Health inspection·January 10, 2020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete invited to attend but did not come to his care plan meeting. Advance directives were discussed today and will continue to remain in place. [Resident #42] currently has a DNR [Do not resuscitate] and Durable Power of Attorney in place. On [DATE] at 3:51 p.m., during an interview with the social worker, he said Resident #42 was his own person and was able to make his own decisions. He said the spouse may have signed the DNR because at that time he may not have been able to make his own decisions. He verified the lack of an incapacity statement for the resident. He said other than the BIMS (Brief interview for mental status) completed on 6/19 showing memory impairment, there was no documentation showing an incapacity. He said he will have to call the physician to conduct an evaluation. Event ID: Facility ID: 106070 If continuation sheet Page 2 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on record review, facility policy and procedures review, and staff interview the facility failed to follow their policies and procedures and neglected to provide the influenza (flu) vaccine in a timely manner to 33 of 43 residents who requested the flu vaccine, which contributed to (Resident #99, #14, #45) hospitalizations due to the flu virus. The facility did not develop a plan of action to ensure the timely vaccination of the residents. The facility failed to implement measures to protect the residents who cannot receive the flu vaccine. The facility failed to notify the Medical Director when the residents did not receive the flu vaccine. These actions resulted in immediate jeopardy that started at the beginning of the flu season on 10/1/19. The facility was informed of the immediate jeopardy on 1/9/20 and was provided the Immediate Jeopardy Template. The jeopardy was removed on 1/10/20 when corrective actions were verified in place. The scope and severity was reduced to E. The findings included: Review of the facility's policy 200.460.1 (revised 8/2016) titled Infection Control, Immunizations and Vaccinations indicated It is the policy of this facility that all residents receive immunization and vaccinations that help in preventing infectious diseases, unless medically contraindicated or otherwise ordered by the resident's attending physician .The flu vaccine should be administered at least two months before the expected start of the flu season in the community. On 1/8/20 at 3:11 p.m., during a review of the facility's immunization program the Director of Nursing (DON) said the facility experienced a flu outbreak in late November early December. The DON said she started employment at the facility on 10/1/19 and realized around 10/30/19 the facility had not initiated the flu immunization for residents and staff. The DON said although they immediately obtained consents and started to administer the vaccines on 10/31/19 to the residents who requested it, it did not prevent the outbreak. She collaborated with the local Health Department who recommended Tamiflu for residents that contracted the flu, but it would be very costly to the residents. On 1/9/20 at 5:26 p.m., the DON verified the facility had not provided the flu vaccine to staff and residents prior to the beginning of flu season. The DON said, The residents did not receive the care they needed. Review of the QAPI (Quality Assurance and Performance Improvement) minutes dated 11/13/19 and 12/11/19 did not have documentation the facility failed to offer and administer the flu vaccine in a timely manner to the residents. On 1/9/20 at 4:46 p.m., during an interview the Assistant Administrator verified neglect could be unintentional lack of care of residents. He said he realized not administering the flu shots to residents in a timely manner was neglect he would have notified the ombudsman. He said the family members should have been made aware three residents were hospitalized and had not been administered the flu vaccine prior to the start of flu season. He said he was not aware why the Medical Director was not informed by the facility of the incident. On 1/9/20 at 5:26 p.m., the Nursing Supervisor said he had not been oriented to the facility policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 3 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0600 Level of Harm - Immediate jeopardy to resident health or safety on providing the flu vaccine. He said when he found out he was late with providing the vaccine to residents he got the consent forms to the residents and families as quickly as he could. On 1/10/20 at 10:00 a.m., the Pharmacist said eight vials of flu vaccine were available at the pharmacy for the facility and have been sitting at the pharmacy since April of 2019. The Pharmacist said the eight vials were enough to vaccinate 80 residents. Residents Affected - Some On 1/10/20 at 10:15 a.m., the Administrator said she defines neglect as intentionally not taking care of residents and not providing the care and services needed. The Administrator said a resident not being offered or receiving a flu vaccine when the vaccine was available for the residents in the facility was considered neglect. On 1/10/20 at 10:35 a.m., the Medical Director said a resident not receiving the flu vaccine when the resident, their family/or legal representative had requested to be vaccinated was neglect. The Medical Director said if the vaccine was available and was not administered in a reasonable time from the time the facility had the consent to administer the vaccine, he would consider it to be unintentional neglect. The Medical Director said the facility has no excuses for not administering the vaccine to the residents when it was available. On 1/9/20 at 3:40 p.m., the DON verified the facility failed to order and administer the flu vaccine to the residents prior to the start of the flu season. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admits she did not inform the Medical Director of the failure to obtain the vaccines in a timely manner, did not address it in QAPI, and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who could not receive the flu vaccine. The DON said although they have a QAPI meeting monthly, the lack of administration of the flu vaccine to the residents was not discussed and was not a priority on their agenda. The DON said she recently appointed Licensed Practical Nurse Staff M to be responsible for the infection control program, even though she had not been trained. Verification of the removal plan included: Reviewed documentation of written consent and administration to all residents who consented to receive the flu vaccine. Reviewed QAPI meeting notes and QAPI action plan dated 1/9/20 which included education of professional staff on influenza and infection control practices. Sign in sheets were reviewed and staff attendance was verified. Reviewed draft of new policy for Immunization and Vaccination which documents the Infection Control Nurse/DON will be responsible for obtaining and administration of the flu vaccine to residents before the beginning of the flu season effective immediately. Verified facility employees were educated regarding the importance of the flu vaccination, and that the employees were offered the vaccine free of charge. Sign in sheets for in-service reviewed. All employees who did not consent to vaccine will be required to wear a mask until the end of the flu season. Reviewed draft of new policy for Immunization and Vaccination included employees will continue to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 4 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0600 be educated on the importance of the flu vaccine and offered the flu vaccine free of charge. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 5 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the state's Long-Term Care Ombudsman Council (LTCOC) of facility-initiated transfers and discharges since 9/17/18. The Ombudsman was not notified of 11 (Resident #3, #14, #15, #17, #22, #25, #31, #35, #37, #45, and #99) of 11 sampled facility-initiated transfer/discharges. The failure to send notices of facility-initiated transfers and discharges to the LTCOC potentially prevents inappropriately discharged resident's access to an advocate to inform them of their options and rights. The findings included: Review of the documentation dated 1/6/20 provided by a representative of the LTCOC revealed their office had not received any notices of transfers or discharges since 9/17/18. Review of the facility discharge log from 2/3/19 through 1/6/20 revealed a total of 168 discharges; which included 67 discharges to the community, 89 transfers to acute care hospitals and 3 transfers to other healthcare facilities. Sampling of facility-initiated discharges 2/3/19 through 1/6/2020 found: Resident #3 had an unplanned discharged to an acute hospital on [DATE]. Resident #14 had a transfer to an acute care hospital on 1/9/2020. Resident #15 had an unplanned discharge to an acute care hospital on 9/16/19 and 9/25/19. Resident #17 had an unplanned discharge to an acute care hospital on 8/6/19. Resident #22 had an unplanned discharge to an acute care hospital on 6/25/19. Resident #25 had an unplanned discharge to an acute care hospital on [DATE]. Resident #31 had an unplanned discharge to an acute care hospital on [DATE]. Resident #35 had an unplanned discharge to an acute care hospital on [DATE]. Resident #37 had an unplanned discharge to an acute care hospital on 4/22/19 and 6/21/19. Resident #45 had an unplanned discharge to an acute care hospital on [DATE]. Resident # 99 had an unplanned discharge to an acute care hospital on [DATE]. There was no documentation at the time of the survey that the facility had notified the LTCOC of the facility-initiated discharges. During an interview on 1/6/20 at 2:55 p.m., with the Administrator, Director of Nursing and Social Worker, they all said they had not been sending the transfer/discharge notices to the Ombudsman's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 6 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0623 office. The Social Worker said the nurses completed the transfer/discharge notices, but were never sent to the LTCOC office Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 7 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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** 2. Resident #2 has a history of a Cerebral Vascular Infarction that occurred on 9/10/16 and suffered from hemiplegia. The MDS dated [DATE] showed the resident has impairment movement on one side. The MDS showed the resident was not receiving therapy and was not on a restorative program. There was no documentation of range of motion provided to the resident. Resident #2 was dependent on two staff members for bed mobility, transfers, dressing, and toileting. Review of the Restorative Care Plan dated 10/04/18 with a target date of 9/12/19 showed the resident was care planned for applying a palmar roll to the resident's right hand. On 1/10/2020 at 9:10 a.m., the Nursing Supervisor verified the care plan for restorative was a current care plan. The Nursing Supervisor verified Resident #2 currently had contractures to both her right upper and lower extremities. The Nursing Supervisor verified the resident needed Passive Range of Motion (PROM) to her right extremities to provide comfort and prevent worsening of the contractures. The Nursing Supervisor verified Resident #2 was currently not care planned to ensure PROM was performed by staff. 3. Review of Resident #3's Restorative Care Plan dated 8/16/19 with a target date of 12/4/19 showed the restorative aide was to apply a splint to the resident's extremities. No instructions or interventions were noted on the care plan. On 1/10/2020 at 9:15 a.m., the Nursing Supervisor said the resident suffered from contracture to her extremities and should be care planned for PROM for her comfort and to prevent decline to her extremities. There was no intervention noted for PROM. 4. Resident #13 had a history of Dementia, Dysphagia, and Chronic Pain. Resident #13's MDS showed she was dependent on two staff members for bed mobility, transfers, dressing, ambulating and dressing. The MDS showed the resident had impairment in movement bilaterally in her upper and lower extremities. Review of the Restorative Care plan provided by the facility initiated on 8/16/19 with a target date of 11/18/19 showed the resident was to have palm protectors to both hands. There was no intervention noted for PROM. On 1/10/2020 at 9:12 a.m., the Nursing Supervisor said the resident suffered from contractures in all of her extremities and would benefit from PROM exercises for comfort and to prevent further decline in her extremities. 