Health inspection·April 27, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have. The facility follows the Minimum Data Set (MDS) calendar to ensure all residents are screened. Resident #41, last screen was completed in February 2023. During an interview on 4/27/2023 at 9:40 a.m. the DOR stated the facility provides residents with the equipment they are in need of. If the facility does not have a specific piece of equipment, the facility would need to procure one. They could order or rent, if necessary. The DOR confirmed the facility needs to provide the resident with the needed equipment. Review of the admission Record, for Resident #41 revealed she was admitted to the facility on [DATE] and her diagnoses included chronic obstructive pulmonary disease and morbid (severe) obesity. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 3/1/2023, revealed Section C Cognitive Patterns a score of 13/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Section G Functional Status indicated Resident #41 needed supervision with set up only with eating, two-person extensive physical assist for transfer and total dependance with locomotion on and off unit. Balance during transition required staff assistance and walking was indicated as Activity did not occur, Functional limitation and range of motion indicated no impair impairment for the upper extremity and lower extremity impairment on both sides, Mobility devices utilized checked as wheelchair. Section O Special Treatments, Procedures, and Programs revealed no restorative nursing minutes, which included range of motion. A review of Resident #41's care plan, initiated on 8/24/2022, revealed a Focus area of: Resident would benefit from personal invites, encouragement, and reminders. Goal: accept invites to groups. Interventions: resident love to draw, resident family supplied materials and the Life Enrichment Department has helped her set up her room for her benefit. Another Focus area showed: assistance with Activities of Daily Living (ADL). Goal to maintain current level. Interventions: need the staff to propel me in my wheelchair to my destination. Review of Resident #41's discharge summary from Occupational Therapy (OT) for dates of service 8/24/2022 to 9/10/2022, showed discharge destination to be a long-term care setting with the reason for discharge: per physician or Case Manager. The summary showed a list of short-term goals with week over week function. The summary showed the resident being discharged from OT on 9/10/2022, short term goal #2 documented as patient will complete hygiene and grooming tasks while sitting in wheelchair at sink with Minimum Assistance (Min (A)) and 25% Tactile Cues for organization and planning in order to perform hygiene and grooming with increased Independence (I) and safety. Resident discharged being able to perform task while seated at the edge of her bed with set up assistance and only occasional cues. Long term goal # 2 documented as, patient will increase personal hygiene and grooming to Modified Independent (MOD I) while sitting in wheelchair at sink for increased independence with ADLs. Resident was discharged with being able to complete this task with set up only. OT documented Resident #41 had a good prognosis to maintain current level of function, with consistent staff follow-through. discharged resident with a home exercise program. Documented training the resident and caregivers in functional maintenance program and energy conservation techniques specifically, to maintain current level of function to prevent decline from current level of skill performance. Review of Resident #41's discharge summary from Physical Therapy (PT) for dates of service 8/24/2022 to 9/10/2022, showed discharge destination to be a long-term care setting with the reason for discharge: change in payer source. Resident #41's short-term goal #1 was documented as increase in static sitting balance to Fair-: and to maintain static balance with minimal assist or upper extremity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 2 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few support spontaneously righting self when needed in order facilitate upright posture. Resident met this goal on 9/8/2022. The short term goal #2 showed, resident will increase dynamic sitting balance to Fair-: able to sit supported with minimum assistance and reach to same side, unable to weight shift spontaneously righting self when needed to facilitate weight distribution. Resident discharged on 9/9/2022, resident was able to sit supported with minimum assistance and reach to same side. The short term goal #3 showed, resident will increase static standing balance to Poor+: requires modified assistance and upper extremity support to maintain standing without balance loss, to facilitate safety while standing. Resident met this goal on 9/8/2022. PT documented resident and staff training with the home exercise program. Resident #41 has a good prognosis to maintain current level of function, with good consistent staff follow through. PT discharged recommendations listed as: home exercise program, bariatric walker, and bariatric wheelchair. Review of the document titled, Resident Screening Form, dated 2/13/2023, the section titled problem showed, Patient complained of increased weakness. Would like to improve transfers and sitting tolerance. The form showed, Recommendations: PT and OT evaluation are marked. Under the comments section the following was revealed: Went to schedule eval [evaluation] with patient. Patient requested to wait until Medicaid process was finalized. Form signed by DOR and dated 2/13/2023. Review of the document titled, Therapy Verification Form (MUST BE COMPLETED PRIOR TO ANY RESIDENT BEING EVALUATED BY THERAPY SERVICES), revealed, no pre-cert required for services. A handwritten note on the form showed, resident would have out of pocket expenses If they don't get approved for Medicaid, Otherwise zero. The form was signed by the Business Office Manager (BOM) and dated 2/14/2023. Review of a letter addressed to the facility from the Vendor Name for Medicaid filing assistance, dated 4/17/2023, documented Resident #41's Medicaid application was approved effective January 2023, ongoing. The top of the document revealed the letter was received at the center via fax on Monday, 4/17/2023. A review of the facility Grievance Logs for September through December of 2022 and January through April 2023 revealed no grievances for Resident #41. Further review of Resident #41's medical record, from 8/16/2022 to current revealed no documentation related to her wheelchair not fitting appropriately. On 4/26/2023 at 3:00 p.m. and 4/27/2023 at 9:45 a.m. requests were made to the Administrator for a policy and procedure regarding equipment for residents' needs. No policies or procedures were received by the time the survey team exited on 4/27/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 3 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #54's Medical record revealed that she was admitted to the facility on [DATE] and had diagnosis that included Type 2 Diabetes Mellitus with Hyperglycemia. Review of the resident's Details revealed that the resident had a current order for reduced consistent Carbohydrate/Diabetic diet. Review of the resident's Nutritional assessment dated [DATE] does not reflect residents preference. Care plan dated 2/7/23 related to nutritional risk with intervention to include You will discuss my food preferences with me. Observation of resident #54 on 04/24/23 at 11:15 AM revealed that she was sitting up in her bed. The resident reported that she gets too much potatoes and rice and is diabetic. Observations of the residents midday meal tray on 04/24/23 at 1:05 PM revealed that her lunch tray included a scoop of mashed potatoes. Observation of the resident morning meal tray on 04/26/23 at 09:40 AM revealed that the resident received cream of wheat, Orange Juice, Applesauce, Waffles, and Regular syrup. The resident reported too much sweets. Interview on 04/26/23 at 10:54 AM with the Nursing Home Administrator (NHA), she reported that the Diet Clerk/Dietary Aide input resident orders daily into the ticket system with resident request for meals and/or preferences. She reported that for those residents who are not alert and oriented the aide will get weekly orders from families. Interview on 04/26/23 at 12:21 PM with the Registered Dietician (RD) revealed that she does nutritional assessments for residents at the time of admission with nutritional screen and then one time a quarter and that she reviews weights weekly. She reported that for carbohydrate controlled diets they do provide diet syrup. She reported that the Diet Clerk does preferences. Observations of Resident #54 on 04/26/23 at 01:00 PM revealed that the resident had her midday meal which consisted of cranberry juice, fresh banana, grilled chicken, Mashed potatoes with gravy, and ice tea, Resident ate chicken half of the banana and said that she will not eat the potatoes because its too much potatoes. Interview on 04/26/23 at 01:03 PM with Staff H, Certified Nursing Assistant (CNA) reported that she is assigned to the resident and works with her often. She reported that the resident always says that she does not like so much potatoes, but she tells her to just eat what she wants. She reported that she has not shared this information with the nurse or anyone else. Interview on 04/26/23 at 02:14 PM with the RD, Director of dining and nutritional services and Staff D, Diet Clerk revealed that RD reported that related to food preferences she