for Scheduled II drugs will be permitted in accordance with facility policy. The facility did not have a specific policy and procedure related to obtaining orders and the implementation of timely services for outside facility therapy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 10 of 13 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 02/08/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations and interview, the facility failed to properly wear Personal Protective Equipment (PPE) to mitigate the spread of COVID-19 for three residents (#7, #63, #10) out of 10 residents positive for COVID-19 in the facility during a COVID-19 outbreak. Residents Affected - Some Findings Included: A review of the facility's Special Droplet/Contact Precautions isolation sign revealed the following: Everyone Must: including visitors, doctors and staff Clean hands when entering and leaving room Wear face mask Wear eye protection (face shield or goggles) Gown and glove at door . A review of Resident #63's Physician order, dated 1/28/24, revealed Isolation-Droplet COVID + every shift for isolation for 10 days. A review of Resident #7's Physician order, dated 1/30/24, revealed Special droplet/contact isolation every shift for COVID + 1/29 for 9 days. A review of Resident #10's Physician order, dated 1/30/24, revealed Special droplet/contact isolation every shift for COVID 19 + 1/20 for 9 days, An observation was conducted on 2/6/24 at 9:04 a.m. Staff B, Licensed Practical Nurse (LPN) was observed to don a gown, then a N95 mask over her surgical mask, she secured the top tie to the crown of her head and left the bottom tie hanging by her neck. She donned a face shield and put on gloves, picked up a medicine cup with pills in it and entered Resident #63's room with a Special Droplet/Contact Precautions sign posted on the door. She came out of the room and only had on a surgical mask. An observation was conducted on 2/6/24 at 9:12 a.m. Staff B, LPN was observed to don a gown, then a N95 mask over the same surgical mask, she secured the top tie to the crown of her head and left the bottom tie hanging by her neck. She donned a face shield, put on gloves, picked up a medicine cup from the PPE cart outside of the room and said, I need to give her this one pill, she entered into Resident #63's room again, with the Special Droplet/Contact Precautions sign posted on the door. When she came out of the room she only had on her surgical mask. A medication administration observation was conducted on 2/6/24 at 9:40 a.m. with Staff B, LPN. She was observed to don a gown, then a N95 mask over her surgical mask, she secured the top tie to the crown of her head and left the bottom tie hanging by her neck. She donned a face shield and put on gloves and entered into Resident #7's room with a Special Droplet/Contact Precautions sign posted on the door. During the medication administration Staff B, LPN was observed to pull both, the N95 mask and the surgical mask, down below her lips under the face shield, leaned towards Resident #7, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 11 of 13 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 02/08/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she spoke to the resident with both masks still below her lips. Staff B, LPN was observed to doff her gloves, gown, face shield, and N95 mask and exited the room with the same surgical mask on. An interview was conducted with Staff B, LPN on 2/6/24 at 10:05 AM she said she was educated not to wear her surgical mask under her N95 and to make sure both straps of the N95 mask were secured around her head. She said wearing the surgical mask under her N95 and not strapping the bottom strap of the N95 mask, It's just what I do. An observation was conducted on 2/6/24 at 9:51 a.m. of Staff C, Certified Nursing Assistant (CNA) coming out of Resident #7's room with a Special Droplet/Contact Precautions sign posted on the door, with her N95 mask and her face shield on. She was then observed to go to Resident #10's room which was observed to have a Special Droplet/Contact Precautions sign posted on the door. She was observed to don a gown, and gloves and entered the room with the same N95 and face shield on. An interview was conducted with the Director of Nursing (DON) on 2/6/24 at 10:25 a.m. she confirmed staff are not supposed to wear a surgical mask under their N95 masks and both straps are supposed to be secured around their head. She said staff should not be pulling their masks down in an isolation room which requires a mask to be worn. She also confirmed face shields and N95 masks are single use and should not be worn room to room. An interview was conducted on 2/8/24 at 9:38 a.m. with Staff D, Infection Preventionist and the DON. They said the facility has been in a COVID-19 outbreak since December 20th, 2023. A review of the facility policy titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, undated, revealed the following: . Remember: PPE must be donned correctly before entering the patient area (e.g. isolation room, unit of cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be readjusted (e.g. retying gown, adjusting respirator/facemask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care. Preferred PPE -Use N95 or Higher Respirator Face shield or goggles N95 or high respirator . One pair of clean, non-sterile gloves Isolation gown Donning (putting on the gear) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 12 of 13 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 02/08/2024 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 0880 4. Put on NIOASH-approved N95 filtering facepiece respirator or higher . Level of Harm - Minimal harm or potential for actual harm Facemask: Mask ties should be secured on crown of head (top tie) and base of neck bottom tie) . Doffing (taking off the gear): Residents Affected - Some 5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles. 6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 13 of 13