5. On 1/6/2019 at 12:35 p.m., Resident #24 was observed with contractures to all his extremities. Both legs of the resident were observed to be bent and fixed. Resident #24 was initially admitted to the facility on [DATE]. He was readmitted on [DATE]. He received Occupational Therapy until 12/27/19. On 1/3/20 the Physical Therapy Director initiated a Restorative Program to apply a palm protector to the resident's right hand and provide active and passive range of motion to upper and lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 8 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 On 1/6/20 the resident was observed to be care planned for splinting program only. There were no interventions listed on the care plan for were or what to splint. On 1/7/20 at 1:00 p.m., the Nursing Supervisor said he started the resident's Restorative Program for range of motion as of that date. Residents Affected - Few On 1/10/20 at 8:27 a.m., the Physical Therapy Director said he was not aware the resident had not been receiving range of motion since 8/5/19 due to the resident being resistant to PROM. The Physical Therapist Director verified there could have been interventions to ease the resident's discomfort while performing PROM. The Physical Therapy Director could not explain why it took seven days for him to complete the Restorative recommendation so that a care plan could be initiated. 6. A review of the medical record for Resident #46 revealed a Restorative Nursing care plan instructing the resident was to receive a left-hand resting splinting program 6 days per week with the restorative aide. The Physician Order, dated 7/3/18, documented Resident #46 was to wear a left resting hand splint on during the day and remove at night. The medical record also documented Resident #46 had a diagnosis of hemiplegia (muscle weakness or partial paralysis on one side of the body). On 1/6/20 at 10:30 a.m., Resident #46 was observed in her room in bed. The resident had a contracture of her left hand. The resident did not have a splint on her left hand. On 1/07/20 at 9:50 a.m., Resident #46 was in her room in bed and she did not have a splint on her left hand. On 1/07/20 at 10:22 a.m., in an interview with the Therapy Director he said he was not working with Resident #46 and had not worked with her in the last six months. The Therapy Director confirmed he does not have a restorative program for Resident #46's left hand splint. On 1/07/20 at 3:24 p.m., in an interview with Licensed Practical Nurse, Staff D said she was not aware Resident #46 had a left-hand splint and confirmed the resident was not able to move her left hand. On 1/08/20 at 8:45 a.m., in an interview the Restorative Aide said she did not have a restorative program to work with Resident# 46 and confirmed she was not applying a splint to the residents left hand. On 1/08/20 at 8:55 a.m., in an interview the Unit Manager said Resident #46 had a splint but confirmed there was no documentation of who was responsible for applying and monitoring the splint. The Unit Manager confirmed Resident #46 had a contracture of the left hand and was not receiving restorative nursing care for application of the splint. Based on observation, record review, family and staff interview the facility failed to develop and implement individualized care plan to meet the nursing and psychosocial needs for 6 (Residents #42, #24, #3, #13, #46, and #2) of 6 Residents reviewed for activities of daily living and activities. The failure of incomplete or inadequate care plans has to potential to negatively impact the resident's quality of life and the quality of care and services. The findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 9 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 1. Review of the Minimum Data Set assessment with an assessment reference date of 8/20/19 revealed it was very important to Resident #42 to be around animals such as pets and keep up with the news. The assessment indicated Resident #42 had moderately impaired cognitive skills for daily decision making, the resident's decisions were poor, and he required cues and supervision. The resident also had periods of inattention and disorganized thinking. Residents Affected - Few The care plan initiated on 4/25/19 with a target date of 1/24/20 did not identify how they would assist Resident #42 keep up with the news. The care plan did not include interventions to address Resident #42's interest to be around animals such as pets. On 1/07/20 at 3:56 p.m., the Activity Director said the care plan was developed based on the assessment to reflect the resident's preferences and what's important to him. She said she had no explanation as to why the resident's activities preferences were not included in the care plan to meet his interests and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 10 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review, and resident, family, and staff interview the facility failed to provide the necessary assistance for grooming, feeding and restorative care for 2 (Residents #21 and #46) of 3 Residents reviewed for Activities of Daily Living (ADL). This has the potential to cause psychological harm, choking during meals and worsening of contractures. Residents Affected - Few The findings included: The facility policy 250.1390.1 (revised 8/2016) Activities of Daily Living stated, It is the goal of the facility to provide necessary care and services to attain or maintain the highest practicable functioning of the resident. 1. On 1/6/20 at 1:00 p.m., Resident #21 was observed with long fingernails, extending approximately 1/2 inch past his fingertips with an accumulation of a brown substance under the nail beds. Resident #21 said his nails were long and needed to be cut. He said someone usually came around to cut them, but they had not recently been in to assist him with nail care. A review of the medical record for Resident #21, revealed a care plan (a detailed approach to care customized to an individual patient's needs) that indicated the resident required extensive to total assistance with his ADLs. On 1/7/20 at 2:55 p.m., in an interview Certified Nurse Aide (CNA) Staff E confirmed the resident was unable to clip his fingernails and it was her responsibility to clip the resident's nails. Staff E said she honestly hasn't paid attention to [Resident #21's] fingernails lately. 2. On 1/6/20 at 12:30 p.m., in an interview the spouse of Resident's #46 said the staff was not assisting the resident when she was eating her meals. He said his wife's appetite and intake at meals were better when she was assisted to eat. A medical record review revealed a care plan documenting Resident #46 had difficulty swallowing and was holding food in her mouth. The care plan indicated the resident was at risk for aspiration (accidental ingestion of fluid or food into the lungs), and instructed the resident was to eat only with supervision. The CNA [NAME] (an information system used by nursing staff to communicate important patient information) instructed Resident #46 was to eat only with supervision. On 1/8/20 at 10:45 a.m., in an interview CNA Staff A said, she is in and out of other resident's rooms to monitor and assist them during meals. Staff A verified that she does not stay with Resident #46 unless the resident requests that she needs assistance. On 1/08/20 at 12:31 p.m., in an interview the Consultant Dietician said the resident's diet was changed to puree consistency because the resident was pocketing her food and chewing for extended periods. The Consultant Dietician said if the CNA leaves Resident #46's room after setting up her meal, then the resident was not being supervised. On 1/08/20 at 12:47 p.m., in an interview with the Unit Manager, he said when a resident was identified as supervised feeding, it meant that the CNA should remain in the room during the resident's meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 11 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility policy 250.3080.1 (revised 8/2016) Restorative: Contractures, documented Residents admitted with contractures (limited movement of a joint) will receive appropriate treatment and services to prevent further decrease in range of motion. A review of the medical record for Resident #46 revealed a Restorative Nursing care plan instructing the resident was to receive a left-hand resting splinting program 6 days per week with the restorative aide. The Physician Order, dated 7/3/18, documented Resident #46 was to wear a left resting hand splint on during the day and remove at night. The medical record also documented Resident #46 had a diagnosis of hemiplegia (muscle weakness or partial paralysis on one side of the body). On 1/6/20 at 10:30 a.m., Resident #46 was observed in her room in bed. The resident had a contracture of her left hand. The resident did not have a splint on her left hand. On 1/07/20 at 9:50 a.m., Resident #46 was in her room in bed and she did not have a splint on her left hand. On 1/07/20 at 10:22 a.m., in an interview with the Therapy Director he said he was not working with Resident #46 and had not worked with her in the last six months. The Therapy Director confirmed he does not have a restorative program for Resident #46's left hand splint. On 1/07/20 at 3:24 p.m., in an interview with Licensed Practical Nurse, Staff D said she was not aware Resident #46 had a left-hand splint and confirmed the resident was not able to move her left hand. On 1/08/20 at 8:45 a.m., in an interview the Restorative Aide said she did not have a restorative program to work with Resident# 46 and confirmed she was not applying a splint to the residents left hand. On 1/08/20 at 8:55 a.m., in an interview the Unit Manager said Resident #46 had a splint but confirmed there was no documentation of who was responsible for applying and monitoring the splint. The Unit Manager confirmed Resident #46 had a contracture of the left hand and was not receiving restorative nursing care for application of the splint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 12 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review, and resident, family, and staff interview the facility failed to implement meaningful resident centered activities to meet the interest and wellbeing of 4 (Resident #42, #46, #9 and #24) of 5 residents reviewed for activities. The lack of individualized activity program has to potential to cause social isolation, boredom, agitation and frustration. Residents Affected - Some The findings included: Review of the facility's policy and procedure titled Activity Program with an original date of 1/10/17 (no revision date) revealed Activity programming shall be provided that meet the interest and wellbeing of residents in accordance with their individual assessment and care plans . Residents who are confined to their room or choose to remain in their room are provided with in-room activities in keeping with lifelong interests. Supplies are provided as needed in order to effectively participate in the activity. In room projects that can be worked on independently are provided, if requested and if in accordance with the care plan . The program should be changed to fulfill resident preferences and interests and functioning ability. 1. Review of the Minimum Data Set assessment with an assessment reference date of 8/20/19 revealed it was very important to Resident #42 to be around animals such as pets and keep up with the news. The assessment indicated Resident #42 had moderately impaired cognitive skills for daily decision making, the resident's decisions were poor, and he required cues and supervision. The resident had periods of inattention and disorganized thinking. Resident #42 required extensive assistance of two staff members for bed mobility and transfer; was totally dependent on 1 person to move to and from distant areas of the building. The care plan initiated on 4/25/19 with a target date of 1/24/20 indicated the resident preferred individual activities such as watching television and listening to music. The Resident enjoyed going outside and staff was to assist Resident #42 outside and encourage him to participate in courtyard activity. The resident's preferred group activities included church activities, balloon and tennis. Observation on 1/6/20 at 10:50 a.m., 1:00 p.m., and 2:50 p.m., revealed Resident #42 supine in bed staring straight ahead. On 1/6/20 at 2:50 p.m., the resident's spouse was observed sitting at the bedside while the resident was staring ahead. The resident remained in bed supine the whole day and was not observed engaged in individual or group activities. On 1/7/20 at 8:57 a.m., and 11:04 a.m., the resident remained in bed, staring straight ahead. On 1/6/20 at 2:52 p.m., during an interview with Resident #42's spouse, she said Resident #42 did not participate in any activity. She said it would be nice if they were able to take him out for a few minutes when the weather was good, he would enjoy that. On 1/7/20 at 1:40 p.m., during an interview, the Activity Director said everyday Resident #42 was invited to participate in group activities. The residents who do not participate in group activities receive one-on-one activities, such as puzzles, hand massage, manicure, and music. She said they document the participation on the daily invitation to activity participation and tracked the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 13 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0679 participation on the monthly logs. Level of Harm - Minimal harm or potential for actual harm Review of the Monthly Resident Participation Log for November and December 2019 failed to reveal documentation Resident #42 participated in any activity. The activity director said she had not started tracking the monthly activities for 1/20. Residents Affected - Some On 1/7/20 at 1:47 p.m., during an interview with the Activity Assistant, she said Resident #42 was receiving hospice services and refuses to get up. She said she mentioned bingo to him a few days ago. She said Resident #42 just stays in his room with his wife but We don't do any activities with him in his room. Resident #42 was not interviewable. 