does a little bit of preferences, and then Diet clerk will do the majority of preferences and that they are all done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 4 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some within 4 days, and documented on the ticket system, if it is conveyed to kitchen that someone does not want an item they will then break up the order to reflect the change. Staff D reported that she sees residents at least weekly for orders, and that CNA's will come to the kitchen and notify them of the resident not wanting a certain item. She reported that they encourage the CNA's to verbalize when the resident does not want an item. She reported that menus are posted on the floors and on channel 2 of the television. The RD reported that if a resident verbalizes a dislike that the aides/nursing should bring that information to the kitchen. Based on observations, record reviews, and interviews the facility failed to ensure three (#196, #54, #349) out of 42 sampled residents were assessed for food and drink preferences, received meals as indicated on menu, and five (#21, #23, #52, #97,and #198) of five residents were offered to have meals in the facility's first floor dining room. Findings included: An observation was conducted on 4/26/23 at 9:45 a.m., of Resident #196 sitting on edge of bed wearing a right arm lower forearm brace as the breakfast tray was delivered. The resident stated that today was the first time that coffee had been offered (not on tray) by the Certified Nursing Assistant (CNA). The observation of the residents' tray indicated a covered glass of orange juice that was 1/2 full, a carton of 2% milk (which staff did not offer to open). The resident stated that it did not matter if the orange juice was only half full because resident did not drink orange juice due to having acid reflux and did not drink milk either but did get the drinks every day. A review of Resident #196's diet ticket indicated that the resident was to receive a regular diet with regular consistency and no restrictions. The resident reported that no one had asked her about food or drink preferences. The diet slip identified that the resident was to receive two (2) strips of bacon, a cheese omelet, a bowl of cream of wheat and a buttered slice of toast. The tray contained a piece of a lightly toasted piece of bread, the cheese omelet, and one strip of lightly cooked piece of bacon. The resident stated today was the first time of not getting scrambled eggs for breakfast. On 4/26/23 at 1:00 p.m., Resident #196's lunch tray contained a small side salad, a scoop of Chili Mac, slice of cornbread and no drink on the lunch tray. The resident asked why the facility was serving Chili Mac because it was spicy. The resident stated that no one had gone over the menu, it's a surprise till you open it up, demonstrating to remove the plate cover. The resident denied that a staff member had come in with possibly a handheld tablet or anything to review menus. The resident reported being told just the other day that a side menu was available and it was possible to get a sandwich if not wanting what was served. On 4/26/23 at 3:54 p.m., Resident #196 was observed ambulating in the hallway holding a Side Menu, and reported that the facility came yesterday to ask about drink preferences but not food. The Mini Nutritional Assessment, effective 4/4/23, did not identify any food or drink preferences. The Nursing Home Administrator (NHA) stated, on 4/26/23 at 10:53 a.m., that the resident dietary preferences are done post- admission by either the Dietician and/or Dietary Clerk. The NHA stated that the Dietary Clerk visits all residents daily during the day shift to obtain menu selections and utilized a device that links to dietary. An interview was conducted on 4/26/23 at 2:16 p.m., with the Registered Dietician (RD), Staff Member D (Dietary Clerk), and the Director of Dining and Nutrition Services (DDNS). The RD explained that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 5 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Staff Member D asked residents their food preferences within 4 days of admission then the RD would follow up. Staff D reported asking about drink preferences, sandwiches, and fruits and that the facility doesn't have preferences in assessments and that the preferences are printed on the tray ticket. Staff D stated residents are not visited daily (despite NHA stating that it happens), each week new admissions and other residents are seen once a week. The RD explained that weekly Staff D leaves a menu and side menu with residents and that menus were also available on channel 2 (television). The staff member reported being unsure if Resident #196 had been spoken to regarding preferences, stated the resident wanted coffee and did not want any juices. The dietary details for Resident #196 did indicate that the resident liked coffee but did not identify that the resident did not want orange juice or any other likes or dislikes. On 4/24/23 at approximately 9:15 am., during the entrance a large dining room was observed near the entrance to the skilled nursing facility, several residents were observed playing a bowling video game. During the survey process on 4/24/23 - 4/27/23, the dining room was not observed as being utilized for meal services. The Nursing Home Administrator (NHA) stated on 4/26/23 at 10:53 a.m., that in regards to the non-use of the Dining Room was that the facility was being mindful of infection protocols since the county transmission rate has been high and nurses offer residents to eat in the dining room but short-term rehabilitation residents choose to eat in rooms. Resident #21 reported on 4/27/23 at 10:30 a.m., of not being offered to use the Dining room and would utilize it at least one time a day if offered, it would be fun. The admission Record indicated the resident was admitted on [DATE] and diagnoses included but not limited to Type 2 Diabetes Mellitus, bilateral primary osteoarthritis of knee, and part unspecified malignant neoplasm of uterus. The admission Minimum Data Set (MDS) dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 11, indicating a moderate cognition impairment. Resident #23 reported on 4/27/23 at 10:34 a.m.,of being offered to use the dining room for meals but was told the staff were to busy handing out trays on the hallway. The resident reported liking to eat in the dining room to meet people, would like to eat with people. The admission Record indicated the resident was admitted on [DATE] with diagnoses that included but not limited to unspecified Type 2 Diabetes Mellitus with diabetic neuropathy, other sequelae of cerebral infarction, and moderate recurrent major depressive disorder. The Quarterly MDS for the resident, dated 3/31/23, identified a BIMS score of 10, indicating a moderate cognition impairment. Resident #52 reported on 4/27/23 at 10:39 a.m., of not being offered to use the dining room for meals and if had been asked would not have been interested in taking meals there. The admission Record indicated the resident was admitted on [DATE] with diagnoses that included but not limited to rhabdomyolysis, not elsewhere classified senile degeneration of brain, and generalized muscle weakness. The comprehensive MDS for the resident, dated 3/29/23, identified a BIMS score of 2, indicating a severe cognitive impairment. Resident #97 reported on 4/27/23 at 10:43 a.m., of not being offered to use the dining room for meals and might have used the room if offered but did not feel denied. The admission Record identified that the resident was admitted on [DATE] with diagnoses that included but not limited to unspecified transient cerebral ischemic attack and need for personal care assistance. The residents' MDS, dated [DATE], identified a BIMS score of 8, indicating a moderate cognition impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 6 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #198 reported on 4/27/23 at 12:40 p.m., of not being offered to eat in the dining room but would not have been interested this isn't exactly fine dining. The admission Record indicated the resident was admitted on [DATE] with diagnoses not limited to subsequent encounter for closed fracture with routine healing (of) fracture of unspecified part of neck of right femur, generalized muscle weakness, and need for personal care assistance. The comprehensive MDS, dated [DATE], identified the residents' BIMS score of 15, indicating an intact cognition. The policy - Resident Choices (revised 4/17, 4/18, 9/19, 3/20, and 8/21) indicated its purpose was To ensure that resident choices are honored (as feasible by the facility) in regards to providing resident centered care. The procedure identified that an interview would be conducted with the resident/resident representative would be conducted on the next business day after admission by a member of the clinical team, the facility's normal practices would be explained to the resident, and that the questions would allow the resident to choose times and situations that are acceptable to them. The policy identified that the facility would honor specific resident choices such as: time to get up, time to go to bed, bathing, and preferred name to be addressed by. The policy - COVID 19 and Transmission Based Precautions (TBP) policy, revised on 9/30/22, indicated it was policy of the facility to minimize exposures to respiratory pathogens and promptly identify residents with clinical features and an epidemiologic risk for COVID-19 and to adhere to Federal and State/Local recommendations (to include, for example: admissions, visitation, testing, and precautions. The policy identified that while adhering to the core principles of COVID-19 infection prevention, communal activities, and dining may occur. 