Health inspection·July 31, 2025

F 0644 20-10 mg twice a day and Depakote 125 mg / 4 capsules at bedtime. Level of Harm - Minimal harm or potential for actual harm Review of Resident #8's level I PASARR completed on 12/22/24 revealed the resident did not have mental illness or suspected mental illness. The diagnoses boxes were unchecked. Residents Affected - Some An interview with the DON conducted on 7/31/25 at 03:30 PM revealed when a resident is admitted or readmitted to the facility, they review the PASRR for correctness and if needed submit a new PASRR or complete a level II PASRR if indicated. The DON stated Resident #8's PASARR should have been corrected and updated and reported not being at the facility during that time. The facility did not provide a PASARR policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 2 of 4 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 07/31/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interviews, observations, and record review the facility failed to implement a plan of care for a resident at risk for dehydration for one resident (#58) of one resident reviewed.Findings included: On 07/29/25 at 09:40 AM an observation revealed Resident #58 lying in bed, eyes closed and did not respond to verbal or tactile stimuli. There was no hydration or fluids observed at bedside.During an observation on 07/29/25 at 03:00 PM, Resident #58 was observed lying in bed. There was no hydration cup or fluids at bedside. On 7/29/2025 at 3:45 PM an interview was conducted with Resident #58's family member who stated Resident #58 needed extra care and could not get a drink of water on their own. The family member stated staff should check on the resident more frequently than they do and offer fluids. During an observation on 07/30/2025 at 9:07 AM, at 12:00 PM and at 4:10 PM, Resident #58 was observed in room. A water cup was observed on the bedside table dated 7/30/25, 11 a.m. -7 p.m. shift, at 04:14 AM. The cup was observed full of ice water. On 07/31/25 at 08:35 AM Resident #58 was observed sitting up in a reclining wheelchair, eyes opened, awake alert and non-verbal. A water cup was observed on the bedside table dated 7/31/25 on 11-7 a.m. shift. This surveyor marked the water cup indicating the water level on cup to monitor how much water resident was drinking. (Photographic Evidence Obtained).On 07/31/2025 at 11:28 AM an observation was made of Resident #58 sitting up in wheelchair awake, alert and attending activities in activity room. There was no hydration or fluids observed being offered at this time. Upon entering Resident #58's room, an observation was made of the water cup sitting on bedside table with water observed at same level from an earlier observation where this surveyor marked the hydration cup. Review of resident #58's medical record revealed diagnoses of Quadriplegia, Pneumonitis, Moderate -protein calorie malnutrition, Dementia, Chronic Kidney Disease stage 3B and an Ileus. The plan of care revealed Resident #58 required assistance with ADLs (Activities of Daily Living) related to activity intolerance, dementia, impaired cognition, quadriplegia; with a goal that the resident will maintain current level of ADL function. The interventions included, I require staff to feed me my meals. Another focus in Resident 58's care plan showed the resident has chronic urinary tract infections (UTIs) with interventions to observe for changes in urine characteristics, .frequent urination and change in urgency to void.Review of a quarterly risk assessment for Resident #58 completed on 7/10/25 revealed the resident was at high risk for hydration/dehydration. Resident 58's MDS (minimum data assessment) dated of 7/10/25, section GG revealed - resident has impairment to bilateral upper and lower extremities and is totally dependent for eating and drinking. An interview was conducted with staff member A, Registered Nurse/Unit Manager (RN/UM) on 7/31/25 at 1:38 PM. Staff A revealed Resident #58 is not able to ask for anything, requires total assistance and cannot hold a cup to get own drink of fluid. Staff A stated for a resident with reoccur ring UTIs, the expectation was to monitor for changes in their bowel movements, administer medications as ordered, if constipated or hasn't had a bowel movement, monitor urine output and changes in color, and providing foley catheter care daily and as needed. Staff A stated the staff know to offer fluids to alleviate constipation and/or urinary tract infections. Staff A, RN/UM stated they do quarterly assessments and any resident with a score of 10 or higher is considered at risk for hydration issues. Staff