Inspection·February 14, 2020

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete her readmission and/or weekly skin evaluations. She stated that we need the documentation so we can tell if she has any new areas, and if new areas appear so we can investigate as to where they came from. Record review of the facility's policy showed, Pressure Ulcer Risk Assessment, revised October 2010, showed routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Monitoring: Staff will maintain skin alert, performing routine skin inspections daily or every other day as needed. Nurse are to be notified to inspect the skin if skin changes are identified. Nurses will conduct skin assessments at least weekly to identify changes. Event ID: Facility ID: 105166 If continuation sheet Page 2 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 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 observation, interview and record review the facility failed to review and revise the Comprehensive Patient Centered Care Plan related to smoking based on the resident's assessment for one (#19) of three sampled residents of 15 total smokers. Findings included: A review of the Current Facility Smokers list was provided by the facility on 2/11/20. The list showed Resident #19 was to be supervised while smoking and the staff was to maintain her supplies. Observation on 02/11/20 at 4:09 p.m. revealed Resident #19 was in the smoking area without supervision present. She stated that she smokes and was allowed to keep her supplies with her. She stated that she was also allowed to smoke without supervision. At 4:45 p.m. Resident #19 was observed again in the smoking area. A staff member was on the porch but took another resident into the facility and left Resident #19 unsupervised in the smoking area. A review of the admission Record for Resident #19 showed that she was admitted to the facility on [DATE]. Diagnoses included but not limited to bipolar, hypertension, and anxiety. Record review of the Smoking Evaluation dated 01/14/20 showed the resident may smoke unsupervised in designated smoking area. Record review of the smoking care plan, initiated on 12/6/19, showed Resident #19 had been assessed as able to smoke with supervision due to poor safety awareness. The resident had been informed of the facility smoking policy. The goals included the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices. The interventions dated 12/06/19 included but were not limited to: maintain smoking materials in designated area (with facility staff); accompany the resident to the designated smoking area and provide supervision; provide assistance with lighting the cigarette; and provide redirection if resident was observed in any unsafe smoking practices. During an interview on 02/13/20 at 5:00 p.m. the Director of Nursing (DON) reviewed the 01/14/20 smoking evaluation and smoking care plan. She stated that the evaluation and care plan did not match. Resident #19 needed supervision with smoking on admission but had come a long way. The care plan needed to have been updated to her current status. The 3 to 11 (3:00 p.m. -11:00 p.m.) supervisor that performed the January (1/2020) evaluation should have communicated the change with the MDS (Minimum Data Set) coordinator so she could update the smoking care plan. Record review of the facility's policy, Smoking Policy-Residents, dated April 2007, showed it is the policy of this facility to establish and maintain safe resident smoking practices. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. Smoking restrictions may be imposed on residents at any time if the Attending Physician and/or Director of Nursing determine that the resident is not able to smoke safely without supervision. Smoking restrictions shall not be assessed against any resident for the mere convenience of the staff, but for the safety and well-being of the resident. Any resident with restricted smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 3 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 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 throughout the entire smoking period. Smoking privileges shall be reviewed quarterly by the Director of Nursing Services, the Attending Physician, and/or the Care Planning Team. All reclassifications of smoking privilege shall be so noted on the care plan. Reclassifications deemed necessary for the safety and well-being of the resident may be made at any time by the Attending Physician and/or the Director of Nursing Services. Residents with independent smoking privileges shall not be permitted to store any types of smoking articles, to include cigarettes, tobacco, etc. within his/her sleeping area. Event ID: Facility ID: 105166 If continuation sheet Page 4 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, staff and resident interview and facility policy review, it was determined the facility failed to ensure that three residents (#7, #13 and #62) of 15 residents who smoke were free from smoking hazards. Findings included : 1. An observation of Resident #7 was conducted on 2/11/20 at 12: 48 p.m. on the smoking patio. Resident #7 was observed smoking a cigarette for approximately ten minutes and then dropping his cigarette butt on the ground instead of the ashtray, which was on the table near the resident. At the beginning of the observation, a staff member was observed at the far end of the patio briefly talking on a cell phone. The staff member ended the call an entered