2. An observation conducted of Resident #349 on 4/24/2023 at 11:16 a.m. Resident #349 had a sign posted on her wall next to her bed that read: No meat PORK eggs fish chicken OR other animal products all dairy fine. During an interview with the resident's representative (RR) on 4/24/20230 at 4:47 p.m., the RR stated that she came with the resident on the night of admission, 4/21/20230 at 5:00 p.m. The RR informed the nurse of her dietary preferences, warm milk with sugar and the restrictions above. The RR visited the following day and noted [Resident #349] received meat on her tray, and a cold milk carton and sugar packets were on the shelf next to her bed. [Resident #349] did not eat anything from the tray nor was she able to open the milk, although she wouldn't have drunk the milk as it was cold. We returned later with food from home. An observation on 4/25/2023 at 12:45 p.m. revealed the resident had meat on her tray. Resident #349 refused to eat it. Review of Resident #349's admission Record revealed she was admitted [DATE] with diagnoses that included hemiplegia unspecified (partial paralysis) following cerebral infarction (stroke) and Vitamin D deficiency. Review of the Minimum Data Set (MDS), dated [DATE], Section C Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) score of 11/15, which meant the resident was moderately cognitively impaired. A review of the Order Summary Report for April 2023, with active physician orders reflected: Regular diet, Regular texture, thin consistency, for Vegetarian, order and start date 4/22/2023; House Supplement three times a day for Weight maintenance 120 ML (milliliters), order dated 4/24/2023 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 7 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some start the evening of 4/24/2023; Prostat AWC three times a day for protein supplement 30 ML may mix with beverage, order dated 4/26/2023 to start 4/27/2023. The care plan for Resident #349 revealed a Focus Area of: I am at nutrition/hydration risk due to variable meal intakes, dementia, limited menu per preferences, dated 4/24/2023. Interventions included: I will make my meal choices from a menu, I will receive my diet as ordered, You will discuss my food preferences with me, all were dated 4/24/2023. An observation on 4/26/2023 at 1:00 p.m. of Resident #349's meal tray revealed the meal included: mixed vegetables, corn bread, small salad and apple juice. The tray card showed resident preferences, no fish, pork, chicken or meat, all dairy fine, Vegetarian. Tray was untouched. During an interview on 4/26/2023 at 1:00 p.m., with Staff B, Certified Nursing Assistant (CNA) and Staff J, CNA confirmed the resident refused her tray. Staff J, CNA stated the family said they would bring in all her meals, we don't need to worry about providing her an alternate. During an interview on 4/26/23 at 2:33 p.m., the Registered Dietitian (RD), Director of Dining and Nutrition Services (DDNS) and Staff D, Dietary Clerk. Staff D, Dietary Clerk stated that when a resident admits on Friday's, someone from nursing brings the new admit form with the resident's requests. Staff D stated that she follows up with the resident or family member the following Monday. Staff D stated she visited with the resident today, she does not speak English. Staff D, Dietary Clerk said, I have not contacted the family. The CNA told me she likes warm milk with sugar, needs a sippy cup, and that the family will bring food from home. The RD and DDNS confirmed this was the process. During an interview with the RR on 4/26/2023 at 3:16 p.m., the RR stated she never said they would bring her meals. [Resident #349] has a number of items she is able to eat. We filled out the menu we found at the nurses' station and marked what [Resident #349] would like, when we removed items we replaced with them with items from the always available menu. During an interview on 4/26/23 at 4:20 p.m. the RD stated the family had completed the menu with the resident's choices. The menu preferences were placed in the computer last night, 4/25/2023. The RD and Staff D, Dietary Clerk validated that Resident #349 should have received what the family chose, tomato soup, 1/2 banana, ice cream, small salad, mixed vegetables and juice for the lunch meal 4/26/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 8 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to issue a bed-hold notice at the time of transfer to the hospital for 1 of 1 (#94) resident sampled for hospitalization. Findings included Review of Resident #94's medical record revealed that this resident was admitted to the facility on [DATE] with diagnosis that include: Polyneuropathy, DMII, End Stage Renal Disease, Acute Pancreatitis, Calculus of Gall Bladder. Continued review of the record revealed SBAR 3/20/23 21:40 CIC [change in condition] Nausea/Vomiting NP [nurse practitioner] stated okay to send to ER for further eval, also per family and patient request. Review of the Nurse note dated 3/20/23 21:51 revealed that This nurse with patient and daughter, [name] via phone. Patient stated she is requesting to go to the hospital due to her feeling sick and c/o [complains of] nausea and stated she vomited at dialysis. Pt has 2x episodes of emesis, color green. Patient stated I want to go to the hospital NP notified of residents request and n/v [nausea/vomiting] complaints. NP stated that okay to send patient. Daughter made aware. Review of nurses note dated 3/20/23 22:04 indicated that a transport vendor was called, and had an ETA [estimated time of arrival] 1130p-12am Review of nurse note dated 3/20/23 23:08 indicated that Patient picked up at 22:30. Continued review of Resident #94's record revealed that there was no evidence that a bed-hold policy was provided to the resident/representative at the time of the transfer to the hospital. Interview on 04/27/23 at 08:18 AM with the Director of Nursing (DON), Registered Nurse (RN), she reported that if someone is going out to the hospital and it is not emergent the following things would be documented: face sheet, SBAR, medication list, recent labs or radiology, bed-hold policy, and transfer form. She reported that the bed-hold policy may be in the to be scanned file. Interview on 04/27/23 at 08:44 AM with Staff G Licensed Practical Nurse (LPN), Electronic Medical Records Coordinator (EMRC) revealed that when a resident is discharged all hard records go into a file to be scanned. At this time Staff G reviewed the to be filed stack of papers and reported that nothing was in the stack for Resident #94. At this time the DON reported that she would check the old Social Service Directors office in case it was there. Interview on 04/27/23 at 09:28 AM with the DON revealed that closed records should be scanned into the residents electronic record or the documents would be in the to be scanned bin. She reported that if it is in neither place then they do not have it. Review of the facility policy titled Bed Hold/readmission Policy dated 12/2010, with the most recent revision date of 10/22 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 9 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. The facility must have policies that address holding a resident's bed during periods of absence, such as during hospitalization or therapeutic leave. Additionally, the facility must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. 2. The regulatory guidance requires the facility to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Re-issuance of the first notice would be required if the bed hold policy under the State plan or the facility's policy were to change. 3. The second notice must be provided to the resident, and if applicable. The residents representative, At the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the residence representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed hold, if any, and the reserve bed payment policy. It should also address permitting the return of the residents to the next available bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 10 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to request a level II PASSR (pre admission screening and resident assessment) screen when documented diagnosis reflected the need for a level II PASSR screen for 1 of 1 (#63) residents sampled. Findings included: Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE]. Review of the resident's facesheet revealed the resident had diagnosis that included the following: Bipolar Disorder, Current Episode Manic without Psychotic Features; Dementia in other diseases Classified Elsewhere, Mild, with other Behavioral Disturbances; Major Depressive Disorder, Recurrent. Review of Resident #63's PASSR level I screen dated 3/20/2023 revealed that in section I. A the resident had Bipolar Disorder, there were no other diagnosis checked in this section. In section II.6 revealed that the resident does not have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an Serious Mental Illness or intellectual Disability. The form indicated that A Level II PASSR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental illness, Review of the residents order summary report which was active as of 4/26/23 revealed the residents diagnosis that included Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Major Depressive disorder, recurrent, unspecified; Bipolar Disorder, current