2. Review of Resident #24's activities care plan shows it was reviewed by staff on 12/9/20 after the resident was readmitted to the facility after an acute hospitalization. The goal was for the resident to participate in activities of choice, and the resident will maintain social activities as desired by the next review date on 2/28/20. Review of Resident #24's Minimum Data Set, dated [DATE] showed in section C the resident was not interviewable. Section D Mood shows the resident was rarely or never understood by staff. Section G showed Resident #24 was dependent on the assistance of two staff members for bed mobility, transfer, dressing, and toileting. Resident #24 needed extensive assistance of one staff member for eating. Section F shows an activities interview was not completed because the resident was rarely or never understood. An Activities-Initial Interview dated 12/9/19 was completed after the resident had an acute hospital stay. The past activities interests showed Resident #24 passively participated in group daily, self-directed with the assistance of staff. The limitations/special needs section showed the resident needed activities to be modified to accommodate his cognitive deficit. The assessment showed Resident #24 needed assistance to get to and from activities. On 1/6/20 at 10:30 a.m., Resident #24 was observed lying on his back with the head of the bed elevated. He was observed to be positioned so that his body was leaning to the left. The resident was observed to have contractures in both side of his upper extremities. The resident was observed to be alert with his eyes opened but nonresponsive verbally to questioning. There was no television or radio observed to be providing auditory stimulus. On 1/6/20 at 12:24 p.m., Resident #24's daughter said she had seen the resident out of bed and in activities, but she did not believe the resident was capable of participating in bingo or socialization with other residents due to his dementia. On 1/6/20 at 1:30 p.m., Resident #24 was observed in the same position lying on his back and leaning toward the left with his head elevated. Certified Nursing Assistant Staff I was observed feeding the resident lunch. At that time the resident was observed to have contractures to both of his legs. Both lower extremities were bent and fixed. Staff I verified the resident's legs were stiff and not able to be straightened. On 1/6/20 at 3:25 p.m., Resident #24 was observed in the same position, lying on his back and leaning to the left. On 1/7/20 at 10:20 a.m. Resident #24 was observed in the same position as the day before, lying on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 14 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his back with his head elevated and leaning to the left. The resident's roommate had his television turned up loudly. On 1/7/20 at 10:40 a.m., Staff I verified she had not gotten the resident out of bed on 1/6/20. She said the resident was dependent on two staff members using a Hoyer lift to transfer the patient and there was not another staff person available to transfer the patient. She said when there were only 3 aides on the floor on 1/6/20 and there was not enough assistance to provide care to the residents that needed transferred with a Hoyer. Staff I said her current assignment had two resident which includes Resident #24 that need to be transferred with a Hoyer. She said her current assignment has two more residents that need the assistance of two staff members to transfer in and out of bed. Staff I said there used to be a shower aide that floated and assisted staff with transfers, but, the facility had not had a shower aide for about a month. The Director of Nursing (DON) had told Staff I that she was going to try to get four aides during the day for the west side of the facility. Staff I verified she had not repositioned Resident #24 after 10:00 a.m., on 1/6/20. She said she had left the facility with another resident being transferred to the hospital at 2:00 p.m., on 1/6/20, and, she had reported Resident #24's care to another aide. Staff I said she could not recall the aide that she had reported Resident #24's care to. On 1/8/20 the Activities Director said Resident #24's roommate has the television on in the room daily. The activities Director said the resident was gotten up daily and was brought to activities room, but he was not capable of participating in activities. She said he was brought down in the morning (during daily bingo) and was back in bed after lunch. The Activities Director said Resident #24 did not have any one-to-one activities with the current Activities Staff. On 1/9/20 at approximately 4:30 p.m., the Assistant Administrator said he could not provide any documentation the Activity Director or Activity Staff had been given any training in providing activities to residents with dementia. The Assistant Administrator said he was not aware of the activity staff being given any resources for providing activities to residents that were not able to communicate or participate in activities. 3. The facility policy 100.100.1 Alzheimer's and Related Dementia, Activity Policy (4/2016), specified after assessment of needs, specialized therapeutic activity programs will be planned that will stimulate memory of normal life activities. On 1/6/20 at 10:30 a.m., during a tour of the secured Butterfly Memory Care Unit, Resident #46 was observed in her room in bed. There were no individualized activities set up within the resident's reach. The blinds were closed, and the room was dark. The television was not turned on. On 1/6/20 at 11:00 a.m., during observation of the facility, the monthly activity calendar was displayed on a wall in the hall outside of the secured Butterfly Memory Care Unit. On 1/6/20 at 12:30 p.m., Resident #46 was observed lying in bed, the television was off and there were no individualized activities within the resident's reach. On 1/6/20 at 12:30 p.m., in an interview with spouse of Resident #46, said that his wife doesn't go to activities because she has dementia. He said he didn't know what activities she could participate in. A review of Resident #46's medical record revealed the resident had a diagnosis of depression and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 15 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0679 Level of Harm - Minimal harm or potential for actual harm anxiety. The activity care plan (a detailed approach to care, customized to meet an individual patient needs) for Resident #46 instructed staff to provide one-to-one bedside in room visits and activities if the resident was unable to attend scheduled group activities. The care plan indicated the resident's preferred activity included watching television. The care plan instructed staff to provide a program of activities that accommodate the resident's abilities. Residents Affected - Some On 1/7/20 at 1:10 p.m., in an interview the Activity Director confirmed that there were no individualized activities to meet the special needs of the dementia patients in the secured Butterfly Memory Care Unit. On 1/07/20 at 2:24 p.m., in an interview the Activity Director said she keeps an individualized log of activities for every resident. The Activity Director provided a copy of the December 2019 Monthly Resident Participation Log of activities for Resident #46. The log for Resident #46 was blank for the month of December, indicating the resident did not participate in any structured or individualized activity. The Activity Director said she had not initiated a Monthly Resident Log for Resident #46 for the month of January. 4. On 1/6/20 10:45 a.m., during an observation, Resident #9 had a sign posted on her door indicating the resident was on contact isolation (staff and visitors were to don gowns and gloves before entering the room). Resident #9 was observed lying in bed in her room, the blinds were closed, and the room was dark. There were no individualized activities within the resident's reach. The television and radio were not turned on. Resident #9 said no one had come to her room to provide activities since she was readmitted to the facility on [DATE] after a brief hospitalization on 1/2/20. On 1/6/20 at 12:30 p.m., Resident #9 was observed lying in bed in a dark room and the television and radio were not turned on. There were no individualized activities set up for the resident. A review of the medical record for Resident #9 revealed the resident was previously admitted on [DATE] and had been a resident of the facility until a brief hospitalization on 1/2/20. The record revealed an activity care plan that indicated the resident enjoyed listening to country and gospel music and preferred watching westerns on the television. On 1/7/20 at 1:10 p.m., in an interview the Activity Director said, Resident #9 was a long-time resident of the facility prior to her recent hospitalization and had kept puzzles and word searches at her bedside. The Activity Director said Resident #9 enjoyed watching westerns on the television. The Activity Director confirmed she had not visited with the resident since her readmission on [DATE], to ensure the resident had the individualized activities within her reach or that her television had been turned on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 16 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide restorative care to prevent further decline in range of motion for 1 (Resident #24) of 2 residents having a potential to cause further decline and pain and discomfort to the resident's joints due to a lack of movement over long periods of time. Residents Affected - Few The findings included: 1. On 1/7/20 at 11:53 a.m. a restorative care plan showed Resident #24 was on Restorative care for a splinting program. There was no intervention listed in the care plan as to what was being splinted or what extremity was being splinted. Review of documentation of the staff over the last 6 months showed Resident #24 was canceled from passive range of motion because the resident was resistant to movement of bilateral upper and lower extremities being touched. The note said the restorative aide and staff attempted multiple times with no change. There was no documentation of any interventions to prevent pain during movement of the resident's extremities. The documentation shows the resident was placed on a splinting program at that time. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] showed in section C the resident was not interviewable. Section D Mood shows the resident was rarely or never understood by staff. Section G showed Resident #24 was dependent on the assistance of two staff members for bed mobility, transfer, dressing, and toileting. Resident #24 needed the extensive assistance of one staff member for eating. The MDS showed the resident had a decline in movement with no services. Review of the Restorative Nursing Programs policy and procedure approved by the facility in 2001 and revised 8/2016 reads, It is the policy of the facility to provide nursing restorative services .All appropriate employees will be informed and trained regarding their responsibility and role in resident restorative care .13. Restorative services are all employee's responsibility after appropriate training. The restorative plan will be available and explained to all nursing personnel and other departments coming in contact with the resident .16. If restorative nursing assistants are utilized in this facility, they and the Therapy Program Manager will be responsible for the Restorative Program. On 1/6/20 at 10:30 a.m., Resident #24 was observed lying on his back with the head of the bed elevated. He was observed to be positioned so that his body was leaning to the left. The resident was observed to have contractures in both side of his upper extremities. The resident was observed to be alert with his eyes opened but nonresponsive verbally to questioning. There was no television or radio observed to be providing auditory stimulus. On 1/6/20 at 1:30 p.m., Resident #24 was observed in the same position lying on his back and leaning toward the left with his head elevated. Certified Nursing Assistant Staff I was observed feeding the resident lunch. At that time the resident was observed to have contractures to both of his legs. Both lower extremities were bent and fixed. Staff I verified the resident's legs were stiff and not able to be straightened. On 1/6/20 at 3:25 p.m., Resident #24 was observed in the same position, lying on his back and leaning to the left. On 1/7/20 at 10:20 a.m. Resident #24 was observed in the same position as the day before, lying on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 17 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 his back with his head elevated and leaning to the left. The resident's roommate had his television turned up loudly. On 1/7/20 at 10:40 a.m., Staff I verified she had not gotten the resident out of bed on 1/6/20. She said the resident was dependent on two staff members using a Hoyer lift to transfer the patient and there was not another staff person available to transfer the patient. She said when there were only 3 aides on the floor on 1/6/20 and there was not enough assistance to provide care to the residents that needed transferred with a Hoyer. Staff I said her current assignment had two resident which includes Resident #24 that need to be transferred with a Hoyer. She said her current assignment has two more residents that need the assistance of two staff members to transfer in and out of bed. Staff I said there used to be a shower aide that floated and assisted staff with transfers, but, the facility had not had a shower aide for about a month. The Director of Nursing (DON) had told Staff I that she was going to try to get four aides during the day for the west side of the facility. Staff I verified she had not repositioned Resident #24 after 10:00 a.m., on 1/6/20. She said she had left the facility with another resident being transferred to the hospital at 2:00 p.m., on 1/6/20, and, she had reported Resident #24's care to another aide. Staff I said Resident #24 at one time had a blue palm protector. She said the Resident did not have a palm protector available on 1/6/20. Staff I said she thinks the blue palm protector had been lost in the laundry. On 1/7/20 at 2:35 p.m., the Nursing Supervisor said it was good timing because Resident #24 had started on a restorative program which included range of motion exercises that day (1/7/20). On 1/7/20 at 2:40 p.m., the Physical Therapy Director (PTD) said Resident #24 had been on occupational therapy from 12/9/19 to 12/27/19. The PTD said the resident was placed on restorative program which included range of motion exercises to his upper extremities and placing a palm protector to his right hand. The PT director said he thought the resident had lost his original palm protector in the laundry. The PTD said he had reordered the palm protector and the resident had the palm protector on Monday (1/6/20). After hearing the surveyor's observations on 1/6/20, the PTD said he was not aware the resident was not wearing the palm protector on 1/6/20. The PTD said he felt the palm protector was available for the resident on 1/6/20. The PTD said the palm protector may have been in the resident's bedside table yesterday. The PTD said he had assisted the aide in transferring the resident today (1/7/20) because she could not find any staff to assist her. He said he was happy to assist the staff member. The PTD said the palm protector and passive range of motion should be interventions on the resident's care plan. He said once the resident was transferred to restorative care it is the nursing staff who are responsible to supervise restorative and ensure the resident's positioning care was provided. On 1/7/20 at 3:51 p.m. the Nursing Supervisor verified Resident #24 was started on active range of motion today. The Nursing Supervisor said the PTD had given him the restorative program on 1/3/20 and told him he did not need to start the program until Monday (1/6/20). The Nursing Supervisor said the only thing he was aware the resident was receiving as a restorative intervention before today was for a rolled-up washcloth in his right hand. He said he did not remember how long it had been since the resident had the blue palm protector. He said he thought he had seen the blue palm protector a couple of weeks ago when he worked on the med cart. The Nursing Supervisor said he knew the restorative aide documents the care she provided to Resident #24. He said he did not know how she documented the care and the documentation was not available to him at the time. On 1/8/20 at 1:00 p.m., the Restorative Aide, Staff B said she had started doing restorative Monday through Friday for residents in April of 2019. She said she was the only aide providing restorative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 18 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 care Monday through Friday. Staff B said she only documented the minutes she spends with residents electronically. Staff B was not able to find documentation Resident #24 received any restorative minutes at that time. She said the resident was only receiving a splint on his hand. Staff B said when the resident was initially receiving range of motion, he was fighting her when she tried to move him. She said she had gone to her supervisor at the time and her supervisor told her if Resident #24 was fighting the restorative aide she (the supervisor) would just remove Resident #24 from receiving range of motion exercises. The aide did not remember the date the resident was removed from range of motion exercises. The aide was not aware of any interventions to deal with the resident's discomfort while receiving range of motion exercises. Review of a nursing note dated 4/12/2019 reads, Resident Exercised right to refuse (restorative) program due to mood/behaviors. Participation is dependent upon occasional outbursts .no signs or symptoms of pain noted. On 1/8/20 at 1:50 p.m., the current Nursing Supervisor said he was not aware Resident #24 was on a splinting program only with no range of motion because of his behaviors while being moved by staff. The Nursing Supervisor said he was not aware of any interventions to assist the resident's comfort while having his joints moved by staff. On 1/8/20 at 1:55 p.m., both the Administrator and the Nursing Supervisor verified Resident #24 was not able to verbally express when he was in pain and discomfort. The Administrator and Nursing Supervisor verified Resident #24's continued lack of joint movement had the potential to cause pain and discomfort to the resident. The Administrator and the Nursing Supervisor verified Resident #24's had an ongoing need for passive range of motion as tolerated. The Administrator and the Nursing Supervisor verified Resident #24 should have interventions in place to provide comfort to the resident prior to initiating passive range of motion exercises. On 1/10/20 at 8:30 a.m., the Nursing Supervisor said he could not provide documentation for any minutes Resident #24 had received for restorative care. The Nursing Supervisor said there had been a glitch and the care plan for restorative had not transferred to the restorative aide. The Nursing Supervisor said he could not explain why the restorative aide had not informed the supervisor she was unable to document Resident #24's restorative minutes and still she was providing restorative care to the resident. The Nursing Supervisor said he had not been supervising the restorative aide prior to the survey. He said all he could do was input the plan provided by the PTD electronically as a care plan. On 1/10/20 at approximately 9:00 a.m., the PTD said he could not explain why Resident #24 went eleven days from 12/27/20 to 1/7/20 before receiving restorative care. The PTD said when he assessed the resident quarterly, he would speak with the aides to determine the care the resident was receiving. The PTD said he could not explain why he was not informed the resident had not been receiving range of motion exercises. The PTD said he never reviewed the resident's care plan or the nursing assistant task list to determine if the resident was receiving the care he needed. The PTD verified there had been a lack of communication between the Therapy Department and the Nursing Department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 19 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview, the facility failed to promote adequate preventive measures to prevent the development of pressure ulcer for 1 (Resident #44) of 1 Resident reviewed for pressure ulcer. Residents Affected - Few The findings included: Review of a 2011 International Pressure Ulcer Prevalence study showed high numbers of linen layers on low-air-loss mattresses may lead to increases in facility-acquired pressure ulcers. (downloaded 1/13/20 from: https://www.o-wm.com/article/laboratory-study-examining-impact-linen-use-low-air-loss-support-surface-heat-and-water-va Review of the clinical record for Resident #44 revealed a physician's order dated 2/20/19 for a Low air loss/alternating pressure mattress for wound care intervention. The minimum data set assessment indicated Resident #44 was totally dependent on the physical assistance of two staff members to reposition himself in bed and for transfers in and out of bed. The resident had a history of stage 2 pressure ulcers to the left and right buttock documented as healed on 12/3/19. On 1/6/20 at 12:05 p.m., during an interview Resident #44 said he had a wound on his buttocks. He said he developed the wound at the facility but could not remember when. On 1/6/20 at 12:05 p.m., during the interview Resident #44 was observed lying in bed on a low air loss and alternating pressure mattress. A low air loss mattress was a special mattress that aids in healing and prevention of development of pressure ulcers. The mattress had tiny laser made air holes in its top surface which continually blow out air. This reduced skin pressure at the mattress surface. As a result, moisture was wicked away and the patient stayed dry. Resident #44's air mattress was covered with a flat sheet, a folded sheet, a reusable incontinent pad, and a disposable incontinent pad. Resident #44 was also wearing a multi layers incontinent brief. The same observation was made on 1/8/20 at 9:49 a.m., while CNA (Certified Nursing Assistant) Staff K and CNA Staff L were providing care. The Resident's buttocks were red. On 1/8/20 at 9:50 a.m., during an interview Staff K said the resident's spouse insisted on having all the different layers on the bed. On 1/8/20 at 10:00 a.m., the observation was verified by the Director of Nursing (DON) who said there shouldn't be so many layers of linen on the bed. She said, it defeats the purpose of the air mattress. She said she would educate the spouse about the proper use of the air mattress. On 1/9/20 at 9:19 a.m., the DON said she discussed with the CNAs the number of layers to place on the air mattress, but she did not document the discussion and did not have an agenda for the in-service. She said the facility did not have a policy on the proper use of the air mattress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 20 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sufficient and competent staff for providing restorative care, activities of daily living care, and assistance with eating to 6 (Residents #24, #40, #41, #45, #21 and #46 ) of 12 residents surveyed resulting in the residents not receiving care and services to maintain the residents highest practical physical, mental, and psychosocial well-being. The findings included: 1. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] showed in section C the resident was not interviewable. Section D Mood shows the resident was rarely or never understood by staff. Section G showed Resident #24 was dependent on the assistance of two staff members for bed mobility, transfer, dressing, and toileting. Resident #24 needed the extensive assistance of one staff member for eating. The MDS showed the resident had a decline in movement with no services. Review of the Restorative Nursing Programs policy and procedure approved by the facility in 2001 and revised 8/2016 reads, It is the policy of the facility to provide nursing restorative services .All appropriate employees will be informed and trained regarding their responsibility and role in resident restorative care .13. Restorative services are all employee's responsibility after appropriate training. The restorative plan will be available and explained to all nursing personnel and other departments coming in contact with the resident .16. If restorative nursing assistants are utilized in this facility, they and the Therapy Program Manager will be responsible for the Restorative Program. On 1/6/20 at 10:30 a.m., Resident #24 was observed lying on his back with the On 1/6/20 at 10:30 a.m., Resident #24 was observed lying on his back with the head of the bed elevated. He was observed to be positioned so that his body was leaning to the left. The resident was observed to have contractures in both side of his upper extremities. The resident was observed to be alert with his eyes opened but non responsive verbally to questioning. There was no television or radio observed to be providing auditory stimulus. On 1/6/20 at 12:24 p.m., Resident #24's daughter said she had seen the resident out of bed and in activities, but she did not believe the resident was capable of participating in bingo or socialization with other residents due to his dementia. On 1/6/20 at 1:30 p.m., Resident #24 was observed in the same position lying on his back and leaning toward the left with his head elevated. Certified Nursing Assistant Staff I was observed feeding the resident lunch. At that time the resident was observed to have contractures to both of his legs. Both lower extremities were bent and fixed. Staff I verified the resident's legs were stiff and not able to be straightened. On 1/6/20 at 3:25 p.m., Resident #24 was observed in the same position, lying on his back and leaning to the left. On 1/7/20 at 10:20 a.m. Resident #24 was observed in the same position as the day before, lying on his back with his head elevated and leaning to the left. The resident's roommate had his television (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 21 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0725 turned up loudly. Level of Harm - Minimal harm or potential for actual harm On 1/7/20 at 10:40 a.m., Staff I verified she had not gotten the resident out of bed on 1/6/20. She said the resident was dependent on two staff members using a Hoyer lift to transfer the patient and there was not another staff person available to transfer the patient. She said when there were only 3 aides on the floor on 1/6/20 and there was not enough assistance to provide care to the residents that needed transferred with a Hoyer. Staff I said her current assignment had two resident which includes Resident #24 that need to be transferred with a Hoyer. She said her current assignment has two more residents that need the assistance of two staff members to transfer in and out of bed. Staff I said there used to be a shower aide that floated and assisted staff with transfers, but, the facility had not had a shower aide for about a month. The Director of Nursing (DON) had told Staff I that she was going to try to get four aides during the day for the west side of the facility. Staff I verified she had not repositioned Resident #24 after 10:00 a.m., on 1/6/20. She said she had left the facility with another resident being transferred to the hospital at 2:00 p.m., on 1/6/20, and, she had reported Resident #24's care to another aide. Staff I said she had not been off for a week prior to 1/6/20. She said Resident #24 at one time had a blue palm protector. She said the Resident did not have a palm protector available on 1/6/20. Staff I said she thinks the blue palm protector had been lost in the laundry. Residents Affected - Many On 1/7/20 at 2:40 p.m., the Physical Therapy Director (PTD) said Resident #24 had been on occupational therapy from 12/9/19 to 12/27/19. The PTD said the resident was placed on restorative program which included range of motion exercises to his upper extremities and placing a palm protector to his right hand. The PT director said he thought the resident had lost his original palm protector in the laundry. The PTD said he had reordered the palm protector and the resident had the palm protector on Monday (1/6/20). After hearing the surveyor's observations on 1/6/20, the PTD said he was not aware the resident was not wearing the palm protector on 1/6/20. The PTD said he felt the palm protector was available for the resident on 1/6/20. The PTD said the palm protector may have been in the resident's bedside table yesterday. The PTD said he had assisted the aide in transferring the aide today (1/7/20) because she could not find any staff to assist her. He said he was happy to assist the staff member. The PTD said the palm protector and passive range of motion should be interventions on the resident's care plan. He said once the resident was transferred to restorative care it is the nursing staff who are responsible to supervise restorative and ensure the resident's positioning care was provided. On 1/7/20 at 3:51 p.m. the Nursing Supervisor verified Resident #24 was started on active range of motion today. The Nursing Supervisor said the PTD had given him the restorative program on 1/3/20 and told him he did not need to start the program until Monday (1/6/20). The Nursing Supervisor said the only thing he was aware the resident was receiving as a restorative intervention before today was for a rolled-up washcloth in his right hand. He said he did not remember how long it had been since the resident had the blue palm protector. He said he thought he had seen the blue palm protector a couple of weeks ago when he worked on the med cart. The Nursing Supervisor said he knew the restorative aide documents the care she provided to Resident #24. He said he did not know how she documented the care and the documentation was not available to him at the time. On 1/8/20 at 1:00 p.m., the Restorative Aide, Staff B said she had started doing restorative Monday through Friday for residents in April of 2019. She said she was the only aide providing restorative care Monday through Friday. Staff B said she only documented the minutes she spends with residents electronically. Staff B was not able to find documentation Resident #24 received any restorative minutes at that time. She said the resident was only receiving a splint on his hand. Staff B said when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 22 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the resident was initially receiving range of motion, he was fighting her when she tried to move him. She said she had gone to her supervisor at the time and her supervisor told her if Resident #24 was fighting the restorative aide she (the supervisor) would just remove Resident #24 from receiving range of motion exercises. The aide did not remember the date the resident was removed from range of motion exercises. The aide was not aware of any interventions to deal with the resident's discomfort while receiving range of motion exercises. Review of a nursing note dated 4/12/2019 reads, Resident Exercised right to refuse (restorative) program due to mood/behaviors. Participation is dependent upon occasional outbursts .no signs or symptoms of pain noted. On 1/8/20 at 1:50 p.m., the current Nursing Supervisor said he was not aware Resident #24 was on a splinting program only with no range of motion because of his behaviors while being moved by staff. The Nursing Supervisor said he was not aware of any interventions to assist the resident's comfort while having his joints moved by staff. On 1/8/20 at 1:55 p.m., both the Administrator and the Nursing Supervisor verified Resident #24 was not able to verbally express when he was in pain and discomfort. The Administrator and Nursing Supervisor verified Resident #24's continued lack of joint movement had the potential to cause pain and discomfort to the resident. The Administrator and the Nursing Supervisor verified Resident #24's had an ongoing need for passive range of motion as tolerated. The Administrator and the Nursing Supervisor verified Resident #24 should have interventions in place to provide comfort to the resident prior to initiating passive range of motion exercises. On 1/10/20 at 8:30 a.m., the Nursing Supervisor said he could not provide documentation for any minutes Resident #24 had received for restorative care. The Nursing Supervisor said there had been a glitch and the care plan for restorative had not transferred to the restorative aide. The Nursing Supervisor said he could not explain why the restorative aide had not informed the supervisor she was unable to document Resident #24's restorative minutes and still she was providing restorative care to the resident. The Nursing Supervisor said he had not been supervising the restorative aide prior to the survey. He said all he could do was input the plan provided by the PTD electronically as a care plan. He said he had only had four days of orientation prior to taking the Nursing Supervisor Job. On 1/10/20 at approximately 9:00 a.m., the PTD said he could not explain why Resident #24 went eleven days from 12/27/20 to 1/7/20 before receiving restorative care. The PTD said when he assessed the resident quarterly, he would speak with the aides to determine the care the resident was receiving. The PTD said he could not explain why he was not informed the resident had not been receiving range of motion exercises. The PTD said he never reviewed the resident's care plan or the nursing assistant task list to determine if the resident was receiving the care he needed. The PTD verified there had been a lack of communication between the Therapy Department and the Nursing Department. On 1/10/20 at approximately 4:30 p.m., the Administrator Assistant said he could not provide any documentation Certified Nursing Assistant (CN)/Restorative Aide Staff B had received any training or in-services regarding restorative care prior to becoming the facility's restorative aide. On 1/10/20 the Nursing Supervisor provided a current list of 38 residents receiving restorative care from one restorative aide Monday through Friday. On 1/10/20 at approximately 6:30 p.m., the Owner said she has seen the list of residents on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 23 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many restorative care. The Owner said she had told Staff B at the time there was no way she could provide care to all those residents. The Owner said the restorative aide (Staff B) had told her, I do the best I can. 2. On 1/6/2020 at 10:30 a.m., Resident #45 was observed to be unshaven and his fingernails were long and dirty. Resident #45 said it had been a month since he had been shaved. He said he kept asking staff and no one assisted him. He said he was told by staff when he asked that they can't touch him because he was diabetic. On 1/7/20 at 9:56 a.m., Resident #45 said the staff were supposed to wrap his legs with ace bandages to prevent them from swelling. He said they had not wrapped his legs today. He said staff would miss days. He said when he reminded staff, he needed his wraps put on his legs, they would tell him in a little while. Resident #45 said when staff told him in a little while it usually meant it would be in three hours. Review of the physician's orders show Resident #45 was to have Ace bandages wrapped on his lower extremities in the a.m. and removed in the p.m. On 1/9/20 at 3:00 p.m., Resident #45 said staff had not wrapped his legs. Ace bandages were observed on the resident's dresser. On 1/9/20 at 3:05 p.m. Licensed Practical Nurse (LPN), Staff M verified she had not wrapped the resident's lower legs with Ace wraps. After reviewing the Treatment Administration Record (TAR) Staff M said the Ace wraps should have been placed on the resident at 6:00 a.m. 3. On 1/9/20 at approximately 4:00 p.m., Resident #40's daughter said she was very upset because there is not enough staff at night to care for her mother. The resident's daughter said she had spoken to the Assistant Administrator because her mother was calling her at night and complaining that the night time staff were leaving her on the toilet for long periods of time. The resident's daughter said her mother called her last night crying and saying staff had just set her supper tray in front of her and left it without assisting he mother in setting up her tray. She said her mother told her another staff member came in after 6 p.m., and found her mother sitting in the dark having not eaten because she could not reach the items on her tray. She said she was ready to take her mother out of the facility. 