A stated they immediately get a physician order to encourage and offer fluids every two hours. Review of Resident #58's medical record revealed there was no care plan focus initiated for Resident #58 being at risk for dehydration, and there were no physician orders to encourage fluids every two hours. The facility did not provide a dehydration policy. Event ID: Facility ID: 106147 If continuation sheet Page 3 of 4 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 07/31/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interviews, observations, and record review the facility failed to ensure proper hydration was provided for one resident (#58) of one resident sampled.Findings included: On 07/29/25 at 09:40 AM an observation revealed Resident #58 lying in bed, eyes closed and did not respond to verbal or tactile stimuli. There was no hydration or fluids observed at bedside.During an observation on 07/29/25 at 03:00 PM, Resident #58 was observed lying in bed. There was no hydration cup or fluids at bedside. On 7/29/2025 at 3:45 PM an interview was conducted with Resident #58's family member who stated Resident #58 needed extra care and could not get a drink of water on their own. The family member stated staff should check on the resident more frequently than they do and offer fluids. During an observation on 07/30/2025 at 9:07 AM, at 12:00 PM and at 4:10 PM, Resident #58 was observed in room. A water cup was observed on the bedside table dated 7/30/25, 11 a.m. -7 p.m. shift, at 04:14 AM. The cup was observed full of ice water. On 07/31/25 at 08:35 AM Resident #58 was observed sitting up in a reclining wheelchair, eyes opened, awake alert and non-verbal. A water cup was observed on the bedside table dated 7/31/25 on 11-7 a.m. shift. This surveyor marked the water cup indicating the water level on cup to monitor how much water resident was drinking. (Photographic Evidence Obtained).On 07/31/2025 at 11:28 AM an observation was made of Resident #58 sitting up in wheelchair awake, alert and attending activities in activity room. There was no hydration or fluids observed being offered at this time. Upon entering Resident #58's room, an observation was made of the water cup sitting on bedside table with water observed at same level from an earlier observation where this surveyor marked the hydration cup. Review of resident #58's medical record revealed diagnoses of Quadriplegia, Pneumonitis, Moderate -protein calorie malnutrition, Dementia, Chronic Kidney Disease stage 3B and an Ileus. The plan of care revealed Resident #58 required assistance with ADLs (Activities of Daily Living) related to activity intolerance, dementia, impaired cognition, quadriplegia; with a goal that the resident will maintain current level of ADL function. The interventions included, I require staff to feed me my meals. Another focus in Resident 58's care plan showed the resident has chronic urinary tract infections (UTIs) with interventions to observe for changes in urine characteristics, .frequent urination and change in urgency to void.Review of a quarterly risk assessment for Resident #58 completed on 7/10/25 revealed the resident was at high risk for hydration/dehydration. Resident 58's MDS (minimum data assessment) dated of 7/10/25, section GG revealed - resident has impairment to bilateral upper and lower extremities and is totally dependent for eating and drinking. An interview was conducted with staff member A, Registered Nurse/Unit Manager (RN/UM) on 7/31/25 at 1:38 PM. Staff A revealed Resident #58 is not able to ask for anything, requires total assistance and cannot hold a cup to get own drink of fluid. Staff A stated for a resident with reoccur ring UTIs, the expectation was to monitor for changes in their bowel movements, administer medications as ordered, if constipated or hasn't had a bowel movement, monitor urine output and changes in color, and providing foley catheter care daily and as needed. Staff A stated the staff know to offer fluids to alleviate constipation and/or urinary tract infections. Staff A, RN/UM stated they do quarterly assessments and any resident with a score of 10 or higher is considered at risk for hydration issues. Staff A stated they immediately get a physician order to encourage and offer fluids every two hours. Review of Resident #58's medical record revealed there was no care plan focus initiated for Resident #58 being at risk for dehydration, and there were no physician orders to encourage fluids every two hours. The facility did not provide a dehydration policy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106147 If continuation sheet Page 4 of 4