episode manic without psychotic features, unspecified. Review of the medical visit from with a service date of 3/22/23 and completed by an APRN (advanced practice registered nurse) revealed that the resident's diagnosis included Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Bipolar Disorder, current episode manic without psychotic features, unspecified; Major Depressive disorder, recurrent, unspecified. Review of the medical visit from with a service date of 3/23/23 and completed by Staff K Advanced Practice Registered Nurse (APRN) revealed that the resident's diagnosis included Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Bipolar Disorder, current episode manic without psychotic features, unspecified; Major Depressive disorder, recurrent, unspecified. Review of the medical visit from with a service date of 3/27/23 and completed by an APRN revealed that the residents diagnosis included Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Bipolar Disorder, current episode manic without psychotic features, unspecified; Major Depressive disorder, recurrent, unspecified. Review of the medical visit from with a service date of 3/28/23 and completed by the residents Primary Physician revealed that the residents diagnosis included Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Bipolar Disorder, current episode manic without psychotic features, unspecified; Major Depressive disorder, recurrent, unspecified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 11 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Initial Wound Evaluations & Management Summary by a speciality physician dated 3/28/23 revealed that the residents diagnosis included Bipolar Disorder, current episode manic without psychotic features, unspecified; Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Major Depressive disorder, recurrent, unspecified. Review of the most recent medical visit from with a service date of 4/13/23 and completed by the residents Primary Physician revealed that the residents diagnosis included Bipolar Disorder, current episode manic without psychotic features, unspecified; Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Major Depressive disorder, recurrent, unspecified. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that the residents active diagnosis as Non-Alzheimers Dementia, Depression other than bipolar, and Bipolar Disorder. Review of Resident #63's record revealed a care plan related to I am at risk for behavioral and mood symptoms R/T to my diagnosis of Bipolar Depression dated 3/29/23. The record included a care plan related to I am at risk for fluid volume deficit related to Diuretic use, h/o fall, dementia, malnutrition risk, depression, Parkinson's dated 3/21/23. Continued review of the the care plans revealed that the resident had diagnoses of Dementia in other diseases classified elsewhere, Mild, with other behavioral disturbances; Bipolar Disorder, current episode manic without psychotic features, unspecified; ; Major Depressive disorder, recurrent, unspecified. Interview on 04/25/23 at 04:36 PM Nursing Home Administrator (NHA) revealed that the Minimum Data Set Coordinator (MDS) or the unit manger and a combination of individuals would review the PASSR for accuracy, and if corrections are needed. Interview with the NHA on 04/25/23 at 04:47 PM revealed that the Admissions team review the form prior to admitting, once in the building the PASSR would be reviewed to see If there are issues by the NHA, DON, Lead MDS Coordinator. She reported that if it was post admission they would have the hospital re-do the PASSR or have one of the facilities RN's do corrected PASSR. On 04/25/23 at 04:53 PM a review was conducted of the PASSR with the NHA. She reported that she would need to review the PASSR closer. The NHA was encouraged to review the PASSR and speak to whoever completes the task of reviewing the PASSR's and return with information on if the resident should have had a level II completed. Interview on 04/26/23 at 10:13 AM with the Transitional Care Liaison and the Admissions Coordinator. The Transitional Care Liaison reported that she is new less than a month, but she would review the hospital referral, speak with the case manger and family, ask for the PASSR and AHCA-3008 admission form, and supposed to review the PASSR preliminary to see if its a level I or if they need a level II. The admissions Coordinator reported that she looks at the referral system, tries to get everything before admission, but the packet is reviewed once the person is in the building. She reported that she is not clinical so she does not check the PASSR. She reported that whoever gets the packet on the floor would check the PASSR, which would be nursing. Interview on 04/26/23 at 10:29 AM with Staff C, MDS Coordinator, RN, and Staff F, MDS Coordinator, RN, revealed that Social Services should review for level I or Level II PASSR. Both reported that in the absence of a Social Worker the NHA and ANHA reviews the PASSR. Staff F reviewed Resident #63's PASSR and medical diagnosis and reported that the resident should have level II. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 12 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0644 A Policy related to PASSR's was requested of the facility, However the facility did not provide the requested policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 13 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to revise the care plan for one (#85) out of four residents who suffered a fall that resulted in a hospitalization. Findings included: The review of Resident #85's admission Record identified that the resident was initially admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to metabolic encephalopathy, unspecified Alzheimer's Disease, and paroxysmal atrial fibrillation. The 5-day Minimum Data Set, dated [DATE], indicated the resident scored 10 out of 15 on their Brief Interview of Mental Status (BIMS) identifying a moderate cognitive impairment. On 4/24/23 at 3:28 p.m., Resident #85 reported falling but had not broken anything. The observation indicated that the resident's door was closed at times, the resident's bed was in the low position with no floor mats. An observation was made on 4/26/23 at 8:44 a.m., sitting in wheelchair in the therapy gym. A staff member was observed removing the leg rests off the wheelchair. The review of Resident #85's progress notes, indicated that on 3/20/23 the resident was found on floor near recliner and the resident was educated on use of call light and to have staff help assist with transfers. The progress note, dated 3/27/23 at 10:50 a.m., identified that the resident was found on the floor and face down. The note indicated that the resident was wearing non-slip socks, bed was in the lowest position, neuro-checks were initiated, and an order for an x-ray to ribs was obtained. A note on 3/27/23 at 7:30 p.m., indicated that the resident was witnessed by a visitor falling and hitting head while walking unassisted in room. Resident #85's family member requested that the resident be sent to emergency room. A review of Resident #85's care plan included a focus identifying that the resident was at risk for falls related to impaired balance, poor coordination, unstable health condition pneumonia, respiratory shortness of breath (SOB), (and) unsteady gait. The focus indicated that on 3/20/23 (the resident) self reported trip and fall, independently (indep) ambulated. The focus was initiated on 3/13/23 and revised on 3/22/23, after fall on 3/20/23. The interventions related to the residents risk for falls included the following: - I am going to wear proper footwear or on-slip footwear when I am up, initiated 3/13/23. - I will have my personal items that I use frequently within my reach, initiated 3/13/23. - I will participate in activities as defined by my care plan, initiated 3/13/23. - My assistive devices will be kept within my reach, initiated 3/13/23. - Staff will encourage/remind and assist me with ensuring foley catheter tubing is secure prior to transfers and ambulation to reduce risk of tripping over tubing, initiated 3/20/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 14 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An interview was conducted on 4/26/23 at 5:07 p.m., with the Regional Registered Nurse (RN), the Minimum Data Set (MDS) RN, and the Director of Nursing (DON) regarding Resident #85's recent falls. The DON reported that a visitor from across hall observed the resident fall on 3/27/23 at 7:30 p.m. and hit head. The DON stated an intervention was implemented for staff to encourage/remind and assist (the resident) with ensuring foley catheter (was not in way). The review of the residents care plan indicated that this intervention was in place prior to the residents falls on 3/27/23. The DON stated that the resident was on therapy caseload prior to the falls on 3/27/23 and therapy was focusing on transferring from edge of bed but did not get onto the care plan. Event ID: Facility ID: 106147 If continuation sheet Page 15 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure physician ordered splints were applied for one dependent resident (#48) of two sampled residents. Findings included: An observation occurred on 4/24/2023 at 11:05 a.m. of Resident #14 with splints on both feet. The left foot was in the splint, and her heel was outside of the boot directly on the bed. The right foot was in the splint correctly. An observation on 4/25/2023 at 1:43 p.m. of Resident #14 revealed the resident did not have splints on either foot. Both heels were