4. On 1/6/20 at 11:27 a.m., Resident #41 stated the call light response time during dinner time (12:00 p.m., to 1:00 p.m.) could be over an hour. 5. On 1/9/20 at 10:00 a.m. LPN, Staff N said there was not enough nursing staff when there were only three nurses in the building to provide care to the residents. She said the owners did not allow for enough hours. She said the owners did not take into account the acuity of the residents. On 1/9/20 at 10:05 a.m., LPN, Staff H said she did not feel there was enough staff for the residents to receive the care they needed on a daily basis. She said if there were three nurses then the nurse in the memory care unit would have to leave the memory care at times to pass medications on the west side. She said that would leave two aides on the memory care unit to supervise the residents. Staff H said several of the residents on the memory care are two staff member assist. If a resident needs a shower in a shower bed, both aides will be off the memory care unit to the shower room with the one resident on the shower bed. She said this leaves the nurse assigned to the nursing care unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 24 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many to supervise all the memory residents while she was passing her medications. Staff H said the owners decided how many the staff to resident ratio without taking into account the acuity of the residents. On 1/9/20 at 10:20 a.m., Certified Nursing Assistant (CNA), Staff E said she was currently assigned to 7 resident and 2 of the residents require two staff members for transfers with a Hoyer lift. Two more of her residents require two staff members to provide transfers and Activates of Daily Living (ADL) care. Staff E verified there were days when residents did not get out of bed due to a lack of staff. Staff E verified there were days when residents get bed baths instead of showers because there was not enough staff. On 1/9/20 at 10:30 p.m., Staff B said there were currently thirteen residents that needed two staff members to transfer with a Hoyer lift. Staff B said there are approximately ten more residents who require two staff members to assist with transferring and ADL care. On 1/9/20 at 10:40 a.m., no aides were observed on the memory care unit. LPN, Staff O was observed at the front of the memory care unit near the nurses' station at her medication cart. Staff O verified two aides were in the shower room assisting a resident. She verified she was the only staff member on the memory care unit. Staff O said on the weekends when physical therapy staff and administrative staff were not in the building, all residents did not receive assistance in getting out of bed and getting showers due to lack of staff. On 1/9/20 at 11:00 a.m., the Staff Coordinator and the DON verified they have no input into how many hours of staffing each resident receives. The DON said she has told the owners the facility needed more staff and they did not listen. The DON said she felt the memory care unit needed 3 CAN's daily due to the resident acuity. The Staffing Coordinator said the Chief Operating Officer (COO) said she can only staff to 2.6 hours of CNA's and 1.1 hour of nurses to each resident daily. The DON said she did not feel she has any input into ensuring appropriate nursing staff. On 1/9/20 at 11:30 a.m. the COO said his background was in radiology and he had no nursing experience. The COO verified he was not aware of the need to account for acuity in resident care. The COO verified he staffed the building above what the state requires at 2.6 hours per resident for CNA's and 1.1 hour per resident for nursing care. On 1/10/20 at 5:37 p.m , the DON said she had only met with the owners twice since accepting the position of DON in October of 2019. She said she had come out at night to pass medication from the medication cart because staff had called off and there was not enough staff to provide care to the residents. The DON said she feels she has no say in the nursing care provided to the residents. 6. The facility policy 250.1390.1 Activities of Daily Living stated, It is the goal of the facility to provide necessary care and services to attain or maintain the highest practicable functioning of the resident. On 1/6/20 at 1:00 p.m., during observation with Resident #21, his fingernails were long, extending approximately 1/2 inch past his fingertips with an accumulation of brown substance under the nailbeds. Resident #21 said his nails were long and need to be cut. He said someone usually came around to cut them, but they had not recently been in to assist him with nail care. A review of the medical record for Resident #21, revealed a care plan (a detailed approach to care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 25 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many customized to an individual patient's needs) indicating the resident required extensive to total assistance with his ADL's On 1/7/20 at 2:55 p.m., in an interview Certified Nurse Aide (CNA) Staff E confirmed the resident was unable to clip his fingernails and it was her responsibility to clip the resident's nails. Staff E said she honestly hadn't paid attention to Resident #21's fingernails lately. 7. On 1/6/20 at 12:30 p.m., in an interview the spouse of Resident's #46 said the staff were not assisting the resident when she was eating her meals. He said his wife's appetite and intake at meals was better when she was assisted to eat. A medical record review revealed a care plan documenting Resident #46 had difficulty swallowing and was holding food in her mouth. The care plan indicated the resident was at risk for aspiration (accidental ingestion of fluid or food into the lungs), and instructed the resident was to eat only with supervision. The CNA Kardex (an information system used by nursing staff to communicate important patient information) instructed Resident #46 was to eat only with supervision. On 1/8/20 at 10:45 a.m., in an interview, CNA Staff A said, she was in and out of other resident's rooms to monitor and assist them during meals. The CNA verified that she did not stay with Resident #46 unless the resident requested that she needed assistance. On 1/8/20 at 12:31 p.m., in an interview the Consultant Dietician said the resident's diet was changed to puree consistency because the resident was pocketing her food and chewing for extended periods. The Consultant Dietician said if the CNA leaves Resident #46's room after setting up her meal, then the resident was not being supervised On 1/8/20 at 12:47 p.m., in an interview with the Unit Manager, he said when a resident was identified as supervised feeding, it meant that the CNA should remain in the room during the resident's meal. The facility policy 250.3080.1 Restorative: Contractures, documented Residents admitted with contractures (limited movement of a joint) will receive appropriate treatment and services. A review of the medical record for Resident #46 revealed a Restorative Nursing care plan instructing the Restorative Aide was to apply the left-hand resting splint 6 days per week. The Physician order dated 7/3/18, documented Resident #46 was to wear a left resting hand splint on during the day and off at night. The medical record also documented Resident #46 had a diagnosis of hemiplegia (muscle weakness or partial paralysis on one side of the body). On 1/6/20 at 10:30 a.m., Resident #46 was observed in her room in bed. The resident had a contracture of her left hand. The resident did not have a splint on her left hand. On 1/7/20 at 9:50 a.m., Resident #46 was in her room in bed and she did not have a splint on her left hand. On 1/7/20 at 10:22 a.m., in an interview the Therapy Director said he was not working with Resident #46 and had not worked with her in the last six months. The Therapy Director confirmed he did not have a restorative program for Resident #46's left hand splint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 26 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0725 Level of Harm - Minimal harm or potential for actual harm On 1/7/20 at 3:24 p.m., in an interview with Licensed Practical Nurse, Staff D said Resident # 46 had a left-hand contracture, however she was not aware Resident #46 had a left-hand splint. On 1/8/20 at 8:45 a.m., in an interview the Restorative Aide said she does not have a restorative program to work with Resident# 46 and confirmed she had not been applying a splint to the residents left hand. Residents Affected - Many On 1/08/20 at 8:55 a.m., in an interview the Unit Manager, said Resident #46 had a splint but confirmed there was no documentation of who was responsible for applying and monitoring the splint. The Unit Manager confirmed Resident #46 had a contracture of the left hand and was not receiving restorative nursing care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 27 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to utilize its resources effectively to ensure the safety and wellbeing of the residents. The administration failed to adequately staff the facility and failed to demonstrate oversight or follow up to obtain and administer influenza vaccination timely. Residents Affected - Many The findings included: 1. On 1/9/20 at 3:40 p.m., the Director of Nursing (DON) said she has been employed at the facility since 10/1/19 and was aware of the staffing issues in the building. She said her concern was the number of falls and family complaining about not getting things done timely for their loved ones. She said although she was aware of the issues, she did not develop a plan of action to rectify the lack of adequate staffing to meet the needs of the residents. The DON said she spoke to the Administrator about the staffing concern, but it was not a formal conversation. She said the Chief Operating Officer (COO) was the only one making the decisions for the staffing pattern of the building based on the State's number requirement, not on the acuity of the residents. 2. During the interview, the DON verified the facility failed to order and administer the influenza (flu) vaccine to the residents prior to the start of the flu season. She said she started employment at the facility on 10/1/19 but did not realize until 10/30/19 that the residents had not received the flu vaccine. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admitted she did not inform the Medical Director of the failure to obtain the vaccines in a timely manner and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who cannot receive the flu vaccine. She said she recently appointed Licensed Practical Nurse Staff M to be the infection preventionist, even though she has not been trained. 3. On 1/09/20 at 1:28 p.m., in an interview the Medical Director said he was not aware the facility did not order the flu vaccine on time. He said his recommendation was to give the flu vaccine to the staff for free and they did not do it. He said he was not involved in any corrective action. The Medical Director said there was a problem with communication in this facility. He added I have said they need to work on their communication with everyone. There are no set rules here, everyone seems to come up with their own. Three people give orders between the owners and if we have one person hopefully things will be done right. The Medical Director added I think the issue is communication, they don't know which one of them here is responsible to give the vaccine. There have been too many changes with the DON. I see it as the owners are in charge not the DON. I can tell you we did not have the staffing here to cover a few months back. I don't know about now. The facility did not inform me of the flu outbreak here, I heard about it from [name]. I did not know about the flu outbreak here until late December, I was just recently informed of it. I found out about the flu outbreak when [Resident #99] was admitted to the Hospital. We need to have a policy here going forward. The medical director added he expected the facility to administer the flu vaccine to the residents in August and September. 4. On 1/10/20 at 10:40 a.m., during a telephone interview, the Medical Director said he used to be involved in administrative decisions a long time ago such as developing and approving facility policies related to residents' care. He said the facility had been without a DON and it's been more than (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 28 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete a year for sure that he has not participated in any recommendation, development, and approval of the facility policies and procedures. 