the building. There was no other staff present on the smoking patio. Review of the facility posted smoking times revealed Resident #7 was smoking outside of a designated smoking time. Review of the list of Current Facility Smokers updated 2/2020, revealed that Resident #7 was listed as a supervised smoker. Review of the medical record for Resident #7 revealed diagnoses on the admission Record of Type II Diabetes Mellitus with Diabetic Neuropathy and Other Hereditary and Idiopathic Neuropathies. A quarterly nursing comprehensive evaluation was completed 1/26/20 which included a smoking evaluation. Review of the resident observation section of the smoking evaluation revealed that Resident #7 did not have the ability to light a cigarette safely with a lighter, does not smoke safely, does not utilize ashtray safely and properly, is not able to extinguish a cigarette safely and completely, and does not have the physical dexterity to smoke safely. The summary of the evaluation indicated that the resident must be supervised by staff, volunteer or family member at all times when smoking and the resident must request smoking materials from staff. Review of a care plan, initiated 11/21/19, with a focus of (Resident #7) desires to smoke. Resident has been assessed and requires supervision when smoking. Goals were listed as, Resident will demonstrate safe smoking practices thru the next review date and Resident will adhere to the smoking policy daily thru the next review date. Interventions included : Maintain smoking materials in designated area, accompany resident to designated smoking area and provide supervision, provide assistance with lighting cigarette, observe for decline in hand dexterity, assist to hold cigarette as needed. An interview was conducted with the Director of Nursing (DON) on 2/13/20 at 6:00 p.m. She reviewed the smoking assessment and care plan for Resident #7 and verified that Resident #7 was to be supervised when smoking. 2. Review of the record for Resident #13 revealed a nursing progress noted, dated 2/5/20 at 2143, which stated Today upon arrival at work, I noticed (Resident #13) sitting outside in the smoking area. (Resident #13 then asked me for a light, to which I responded that I was not aware if he was a supervised smoker or not. (Resident #13) has a pack of cigars. I mentioned that I did not know that (Resident #13) smoked. (Resident # 13) responded by saying 'I smoke cigars sometimes but I had to get away from (another resident) . Review of an admission nursing comprehensive evaluation, dated 9/21/19, revealed a smoking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 5 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evaluation which indicated that Resident #13 did not use tobacco products. Review of a nursing comprehensive evaluation, dated 2/5/20 , revealed a smoking evaluation which indicated that Resident #13 did not use tobacco products. Review of all current care plans for Resident #13 revealed no care plan related to smoking. An interview was conducted with the DON, on 2/13/20 at 6: 05 p.m. She reviewed the nursing progress note from 2/5/20 and stated that she was not aware of this event and was not aware that Resident #13 smoked. She stated that a new smoking evaluation and care plan needed to be completed. An interview was conducted with Resident #13, on 2/14/20 at 11: 23 a.m. He stated he occasionally smokes a cigar. 3. The Current Facility Smokers list, dated 2/2020, showed Resident #62 was an independent smoker and was to use a smoking apron while smoking. The staff was to maintain his supplies. Resident #62 was observed on 2/11/20 at 3:07 p.m. in the smoking area alone. He was smoking a brown cigarette. Facility staff were not present. He stated he keeps his own smoking materials. The resident did not have on a smoking apron. Resident #62 was observed on 2/12/20 at 10:25 a.m. sitting in the hallway. He self-propelled himself to the smoking area. He had his own smoking materials. He lit a cigarette while in the smoking area. He did not have a smoking apron on. A review of the admission Record for Resident #62 showed that he was admitted on [DATE]. Diagnoses included but were not limited to Cerebral Vascular Accident (CVA), Chronic Obstructive Pulmonary Disease (COPD) and seizures. Record review of the Nursing Comprehensive Evaluation dated 12/21/19 showed Resident #62 may smoke unsupervised in designated smoking areas. He must wear a smoking apron at all times. He must request smoking materials from the staff. Record review of the smoking care plan, initiated on 10/9/19, showed he desires to smoke. The resident had been assessed as able to smoke unsupervised with a smoke apron. He verbalized understanding of the smoking policy and requirements of independent smoking. The goals included the resident will demonstrate safe smoking practices and will adhere to the smoking policy daily. Interventions dated 10/09/19, included but were not limited to maintain smoking materials in designated area (with the staff); provide assistance with lighting cigarette; apply/remove smoking apron; provide redirection if resident was observed in any unsafe smoking practices; seek the assistance of managers / supervisors if needed; observe for decline in hand dexterity; and assist to hold cigarette, as needed. During an interview on 2/13/20 at 5:00 p.m. the DON reviewed the 12/21/19 Nursing Comprehensive Evaluation as well as the smoking care plan. She stated that the