directly on the bed. An observation on 4/26/2023 at 9:22 a.m. of Resident #14 revealed the resident had both of her feet on the bed with no splints applied. During an interview conducted on 4/26/23 at 12:39 p.m., Staff A, Registered Nurse (RN), stated the certified nursing assistant (CNA), restorative CNA, or therapy (staff) place Resident #14's splints on. Staff A confirmed she does not usually put them on, although she documents on the Administration Record (Treatment Administration Record) that they are on. During an interview on 4/26/2023 at 12:35 p.m., Staff B, CNA stated, Therapy puts [Resident #14's] splints on. I am only responsible for the Controlled Ankle Motion (CAM) boot to right leg. Which the resident does not need any longer. An interview was conducted on 4/26/23 at 1:03 p.m. with the Regional Director of Therapy (RDOR). The RDOR confirmed that Resident #14 was discharged to restorative nursing with a splinting schedule and exercises for both ankles, along with Podus boots to prevent contractures. Review of Resident #14's Physical Therapy Discharge Summary for dates of service 10/28/2022 to 1/26/2023 showed a therapist documented the Resident had reached her maximum potential and was being referred to restorative nursing program. Intervention summary revealed, resident participated in orthotic training for bilateral Podus boots to manage bilateral ankle contractures. The summary of training revealed: instructed nursing caregivers in positioning maneuvers and Restorative Nursing Program specifically, orthotic management in order to prevent further contractures in the presence of reduced cognitive abilities with 100% carryover demonstrated. Review of a document titled, Therapy Referral for Restorative Nursing/Functional Maintenance Program Form, revealed therapy referred Resident #14 with recommendations: Passive Range of Motion exercises of bilateral lower extremities towards all available planes with end-range stretch of bilateral ankles towards dorsiflexion and pronation. Bilateral Podus boots to be donned for 6 to 8 hours during the day shift. Start date: 1/23/2023 with a frequency: 6 days per week. A review of the Order Review Report with 2 active physician orders as of 4/26/2023 reflected the following: (1) CAM boot to right foot only when walking. Wean as tolerated. Every shift for surgical site, start date of 12/1/2022. (2) patient to wear bilateral Podus boots for 6-8 hours during 7-3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 16 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift. Skin check pre and post splinting as needed one time a day for prevention with a start date of 1/27/2023. Review of Documentation Survey Report v2 for April 2023, revealed: Intervention/Task: Nursing Rehab: Assistance with split or brace (2) PROM (passive range of motion) of BLE (bilateral lower extremities) towards all available plane with end range of both ankles toward dorsiflexion. Podus boots to be donned for 6 - 8 hours during the day shift. Document shows no initials of a staff member completed the Intervention/Task for 20 of the 25 days reviewed for April 2023. Review of Resident #14's admission Record revealed an admission date of 9/21/2022 with diagnoses that included frontal lobe and executive function deficit following cerebral infarction (stroke), displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, spinal stenosis of cervical region and muscle weakness. A review of the Minimum Data Set (MDS) assessment, dated 3/04/2023, revealed in Section C Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 2/15, which meant the resident is severely cognitively impaired. Section G Functional Status of the MDS revealed she required extensive to total assistance with mobility and activities of daily living (ADL) performance and had functional limitations in range of motion on both sides for upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle foot). Section O Special Treatments and Programs revealed no minutes performed for passive range of motion, no minutes for active range of motion and no minutes for splint or brace assistance. The care plan for Resident #14 revealed a Focus Area of assistance with my ADLs related to limited range of motion, initiated 9/21/2022 and revised on 1/16/2023. Goal: maintain my current level of ADL function using my care plan, initiated 4/26/2023, revised 4/26/2023, Intervention: cam boot to right foot, initiated 10/28/2022. Review of the facility policy titled, Restorative/ADL Nursing, most current revised date of 3/22, revealed: Policy: A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a decline is unavoidable. Procedure: #10. Interventions for the restorative program will be sent to the [NAME] as part of the resident information for the Restorative Aides and CNAs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 17 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The admission Record identified that Resident #79 was admitted on [DATE] and on 4/14/23. The record included diagnoses not limited to unspecified malignant neoplasm of pancreas, unspecified anxiety disorder, and unspecified depression. The comprehensive assessment for Resident #79, dated 3/11/23, indicated a Brief Interview of Mental Status (BIMS) score of 14 indicating an intact cognition, a mood score of 16 out of 27 identifying the resident had sleep, energy, appetite and concentration issues nearly every day, and felt bad about self half or more of the days. The assessment indicated that Resident #79 had not exhibited any behaviors. The active Order Summary Report, dated 4/27/23 at 4:56 p.m, included the following physician orders: - Alprazolam 0.5 milligram (mg) - Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 days, ordered 4/14/23 and to end on 4/28/23. - Venlafaxine hydrochloride (HCl) 75 mg - Give 75 mg by mouth two times a day for depression, ordered 4/14/23. - Zolpidem Tartrate 10 mg - Give 10 mg by mouth at bedtime for insomnia, ordered on 4/14/23. - Observe for side effects - (Antidepressant/Antianxiety/Hypnotic) Y= yes side effects were noted - see progress notes. N= no side effects noted. Every shift. - Psych consult for depression, ordered 3/23/23. A review of Resident #79's April Medication Administration Record (MAR) indicated that the resident had been administered, prior to the readmission date of 4/14, Zolpidem 10 mg at bedtime for insomnia, Venlafaxine 75 mg twice daily for depression, and Alprazolam 0.5 mg every 12 hours as needed. The MAR indicated that side effects were being monitored for the different types of psychotropic medications: antidepressant, antianxiety, and hypnotics. The review of Resident #79's April MAR and Treatment Administration Record (TAR) did not include documentation that the resident's behaviors related to the ongoing administration of the antidepressant venlafaxine, antianxiety - alprazolam, and/or the sedative/hypnotic zolpidem were being monitored. A review of Resident #79's progress notes, indicated that on 4/25/23 at 1:08 a.m., alprazolam was administered given per resident request. On 4/24/23 at 10:57 p.m., a progress note indiated that staff had documented that Daily skilled charting completed. Is receiving physical therapy as ordered. The notes did not identify that the resident had exhibited any behaviors. A Social Service note, dated 3/6/23 at 3:51 p.m., indicated that Resident #79 had been making statements regarding wanting to die, and was tearful in speaking about prognosis. The note identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 18 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0758 that a referral was made for psych services. Level of Harm - Minimal harm or potential for actual harm The Psychiatric Diagnostic Evaluation, initial evaluation, dated 3/15/23, indicated Resident #79 had described his mood has being up-and-down and shared being depressed at first but feeling better. The note identified that the resident was on alprazolam for anxiety and venlafaxine for depression. The Psychiatric Evaluation, dated 3/22/23, indicated that the resident continued to describe their mood as up-and-down, worried about health, and feeling discouraged. The note indicated that the resident continued with the medications alprazolam and venlafaxine. Residents Affected - Some A review of Resident #79's care plan included a focus that identified the resident was at risk for side effects related to the use of antidepressants, hypnotics, and anxiolytics, initiated on 3/5/23 and revisied on 3/17/23. The interventions associated with this focus indicated staff will observe for changes in my behaviors and revise/update my care plan as neede to support my current status. The care plan identified that the resident and staff would observe for adverse side effects related to the need for hypnotic, antianxiety, and antidepressant medications. The care plan for Resident #79 identified that the residents overall mood is affected by anxiety, feeling bad about myself, feeling tired, feelings of sadness, having trouble concentrating, ineffective coping, little interest in doing things, low self-esteem, my change in independence, my tearfulness, my thoughts or verbalizations of being better off dead. The interventions instructed to staff to encourage and allow the resident to express feelings and participate in a therapeutic work program. The focus that indicated that the resident was at risk for behavioral and mood symptoms related to diagnoses of anxiety and depression included interventions that did not instruct staff to monitor/document the residents' behaviors. On 4/27/23 at 12:18 p.m. an interview was conducted with the Director of Nursing (DON) and Staff Member F (MDS Coordinator). The DON stated she knew there was side effect monitoring but was unsure if there was behavior monitoring, but sounds like there isn't anything in place. The DON reviewed Daily Skilled Notes, on 4/27/23 at 3:06 p.m., and stated her expectation would be that the skilled note should document skin assessments and behaviors and the reason for as needed use of Xanax should indicate how the resident exhibited anxiety. 