5. Review of the Quality Assurance and Performance Improvement (QAPI) minutes dated 11/13/19 and 12/11/19 failed to reveal documentation the facility's administration addressed the lack of adequate staffing to meet the needs of the residents or the failure to offer and administer the flu vaccine on a timely manners to the residents. Event ID: Facility ID: 106070 If continuation sheet Page 29 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/10/20 at about 10:30 a.m., documentation of governing body activity was requested. Review of the QAPI minutes dated 11/13/19 and 12/11/19 failed to reveal documentation the facility addressed the lack of adequate staffing to meet the needs of the residents or the failure to offer and administer the influenza vaccine on a timely manner to the residents. On 1/10/20 at about 1:30 p.m., the Assistant Administrator was reminded about the request for governing body information. He responded he had provided the Quality Assurance Program Improvement (QAPI) documents and asked, What is the governing body? On 1/10/20 at 2:21 p.m., the facility provided a single-page document prepared this day that named the members of the governing body. This policy (revised date 1/2020) stated, The Governing Body represents the owner(s), an owner appointed Administrator and Director of Nursing. Together the Governing body shall aide in the implementation and monitoring of policies and procedures of the facility. The procedure stated, In executive order: President/Owner Chief Operating Officer Administrator Assistant Administrator Director of Nursing The Governing Body shall meet at least on a bi-monthly basis to discuss and address all appropriate issues. All meeting minutes will be documented and saved for reference. Based on interview and record review the facility failed to have an active governing body to ensure effective management of the facility. The Governing Body failed to establish and implement policies for the effective management and operation of the facility. The findings included: In an interview on 1/9/20 at 1:28 p.m., the Medical Director said, There are no set rules here, everyone seems to come up with their own. Three people give orders between the owners and if we have one person hopefully things will be done right. In an interview on 1/9/20 at 11:30 a.m. the Chief Operating Officer (COO) said his background was in radiology and he had no nursing experience. The COO verified he was not aware of the need to account for acuity in resident care. The COO verified he staffed the building above what the state (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 30 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0837 requires. Level of Harm - Minimal harm or potential for actual harm In an interview on 1/9/20 at 3:40 p.m., the Director of Nursing (DON) said she spoke to the Administrator about the staffing concern, but it was not a formal conversation. She said the COO was the only one making the decisions for the staffing pattern of the building based on the State's minimum requirement, not on the acuity of the residents. Residents Affected - Many During a telephone interview on 1/10/20 at 10:40 a.m., the Medical Director said he used to be involved in administrative decisions a long time ago such as developing and approving facility policies related to residents' care. He said the facility had been without a DON and it's been more than a year for sure that he has not participated in any recommendation, development, and approval of the facility policies and procedures. In an interview on 1/10/20 at 12:10 p.m., the DON said she had never seen the facility assessment tool. In a telephone interview on 1/10/20 at 12:15 p.m., the Administrator said she was not aware of the facility assessment tool and was not aware that it was used to assess the acuity of the residents at the facility. In an interview on 1/10/20 at 12:15 p.m., the COO said he had never seen the facility assessment and was not aware it should be used for assessing the acuity of the residents at the facility and the staff needed to provide care to the residents. In an interview on 1/10/20 at 5:37 p.m., the DON said she had only met with the owners twice since accepting the position of DON in October of 2019. She said she had come out at night to pass medication from the medication cart because staff had called off and there was not enough staff to provide care to the residents. The DON said she [NAME] she has no say in the nursing care provided to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 31 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review the facility failed to revise the facility assessment tool when the acuity level of the residents changed resulting in insufficient staff to provide transferring and mobility of the residents and the care of residents needing assistance with eating. The findings included: Review of the Facility Assessment revealed it was created in July of 2019. Under 1.5 the document reads Describe your resident's acuity levels that help you understand potential implications regarding the intensity of care and services needed. The assessment showed in July 2019 there were 10 residents dependent on transfers. In July 2019 there were 5 residents dependent on staff for toileting. In July 2019 here were 3 residents dependent of staff eating. Review of the Census and Condition dated 1/6/20 showed there was currently a census of 43 residents. 18 of the residents at the facility were dependent on staff for transferring. 20 residents were dependent on staff for toileting, and 10 residents were dependent on staff for eating their meals. Currently 33 of the 43 residents in the facility need assistance from 1 or 2 staff members with eating. On 1/10/20 at 11:50 a.m., the Contracted Physical Therapist said she had had no input in creating the facility assessment tool. On 1/10/20 at 11:55 a.m., the Director of Physical Therapy said he had been at the facility since April 2019 and he had not been involved with the facility assessment tool. On 1/10/20 at 12:10 p.m., the Director of Nursing said she had never seen the facility assessment tool. On 1/10/20 at 12:15 p.m., the Administrator said she was not aware of the facility assessment tool and was not aware that it was used to assess the acuity of the residents at the facility. On 1/10/20 at 12:15 p.m., the Chief Operating Officer said he had never seen the facility assessment and was not aware it should be used for assessing the acuity of the residents at the facility and the staff needed to provide care to the residents. (Refer to F725) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 32 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure effective ongoing coordination and develop an individualized care plan to meet the needs of 1 (Resident #42) of 1 resident receiving hospice services. The failure to effectively coordinate the care places the resident at risk for not receiving the necessary services to meet the resident's physical and psychosocial needs at the end of life. The findings included: Clinical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and generalized muscle weakness. The minimum data set assessment as of 8/20/19 indicated Resident #42 was receiving hospice services. The facility's current care plan for activities, advanced directives, activities of daily living, cognition, dehydration, falls, pressure ulcer and pain indicated hospice to collaborate care. The care plan was not specific and did not include what services hospice was to provide. The clinical record did not contain a certificate of terminal illness, a hospice care plan or documentation of the hospice election form. On 1/8/20 at 10:57 a.m., Licensed Practical Nurse (LPN) Staff N said the hospice Certified Nursing Assistant (CNA) came in daily to assist Resident #42 with his lunch meal. On 1/8/20 at 12:50 p.m., CNA Staff L was observed feeding the resident at lunch time. She said she started feeding the resident since she didn't see the hospice CNA in the building. She said she didn't know the schedule of the hospice CNA and wasn't sure what day she was scheduled to assist Resident #42. On 1/8/20 at 12:39 p.m., the Nursing Service Supervisor said the hospice nurse came once a week and did the wound care and the CNA came in to feed him. He agreed the care plan did not delineate hospice responsibility versus the services the facility is to provide. On 1/8/20 at 11:49 a.m., during an interview the Director of Nursing (DON) and the Social Worker verified the resident's clinical record did not contain the required information to effectively care for the resident. She said she didn't know what services hospice provided and did not know the schedule of the hospice CNA. The DON said she was not aware the facility had to designate a specific team member to collaborate with hospice representatives to ensure the quality of care for the resident and family member. She said, please educate me. The Social Service Director said he would contact hospice and request the missing information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 33 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and staff interview the facility failed to have an effective on-going Quality Assurance Performance Improvement (QAPI) that recognizes, prioritizes, and implement corrective actions to address quality deficiencies that pose a high risk to residents' safety and well-being. The failure to maintain an effective quality assurance program causes ongoing deficient practices with a likelihood of negative consequences to the residents. The findings included: Review of the facility's policy and procedure titled Quality Assurance Performance Improvement (QAPI) with an original date of 6/16 revealed The QAPI committee has the responsibility for designing and implementing corrective action plans as needed to resolve identified resident care/service problems. This is accomplished within local, state, federal and facility guidelines. All improvement plans will contain: * What is to be changed * When and how the corrective action will be implemented * Who is responsible for the implementation of the corrective action * What time interval is set for reassessment of the implemented changes Improvement plans and effectiveness of actions will be documented in the committee minutes. 1. During a review of the facility's QAPI program on 1/9/20 at 3:40 p.m., the Director of Nursing (DON) said she has been employed at the facility since 10/1/19 and was aware of the staffing issues in the building. She said her concern was the number of falls and family complaining about not getting things done timely for their loved ones. She said although she was aware of the issues, she did not bring it as a priority item to the QAPI meetings, nor did she develop a plan of action to rectify the lack of adequate staffing to meet the needs of the residents. The DON said she spoke to the Administrator about the staffing concern, but it was not a formal conversation. She said the Chief Operating Officer (COO) was the only one making the decisions for the staffing pattern of the building based on the State's number requirement, not on the acuity of the residents. 2. On 1/9/20 at 3:40 p.m., the DON verified the facility failed to order and administer the influenza (flu) vaccine to the residents prior to the start of the influenza season. She said she started employment at the facility on 10/1/19 but did not realize until 10/30/19 that the residents had not received the flu vaccine. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admitted she did not inform the medical Director of the failure to obtain the vaccines in a timely manner, did not address it in QAPI, and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who cannot receive the flu vaccine. The DON said although they have a QAPI meeting monthly, those items were not discussed and were not a priority on their agenda. She said she recently appointed Licensed Practical Nurse Staff M to be the infection preventionist, even though she had not been trained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 34 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0867 Level of Harm - Minimal harm or potential for actual harm 3. Review of the QAPI minutes dated 11/13/19 and 12/11/19 failed to reveal documentation the facility addressed the lack of adequate staffing to meet the needs of the residents or the failure to offer and administer the influenza vaccine on a timely manner to the residents. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 35 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/6/20 at 11:20 a.m., the following observations were made: Residents Affected - Some A graduated container used to measure the urine from the Foley catheter of Resident #42 was stored uncovered on a paper towel on the toilet. Resident #42 shares the bathroom with a roommate. On 1/9/20 at 10:30 a.m., the Director of Nursing (DON) verified the container was used to empty urine from the catheter. 3. The bathroom of room [ROOM NUMBER] had two wash basins that were stacked, uncovered and stored on the floor behind the toilet. A graduated container used to measure urine output was stored on the toilet. An uncovered wash basin was stored next to the graduated container on the toilet. 