Health inspection·January 28, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide antiretroviral medication for an immunocompromised resident for one resident (# 1) out of three residents sampled.Findings included: On 1/28/2026 at 9:45 AM., an observation was made revealing Resident #1 lying in bed. He was observed alert with no signs of distress. Resident #1 stated he had issues in the past with his insurance which caused him delays in getting his medication, for which he missed some doses.Review of Resident #1 admission Record showed he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to an immunocompromised Disease, Type 2 Diabetes Mellitus Hyperglycemia, major depressive disorder, recurrent, unspecified. Review of Resident #1‘s Medication Administration Record [MAR] dated October 2025 revealed Biktarvy Oral Tablet 50-200-25 Milligram [MG], (Bictegravir Emtricitabine-Tenofovir Alafenamide Fumarate) Give one tablet by mouth one time a day for start date 10/18/25. The documentation revealed number 9 was marked on the 19th and the 20th. The MAR revealed 9 meant other/see progress notes.Progress notes for the month of October 2025 were requested but not provided by the facility. Review of Resident #1‘s MAR dated November 2025 revealed Biktarvy Oral Tablet 50-200-25 Milligram [MG], (Bictegravir Emtricitabine-Tenofovir Alafenamide Fumarate) Give one tablet by mouth one time a day. The documentation revealed the medication was not administered 6 times during this month on 11/18, 11/20, 11/23,11/24, 11/25 and 11/26, 2025. The documentation in the MAR revealed number 9 was marked, which meant other/see progress notes.Review of Order Administration progress notes for Biktarvy Oral Tablet 50-200-25- Milligram [MG], revealed the medication was not administered with the following notes:On 11/18/2025 medication is not available - [Nurse] notified the patient. He said it was already ordered. Just waiting for it to arrive.On 11/20/2025 awaiting resident to bring in.On 11/21/2025 awaiting resident to bring from home.On 11/23/2025 med not available., Spoke with resident re: Biktarvy medication. Reason he has been out is d/t (due to) insurance changes. He needs to call [Name of Pharmacy] to have medication refilled.On 11/24/2025 awaiting resident to bring med from home, MD (Medical Doctor) aware.On 11/25/2025 pending delivery, per resident it will arrive in the morning.On 1/28/2026 at 1:45 PM. an interview was conducted with Staff A. License Practical Nurse [LPN]. Staff A said she was familiar with Resident #1. She was his nurse when he was on the first floor. Staff A said Resident #1 was out of his medication for a while. She stated the facility doesn't provide that type of antiretroviral medication due to the cost. She stated she would let Resident #1 know whenever his medication was low so he could reach out to his family to bring his medication to the facility. She stated he went for two days in a row without receiving his Biktarvy medication. She said she reached out to Resident #1 's doctor about the medication. Staff A said the physician told her to put the medication on hold at that time. Staff A stated the Biktarvy medication and Cancer medications are not provided by the facility due to the cost.On 1/28/2026 at 2:22 PM., an interview was conducted with Staff B, License Practical Nurse [LPN]. Staff B Residents Affected - Few Page 1 of 2 105037 105037 01/28/2026 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #1 was not given Biktarvy medication because it was not available most of the time and it was not a medication provided by the facility. Staff B stated when she reached out to Resident #1's family to bring his medication, she was told Resident #1 was out of his medication due to issues with his insurance. Staff B stated the facility does not pay for Resident #1 Biktarvy medication due to the cost. On 1/28/26 at 3:16 PM. an interview was conducted with Staff C, Registered Nurse, [RN]. Staff C said Resident #1 was responsible for providing the facility with his antiretroviral medication. Staff C stated Resident #1 could not receive his medication, It was not a medication the facility provided due to the cost.On 1/28/2026 at 1:30 PM., an interview was conducted with the interim Director of Nursing (DON). The DON said upon admission to the facility, they explained to Resident #1 that he was responsible for the Biktarvy medication because it was too expensive for the facility to provide. The DON did not confirm if any resources or assistance were provided to enable Resident #1 to obtain the medication.On 01/28/2026 at 3:30 PM., an interview was conducted with the Nursing Home Administrator, [NHA]. The NHA stated when a resident is first admitted to their facility, the pharmacy sends an email alert if there is a high-cost medication for approval. The email is sent to the NHA, the DON, the Assistant DON and the Unit Managers. The NHA said they review the medication to see if there is an alternative medication and then reach out to the physician to see if they can change the medication to a more cost-efficient medication. She stated then they follow the physician order. The NHA stated she was made aware of Resident #1's Biktarvy medication. The NHA stated she does not approve medication because she is not clinical. She stated the DON at the time made the decision not to approve Resident #1's medication. The NHA stated if she would have known Resident #1 had issues getting his medication, she would have made sure the facility covered the cost. On 1/28/2026 to 4:33 PM an interview was conducted with Resident #1's physician. The physician said he had followed Resident #1 for over a year. The physician said Resident #1 was immunocompromised, but it is controlled. The physician stated he was notified about the situation with his medication and his weight loss. He said Resident #1 had issues getting his family to bring his Biktarvy medication to the facility. The physician said he was informed Resident #1 did not receive his medication for a week and a couple of days. He stated he told the facility that they had to make sure Resident #1 got his medication. The physician stated, that is a medication Resident #1 cannot go without, he has to take it every day.The facility administration said they did not have a policy about their process for providing antiretroviral medications. 105037 Page 2 of 2