5. A review of Resident #85's admission Record indicated that the resident was admitted on [DATE] and included diagnoses not limited to metabolic encephalopathy, unspecified Alzheimer's disease, unspecified recurrent major depressive disorder, and unspecified insomnia. The comprehensive assessment, dated 4/3/23, indicated Resident #85 had a Brief Interview of Mental Status (BIMS) score of 10, indicative of a moderate cognition impairment, that the resident had sleep, energy, and appetite issues nearly every day, and did not exhibit any behaviors. A review of Resident #85's Order Summary Report, active as of 4:27 p.m. on 4/27/23, indicated that the resident was to recieve 50 mgs of the antidepressant medication Sertraline daily for depression and staff were to observe for side effects related to the administration. The order report did not include physician orders to observe/monitor for behaviors related to the use of the antidepressant medication. The Psychiatric Diagnostic Evaluation, dated 3/15/23, indicated that Resident #85 reported an up-and-down mood due to health, wanted to be home with family, and denied any current depression. The evaluation identified that the resident was receiving melatonin for sleep and sertraline for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 19 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some depression, it was recommended that that the resident continued the medication and to continue to monitor mood. The evaluation indicated that the resident was anxious, intermittently dysphoric, had ruminating thoughts, and excessive worry/anxiety. The provider identified that the resident was on lowest effective medication at a Gradual Dose Reduction (GDR) was contraindicated due to intermittent verbal aggression. The Psychiatric Diagnostic Evaluation, dated 4/12/23, indicated that Resident #85's chief complaint was intermittent anxiety, depression, and insomnia. The evaluation indicated that the residnet denied depression at that time, was receiving sertraline and was sleeping good with melatonin. The review of systems indicated that the resident exhibited a sad affect, intermittently anxious, and unsettled. The note indicated that the resident was on lowest effective medication, and a GDR was contraindicated due to intermittent verbal aggression. A review of progress notes, dated 3/28 to 4/27/23, for Resident #85 indicated that one note on 4/2/23 at 11:52 p.m., indicated the resident had a new onset of increased confusion. The progress notes, which included Medication Administration Record notes, did not include any further behaviors associated with the medication, sertraline. The care plan for Resident #85 indicated that the resident was at risk for behavioral and mood symptoms related to the diagnosis of depression, which included interventions directed the resident was to receive psych services as needed and ordered, recieve medications as ordered, staff were to encourage the resident with visits and interests, and to redirect the resident when behaviors begin. The care plan revealed that the resident was at risk for side effects related to the use of antidepressants and staff were to observe for changes in my behaviors and revise/update my care plan as needed to support my current status. The DON stated, on 4/27/23 at 2:53 p.m., that staff should be monitoring visual observations, and that the previous Social Worker had been doing a Behavior Monitoring Form (BMF) and if behaviors were observed staff should be documenting but nothing was scheduled. The DON did stated the facility does have a psychotropic meeting monthly, the daily skilled note should include anything pertinent to the resident. She reviewed a couple of the residents' Daily Skilled notes and stated that the expectation would be that something be documented as to behaviors, colostromy, and/or catheter. Review of facility policy titled, Administrative - Psychoactive Medications/GDR/Unnecessary Medications, revised 10/2022 revealed: 2. Psychotropic drugs mean any drug that affects brain activities associated with mental processes and behavior such as: -Antipsychotic -Antidepressant -Anti-anxiety -Hypnotic 3. Residents receiving psychoactive medications will have a care plan initiated that contains (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 20 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0758 resident Level of Harm - Minimal harm or potential for actual harm diagnosis and interventions regarding the target behaviors and possible adverse side effects of the medications(s). Residents Affected - Some 10. Nursing will document once a shift (with any increase, decrease, new medication) for 2 weeks to determine if the resident is experiencing an increase/decrease in the target behaviors. 14. UNNECESSARY DRUGS - Every resident's drug regimen is to be free from unecessary drugs. An unnecessary drug is any drug when used: In excessive dose .For excessive duration .Without adequate monitoring . Based on interviews and record review, the facility failed to ensure behavior monitoring was in place related to psychotropic medication use for five residents (#76, #34, #85, #79, #14) out of five sampled residents. Findings included: 1. The admission record for Resident #34 revealed admission date of 08/16/22 and diagnoses that included dementia and depression. The Minimum Data Set (MDS) dated [DATE], Section C, revealed a Brief Interview for Mental Status (BIMS) score of 7 which meant the resident had moderate cognitive impairment. Sections D and E of the MDS revealed no mood disturbance and no presence of behavioral symptoms. Active physician orders revealed medication duloxetine 60 mg (milligrams) at bedtime for depression, start date 10/28/22. There was an order for monitoring side effects related to duloxetine use, but no order to monitor behaviors. The care plan for Resident #34 revealed a focus area for use pf psychotropic medications and interventions that included, My use of psychotropic medications will be reviewed quarterly by a pharmacist and the interdisciplinary team to ensure the need for continued use and the appropriateness for a gradual dose reduction. Review of medication administration records (MAR) for February 2023, March 2023, and April 2023 revealed duloxetine 60mg at bedtime was administered as ordered, side effects were monitored, but there was no documentation related to behavior monitoring or mood/behavior. 2. The admission record for Resident #76 revealed admission date of 07/30/22 and diagnoses that included dementia, major depressive disorder, generalized anxiety disorder, and adjustment disorder with mixed anxiety and depressed mood. The MDS dated [DATE], section C, revealed a BIMS score of 10 which meant the resident had mild cognitive impairment. Sections D and E of the MDS revealed no mood disturbance and no presence of behavioral symptoms. Active physician orders revealed medication sertraline 100mg one time a day for depression, start date 03/23/23. There was an order for monitoring side effects related to sertraline use, but no order to monitor behaviors. Review of MAR for February 2023 revealed sertraline 75mg ordered and administered once daily start date 2/24/23, end date 3/22/23. MARs for March 2023 and April 2023 revealed sertraline administered daily. MARs revealed side effects monitored related to sertraline, but no documentation related to behavior monitoring or mood/behavior. The care plan for Resident #76 revealed a focus area for use of psychotropics and interventions included, You will observe for changes in my behaviors and revise/update my care plan as needed to support my current status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 21 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with the facility Director of Nursing (DON) on 04/27/23 at 2:53 p.m. She confirmed behaviors should be monitored and documented for residents receiving psychotropic medications. She stated the facility did not have a specific assessment for documenting behaviors or anything else that was a scheduled task. She stated facility nursing should be using a behavior assessment or documenting in a narrative note if they observed a behavior, but again stated there was nothing formally scheduled for facility nurses to document. The DON reviewed the medical records for Resident #34 and Resident #76 and confirmed there was no behavior monitoring documented in their records and stated she would expect there to be some. The DON confirmed that monitoring behaviors with use of psychotropics was important for determining effectiveness and appropriateness. 