4. room [ROOM NUMBER] had a bedpan partially inserted in a plastic bag and stored on the floor next to the toilet. The leg of the raised toilet seat was resting in the bedpan. A bedpan in a plastic bag was stored on the floor behind the toilet. A bedpan in an opened plastic bag was stored between the handrail and the wall. 5. On 1/9/20 at 10:30 a.m. the DON said the bedpans, wash basins and graduated containers should be rinsed after use, placed in plastic bags and stored in the bottom drawer of each resident's nightstand. She said the facility did not have a policy addressing the storage of resident's personal care items and she did not have documentation the staff was trained on the proper storage of reusable resident's care items. ***Photographic evidence obtained*** Based on observation, staff interview, and facility policies and procedures review the staff failed to handle clean linens to prevent contamination and failed to store resident's equipment in a sanitary manner. The failure to properly handle and transport clean linens and store resident's equipment has the potential to spread infections to residents. The findings included: 1. The facility policy 220.60.1 Laundry, Infection Control (revised 2/17) stated When folding clothes, never let laundry touch your body or the floor .When handling clean laundry, never carry clothes against your body. On 1/6/20 at 11:04 a.m., during an observation Laundry Aide Staff C was in the hallway placing clean folded linen from a cart onto the large linen cart in the hallway. The aide was holding the clean linen against her body and the clean linen was in contact with her uniform. The aide did not have a protective covering over her uniform. On 1/7/20 at 9:17 a.m., Staff C was observed removing and folding clean linen from the dryer. The clean linen was in contact with her body and uniform while removing and folding the clean laundry. On 1/10/20 at 5:01 p.m., in an interview with Housekeeping Aide Staff G said, I can tell you the policy is when handling clean linen, a protective covering is required to prevent the clean linen from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 36 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 contact with the work uniform. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 37 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedures review, and staff interview the facility failed to follow their policies and procedures and neglected to provide the influenza (flu) vaccine in a timely manner to 33 of 43 residents who requested the flu administration, which resulted in 3 (Resident #99, #14, #45) unnecessary hospitalizations due to the flu virus. The facility failed to order the flu vaccine in a timely manner. The facility failed to notify the Medical Director when the residents did not receive the flu vaccine. The facility did not develop a plan of action to ensure the timely vaccination of the residents. The facility failed to implement measures to protect the residents who cannot receive the flu vaccine. These actions resulted in immediate jeopardy that started on [DATE]. The facility was informed of the immediate jeopardy on [DATE] and was provided the Immediate Jeopardy Template. The jeopardy was removed on [DATE] when corrective actions were verified in place. The scope and severity was reduced to E. Residents Affected - Some The findings included: 1. Review of the facility's policy 200.460.1 (revised 8/2016) titled Infection Control, Immunizations and Vaccinations indicated It is the policy of this facility that all residents receive immunization and vaccinations that help in preventing infectious diseases, unless medically contraindicated or otherwise ordered by the resident's attending physician .The flu vaccine should be administered at least two months before the expected start of the flu season in the community. On [DATE] at 3:11 p.m., during a review of the facility's immunization program the Director of Nursing (DON) said the facility experienced a flu outbreak in late November early December. The DON said she realized around [DATE] the facility had not initiated the flu immunization for residents and staff. The DON said although they immediately obtained consents and started to administer the vaccines on [DATE] to the residents who requested it, it did not prevent the outbreak. She collaborated with the local Health Department who recommended Tamiflu for residents that contracted the flu, but it would be very costly to the residents. 2. The DON said Resident #99's responsible party requested the flu vaccine on [DATE]. On [DATE] the resident was sent to the hospital with a high temperature and was diagnosed with influenza. The resident returned to the facility on [DATE] but since he was on antibiotic for extended spectrum B-Lactamase, (a bacteria resistant to some antibiotics) infection in his stools, he did not receive the flu vaccine. The DON said the resident expired at the facility on [DATE]. Healthline information about the flu explains, If you develop a secondary infection while you have the flu, that can also cause your organs to fail. The bacteria from that infection can get into your bloodstream and cause sepsis, as well. (downloaded [DATE] from: https://www.healthline.com/health/can-you-die-from-the-flu). 3. The DON said Resident #14's granddaughter requested the flu vaccine for her loved one on [DATE]. She received the vaccine on [DATE] but on [DATE] the resident experienced a high temperature and was transferred to the hospital. Resident #14 was diagnosed with flu A at the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 38 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0883 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 4. The DON said Resident #45 requested the flu vaccine on [DATE] but the vaccine was not administered until [DATE]. On [DATE] the resident developed a high fever and altered mental status. Resident #45 was transferred to the hospital on [DATE] where he was diagnosed with flu A. 5. According to the Centers for Disease Control and Prevention: .is that it is possible to be exposed to influenza viruses, which cause the flu, shortly before getting vaccinated or during the two-week period after vaccination that it takes the body to develop immune protection. This exposure may result in a person becoming ill with flu before protection from the vaccine takes effect. (Downloaded [DATE] from: https://www.cdc.gov/FLU/PREVENT/MISCONCEPTIONS.HTM) 6. The DON said when the first case of flu was discovered in the facility, she instructed the Unit Manager to obtain residents consents for the flu vaccine. She said employees were not encouraged to have the flu vaccine before [DATE]. She said the facility offered the vaccines to the employees at a cost of $25.00 that could be paid through payroll deduction. The DON said employees declined to receive the immunization due to the expense. Staff were then advised to take Tamiflu (a medication for the prevention and treatment of the flu) and to wear a mask during the flu outbreak. The DON said she did not keep track of employees who did not receive the flu shot and did not enforce the wearing of the mask for those employees who were not immunized. The DON said, unfortunately, the Activity Assistant who conducts group and individual activities for all the residents was diagnosed with the flu on [DATE] at the hospital. 7. Review of a tracking log indicated on [DATE] the Activity Assistant started experiencing a high temperature, headache, nausea and weakness. The employee time detail report revealed the Activity Assistant worked on [DATE] and [DATE] despite the onset of symptoms. The DON said Licensed Practical Nurse (LPN) N worked on [DATE] and was diagnosed with the flu on [DATE] at the doctor's office. 8. The DON presented a flu vaccine order dated [DATE] in which the facility requested 8 multidose vials (80 doses) of the flu vaccine. She said they never received it. On [DATE] at 5:30 p.m., in an interview with the Unit Manager (UM), he said he was assigned the UM position in 9/19 but did not receive training. He said he was responsible for getting consents, obtaining, and administering the flu vaccine to the residents but was not aware to do so until the pharmacy called [DATE]. The pharmacy wanted to know why the facility had not ordered the flu vaccines for the residents. The UM said, I did not know and was told I was supposed to order the vaccine in April. The UM said he realized he had a big problem and notified the DON he was not trained to order the vaccine. The UM said in orientation, he was told the pharmacy sends the vaccine all he had to do was get the consents. He said he started obtaining the consents on [DATE]. On [DATE] at 10:57 a.m., in an interview LPN Staff O said she has been employed at the facility for approximately 5 years and was the UM from [DATE] to [DATE] but did not order the flu vaccine for the current flu season. She said she was not informed it was her responsibility. LPN Staff O said, I have never ordered the flu vaccine, it has always been the responsibility of the Infection Control Nurse. Staff O said in June and [DATE], she and the previous DON received emails from the pharmacy regarding ordering of the flu vaccines but we were in transition with a new DON and with staff changes. Staff O said she trained the current Unit Manager for a one week and gave him a quick overview. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 39 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0883 showed him the form to order the vaccines but there were no directions to go by. Level of Harm - Immediate jeopardy to resident health or safety On [DATE] at 12:51 p.m., in a telephone interview the Pharmacy Supervisor said the facility ordered 8 vials of the flu vaccine in April, which contained 80 doses. The facility never completed the required paperwork for the vials to be sent, including the individual questionnaires for the residents and staff and the medical orders for the vaccine. The Pharmacy Supervisor said he received approximately 36 individual flu vaccine requests for residents in [DATE] and [DATE] and the pharmacy sent them. Residents Affected - Some 9. On [DATE] at 12:36 p.m., in an interview with the attending Physician, he said the flu is spreading everywhere and he recommends the facility vaccinates in October. He said, I don't know why the facility did not give the influenza vaccine and said the residents who had the flu were sent to the hospital. On [DATE] at 1:28 p.m., in an interview the Medical Director said he was not aware the facility did not order the flu vaccine in a timely manner. He said he was not notified about the flu outbreak until late after the residents contracted the flu. He said his expectation was to administer the flu vaccine in August and September to the residents. The Medical Director said his recommendation was to give the flu vaccine to the staff for free and they did not do it. 10. During a review of the facility's Quality Assurance and Performance Improvement (QAPI) program on [DATE] at 3:40 p.m., the DON verified the facility failed to order and administer the flu vaccine to the residents prior to the start of the flu season. She said she did not realize until [DATE] that the residents had not received the flu vaccine. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admitted she did not inform the Medical Director of the failure to obtain the vaccines in a timely manner, did not address it in QAPI, and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who cannot receive the flu vaccine. The DON said although they have a QAPI meeting monthly, those items were not discussed and were not a priority on their agenda. She said she recently appointed LPN Staff M to be the infection control nurse, even though she has not been trained. Verification of the removal plan included: Reviewed documentation of written consent and administration to all residents who consented to receive the flu vaccine. Reviewed QAPI meeting notes and QAPI action plan dated [DATE] which included education of professional staff on influenza and infection control practices. Sign in sheets were reviewed and staff attendance was verified. Reviewed draft of new policy for Immunization and Vaccination which documents the Infection Control Nurse/DON will be responsible for obtaining and administration of the flu vaccine to residents before the beginning of the flu season effective immediately. Verified facility employees were educated regarding the importance of the flu vaccination, and that the employees were offered the vaccine free of charge. Sign in sheets for in-service reviewed. All employees who did not consent to vaccine will be required to wear a mask until the end of the flu season. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 40 of 41 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 106070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266 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 0883 Reviewed draft of new policy for Immunization and Vaccination included employees will continue to be educated on the importance of the flu vaccine and offered the flu vaccine free of charge. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106070 If continuation sheet Page 41 of 41