3. A review of Resident #14's admission Record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety, psychotic disturbance, and mood disorder. A review of Resident #14's April 2023 physician's orders revealed an order, dated 10/10/2022 for Buspirone HCl tablet 5mg (milligram) give 5mg by mouth two times a day for anxiety. Resident #14's physician's orders did not reveal orders for monitoring of behaviors for the Buspirone. An interview was conducted on 4/27/2023 at 3:07 p.m. with the Director of Nursing (DON). The DON confirmed there was no documentation of behavioral monitoring for Resident #14, and she would expect the documentation to be there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 22 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and four errors were identified for two (#48 and #96) of seven residents observed. These errors constituted a 14.81% medication error rate. Residents Affected - Few Findings included: 1. On 4/25/23 at 8:39 a.m., an observation of medication administration with Staff Member E, Licensed Practical Nurse (LPN), was conducted with Resident #48. The staff member dispensed the following medications: - Levemir FlexPen - dialed the dosage selector to 18 units which was verified by another floor nurse. - Losartan 50 milligram (mg) tablet - Metformin 500 mg tablet - Hydrochlorothiazide 12.5 mg capsule - Famotidine 20 mg tablet - Artificial tears bottle - Acidphilus (lactobacilli) 500 million cells The medication profile for Resident #48 identified that the resident was scheduled at 7:00 a.m. to receive Novolog. The staff member entered Resident #48's room and at 8:56 a.m. on 4/25/23, obtained a blood glucose level of 117 from the residents left pointer finger. Staff E informed the resident of not getting the short-acting insulin, Novolog, and only the Levemir. The dosage of 18 units of Levemir was verified, again, prior to the staff member injecting into the residents' upper left extremity. The staff member removed gloves, sanitized hands, then re-gloved prior to wiping both eyes of the resident with a tissue. The staff member applied gloves then placed one drop of Artificial tears in the left eye then one drop into the right eye. Staff E administered oral medications at 9:02 a.m. on 4/25/23. Immediately following the observation, Staff E explained that Resident #48 was due to have Novolog administered at 7:00 a.m., but the insulin was given closer to breakfast (which was delivered during the observation). The staff member stated insulin pens were only primed when first opening them, when it was a brand new pen. A review of Resident #48's Medication Administration Record (MAR) indicated the following: - Saccharomyces boulardii 250 mg capsule - Give 1 capsule by mouth two times a day for probiotic, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 23 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0759 scheduled for morning administration. Level of Harm - Minimal harm or potential for actual harm - Artificial Tears solution 0.2-0.2-1% - Instill 1 drop in right eye four times a day for dry eye syndrome. Residents Affected - Few According to webmd.com (https://www.webmd.com/vitamins/ai/ingredientmono-332/saccharomyces-boulardii), Saccharomyces boulardii is a probiotic yeast, whereas Acidophilus (Lactobacillus acidophilus) is a bacteria (https://www.webmd.com/vitamins/ai/ingredientmono-790/lactobacillus-acidophilus). The website indicated, for both probiotic's, to not confuse either S. boulardii and L. acidophilus with other probiotic's, they are not the same. The manufacturer instructed users of a Levemir Flexpen (https://www.novomedlink.com), to give an airshot before each injection. The instructions identified that Before each injection, prime your pen by performing an airshot. The literature instructed users to turn the dose selector to 2 units, hold the FlexPen with the needle pointing up, tap the cartridge a few times to make any air bubbles to collect at the tip, while keeping the needle pointing upwards to press the push button all the way, and the dose selector returns to zero (0). A drop of insulin should be observed at the needle tip and if not to change the needle and repeat the procedure. 2. On 4/25/23 at 5:05 p.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #96. The staff member dispensed the following medications: - Insulin Lispro pen - Hydralazine 25 mg tablet (blood pressure 152/63) - Ferrous Sulfate 325 mg tablet On 4/25/23 at 5:13 p.m., Staff I administered the oral medication to Resident #96, then obtained a blood glucose level of 304 from the left pinky finger. The staff member dialed the insulin pen to 8 units, and interjected the insulin into the back of the left upper arm of the resident. On 4/25/23 at 5:27 p.m., Staff Member I stated that the insulin pens did not have to be primed, was educated earlier today on priming insulin pens and don't have to prime the new ones. According to the manufacturer of Insulin Lispro, (https://www.lillyinsulinlispro.com/#) users should Prime before each injection. The literature indicated that Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, yo may get too much or too little insulin. The manufacturer instructed how to prime the pen was to turn the dose knob to select 2 units, hold your pen with the needle pointing up, tap the cartridge to collect air bubbles at the top, while continue holding pen with needle pointing up push the dose knob until it stops and 0 is seen in the dose window. Hold the dose knob in and count for 5 seconds slowly, insulin should be seen at the tip of the needle. The instructions indicate that if insulin is not seen at the tip repeat the steps no more than 4 times, if insulin is still not seen change the needle and repeat the priming steps. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 24 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 4/26/23 at 6:17 p.m., the Director of Nursing (DON) stated that based on policy nurses are to prime insulin pens. The policy - Insulin Pens, revised on 1/19, 10/19, and 1/21, indicated the purpose of the policy was To ensure safe and accurate administration of insulin for residents using their own insulin pen. The procedure identified #6: Priming the Pen: - a. Prime the Pen before each injection i. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. ii. If you do not prime before each injection, you may get too much or too little insulin. - b. To prime the pen, turn the dose knob to select 2 units. - c. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. - d. Continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. - If you do not see insulin, repeat the priming steps, but not more than 4 times. - If you still do not see insulin, change the needle and repeat the priming steps. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 25 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to ensure that the Dietary Manager met the requirements related to Certification for the position of Dietary Manager when a qualified dietitian or nutrition professional was not employed full time. Findings included: On 04/24/23 at 09:20 AM the initial tour of the kitchen began. Interview with the Director of Dining and Nutrition Services revealed that he is the Dietary Manager and is charge of running the kitchen. He reported that he is not a Certified Dietary Manager (CDM), but is going through a training course now. He reported that he is in charge of the kitchen, and is supervised I think by the Administrator. He reported that the Registered Dietician (RD) comes to the facility on Tuesdays and Thursdays. On 04/26/23 at 03:06 PM the comprehensive tour of the kitchen began. Interview with Director of Dining and Nutrition Services and the Assistant Director of Dining and Nutrition Services revealed that neither individuals are CDM's. They reported that the kitchen does not have a Certified Dietary Manager right now, and that they both are waiting to be signed up for the CDM course which has to be paid for by the facility. Interview with the RD at this time she reported that she comes to the facility on Tuesdays and Thursdays for a total of 16 hours. She reported that the Director of Dining and Nutrition Services is in charge of the kitchen that when she comes she deals with clinical issues and will sometimes give oversight in the kitchen but does not supervise the kitchen. Review of the facility's Job Description of the Director of Dining and Nutrition Services revealed under Entry Minimum Qualification/Requirement, that the individual Must meet one of the following criteria, as defined by federal regulation, or be willing to complete these requirements within a defined timeframe: -A certified dietary manager;or -A certified food service manager; or -Has similar national certification for food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning. The facility's Entry Qualifications listed in the job description mirrored the language from the regulation, that the Dietary Manager at a minimum one of the qualifications (A) A certified dietary manager; or (B) A certified food service manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 26 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain the kitchen in an clean and sanitary manner. Residents Affected - Many Findings included: During the initial tour of the kitchen on 04/24/23 at 09:20 AM with the Dietary Manager present The following was revealed: -The range hood was noted with grease drippings on light covers. -Debris was noted on top of the dish machine. -Food prep pans were noted to be to be drying face up. -Food storage bins were noted to be drying face up. (Photographic Evidence Obtained) On 04/26/23 at 03:06 PM a Comprehensive tour of the kitchen was conducted with the Dietary Manager and the Assistant Dietary Manager present. The following was revealed: -The range hood was still noted with grease drippings on light covers. -Debris was noted on top of the dish machine. -The reach-in freezer was noted to have a large area of ice build-up. (Photographic Evidence Obtained) During an interview with the Dietery Manager at this time He reported that I will make sure everything is corrected right away. Review of the facility policy titled Hoods and Filters with an original date of 6/2021 revealed the following: STove hoods and filters willbe cleaned according to a cleaning schedule, or at least monthly. A request for a policy to address the overall maintaince of the kitchen was requested from the facility but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 27 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0814 Dispose of garbage and refuse properly. 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 dispose of garbage and refuge in an appropriate manner. Residents Affected - Many Findings included: During the initial tour of the kitchen on 04/24/23 at 09:20 AM with the Dietary Manager present an inspection of the dumpster area was conducted. The dumpster area was noted to have debris and refuge around the trash receptacles. (Photographic Evidence Obtained). Continued inspection of the dumpster areas revealed that there was a used oil receptacle next to the dumpster. The used oil receptacle was noted to have a lid which was uncovered and debris and refuge was noted to be sitting on the inner surface of the opened container. (Photographic Evidence Obtained). Interview with the [NAME] Manager at this time revealed that the dumpster area is used by the entire facility and that he was unaware of the condition of the the dumpster area. He reported that he is unsure why the used oil receptacle was open. Review of the facility policy titled Use of Outside Waste Disposal Dumpster with an original date of 12/9/17 and a revised date of 3/19/21 revealed the following: Items to be discarded, including food waste garbage, trash and delivery packaging, will be disposed of, as needed throughout the day and at the end of each day. Such items will be held for pick up in covered dumpsters in good repair provided via contract service with a disposal company. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 28 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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 interview, the facility failed to ensure the binding arbitration agreement, explicitly informed the resident or their representative of the right not to sign and nor was contract contents understandable for three residents (#14, #41, and #349) of three residents sampled. The facility failed to offer an option to rescind the agreement within 30 days for one (Resident #14) of three sampled residents. Residents Affected - Some Findings included: On 4/20/2023 at 1:00 p.m., an interview was conducted with the Nursing Home Administrator (NHA). NHA stated all residents review and sign arbitration agreements upon admission. The NHA stated no one has declined to sign the arbitration agreement. NHA provided a Facility admission Agreement with Blue [NAME] 3/21 on the bottom left corner, which incorporated the Arbitration Agreement. 1. Review of Resident #14's admission Record revealed Resident #14 was admitted on [DATE]., with diagnoses that included frontal lobe and executive function deficit following cerebral infarction (stroke), dementia without behavioral disturbance, anxiety, cognitive communication deficit, and Alzheimer's disease. Review of the Minimum Data Set (MDS), provided by the facility and dated 9/27/2023, Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was 02 out of 15, indicating the resident has severe cognitive impairment. Review of the Facility admission Agreement - Blue [NAME] 3/21 located in the bottom left corner, the binding arbitration agreement, which was incorporated in the admission Agreement, revealed it was signed by Resident #14, herself, dated 9/22/2022. There was no evidence of that she understood the agreement nor was there evidence in the agreement the resident or representative could rescind within 30 days. An interview with Resident #14 was not possible due to her cognitive status. 2. Review of Resident #41's Face Sheet revealed Resident #41 was admitted on [DATE] and readmitted on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease and Covid 19 (recovering). Review of the Minimum Data Set (MDS), provided by the facility and dated 8/29/2023, Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was a 13 out of 15, indicating the resident was cognitively intact. Review of the Facility admission Agreement - TLC - Florida-10/17 located in the bottom left corner, revealed the binding arbitration agreement is incorporated in the admission Agreement. Resident #41 signed the document, dated 8/26/2022. An interview was conducted with Resident #41 on 4/27/2023 at 9:00 a.m. Resident #41 stated she was handed an iPAD and was shown where to sign by a gentleman from the office. She does not recall that an Arbitration Agreement was in the document. Resident #41 believes this would be remembered due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 29 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the importance. Resident #41 stated, I also did not feel the greatest, I had just come back from the hospital, so I am not 100%. 3. Review of Resident #349's admission Record revealed, Resident # 349 was admitted on [DATE], with diagnoses to include Cerebral infarction due to Thrombosis of right posterior cerebral artery (stroke) and depression. Review of a Brief Interview for Mental Status (BIMS) completed 4/24/2023 revealed a score of 11 out of 15, indicating the resident is moderately impaired-decisions poor; cues/supervision required. Review of the Facility admission Agreement - TLC - Florida-10/17 located in the bottom left corner, revealed the binding arbitration agreement is incorporated in the admission Agreement. Resident #349's responsible party, signed the document on 4/21/2023. An interview with Resident Representative (RR) on 4/24/2023 at 4:45 p.m., RR stated a nurse came in and handed us a stack of papers to sign. RR did have questions; the nurse was able to answer some but not all the questions. RR does not recall any arbitration agreement. RR stated, my spouse and I are well educated, both with doctorate level degrees, we read the agreement. We did not totally understand some of the sections nor was the nurse able to answer the questions we had. The nurse just asked us to sign the documents so they could treat her. RR requested copies of the forms they signed. Copies were never brought back. An interview with RR on 4/26/2023 at 3:16 p.m., no one from the facility had yet to be in contact with them. RR did not have the copies requested as of this time. On 4/27/2023 at 9:47 a.m., an interview was conducted with the admission Coordinator. (AC) stated, nursing is responsible for completion of the Facility admission Agreement which has the binding arbitration agreement included. AC stated, I have not really digested the arbitration agreement completely as Nursing completes that section. AC stated she does validate with the family that nursing did have them sign documents. On 4/27/2023 at 10:03 a.m., an interview was conducted with Staff E, LPN. Staff E, LPN states, if admitting a resident, the normal nursing assessments are completed along with some other admission documents for consent and treatment. I am not entirely sure what they all are, we just have them sign them. On 4/27/2023 at 10:35 a.m., an interview was conducted with the Director of Admissions (DOA). DOA stated she doesn't really complete the admission paperwork with residents or representatives. Those are the AC responsibilities. DOA stated that she has completed them, just not many. DOA stated that the arbitration agreement is imbedded in our Facility admission Agreement, they have to sign the packet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 30 of 31 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 106147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Heron Health and Rehabilitation 5085 Eagleston Blvd Wesley Chapel, FL 33544 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. 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 interviews, the facility failed to ensure the arbitration agreement provided for the selection of a venue that was convenient to both parties for three (Resident #14, #41 and #349) of three sampled residents. Residents Affected - Some Findings included: On 4/20/2023 at 1:00 p.m., an interview was conducted with the Nursing Home Administrator (NHA). NHA stated all residents review and sign arbitration agreements upon admission. The NHA stated no one has declined to sign the arbitration agreement. NHA provided a Facility admission Agreement with Blue [NAME] 3/21 on the bottom left margin, which incorporated the Arbitration Agreement. Review of the Facility admission Agreement - Blue [NAME] 3/21 in the bottom left of the page. The binding arbitration agreement, which is incorporated in the admission Agreement, revealed it was presented to Resident #14 on 9/22/2022. There was no evidence of offering a neutral arbitrator. Review of the Facility admission Agreement - TLC - Florida-10/17 was revealed in the bottom left of the page, revealed the binding arbitration agreement is incorporated in the admission Agreement. The agreement presented to Resident #41 on 8/26/2022 and presented to Resident #349 on 4/21/2023 failed to show the arbitration agreement provided for the selection of a venue convenient to both parties. On 4/27/2023 at 9:47 a.m., an interview was conducted with the admission Coordinator. (AC) stated, she does not know what is in the agreement and what is not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 31 of 31