Evaluation showed Resident #62 may smoke unsupervised with a smoking apron and the materials were to be kept by the staff. The care plan showed he was to use a smoking apron and the materials were to be kept in a designated area. The DON stated that the facility staff was to keep his materials because he kept stating that his cigarettes were being taken by others. So, to solve that problem the facility staff was keeping his materials. The DON stated that the care plan needed to be updated related to the materials. She also stated that Resident #62 was supposed to wear a smoking apron when he was smoking. She also stated that each resident had their own apron that they kept with them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 6 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 4. Record review of the facility's policy titled, Smoking Policy-Residents, dated April 2007, showed it is the policy of this facility to establish and maintain safe resident smoking practices. Smoking Restrictions: Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. Smoking restrictions may be imposed on residents at any time if the Attending Physician and / or Director of Nursing determine that the resident is not able to smoke safely without supervision. Smoking restrictions shall not be assessed against any resident for the mere convenience of the staff, but for the safety and well-being of the resident. Any resident with restricted smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period. Review of Smoking Restrictions: Smoking privileges shall be reviewed quarterly by the Director of Nursing Services, the Attending Physician, and / or the Care Planning Team. All reclassifications of smoking privilege shall be so noted on the care plan. Reclassifications deemed necessary for the safety and well-being of the resident may be made at any time by the Attending Physician and / or the Director of Nursing Services. Smoking Articles: 1. Residents with independent smoking privileges shall not be permitted to store any types of smoking articles, to include cigarettes, tobacco, etc. within his/her sleeping area. Residents may be issued a smoking apron and/ or adaptive / safety devices when deemed necessary for their independent smoking protection. 2. Residents without independent smoking privileges shall not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc., either on his or her person or within his/her living or sleeping area, at any time other than when the resident is under direct supervision. This facility shall provide reasonable means of providing direct supervision to those residents wishing to smoke. Staff members, guardians, visitors, and volunteer workers may assist in providing this service to residents. Any person (s) providing smoking supervision to residents must be instructed in smoking regulations prior to rendering such service. Event ID: Facility ID: 105166 If continuation sheet Page 7 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 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 - Few 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** Based on observation, interview and record review the facility failed to monitor for behaviors, effects and side effects related to psychotropic medications for one resident (#5) of five sampled residents. Findings included: Resident #5 was observed sleeping during the morning hours on 2/11/20. On 2/11/20 at 3:32 p.m. the resident was lying on her right side in bed. A review of the admission record revealed that Resident #5 was admitted on [DATE] and readmitted from the hospital on [DATE]. Record review showed diagnoses included but were not limited to lung and bone cancer, anxiety, depression, and mood disorder. Review of the physician orders and Medication Record Administration (MAR) for February 2020 showed the resident was receiving Trazodone HCL 50 mg (milligrams) at bedtime for depression with a start date of 12/28/19, Lexapro 20 mg daily for depression with a start date of 12/29/19, and Lorazepam 2 mg / ml (milliliters) give 0.5 ml every 4 hours as needed for anxiety with a start date of 2/3/20. The physician orders lacked orders to monitor for behaviors, or for effects and side effects. Review of the care plan, initiated on 1/21/20 showed Resident #5 had alteration in mood related to anxiety and depression. The interventions included but were not limited to observe for changing in mood state, report to physician as needed. Review the record showed a care plan initiated on 8/8/19 for the potential of adverse side effects related to the use of psychotropic medications due to antidepressants, antianxiety. Interventions included but were not limited to observe for effectiveness of psychotropic medications, observe for adverse side effects related to psychotropic medication use and report to physician if noted and observe for changes in mood/behavior and report to physician if needed. During an interview on 2/13/20 at 5:00 p.m. the Director of Nursing (DON) reviewed Resident #5's physician orders. She stated that the resident was prescribed Trazodone, Lexapro and Lorazepam. She stated that psychotropics were to have behavior monitoring performed. She verified that no behavior monitoring was being performed for the resident. She stated that she would expect to find the behavior monitoring. She stated that the resident was being monitored prior to hospitalization and when she returned the monitoring was not ordered. During an interview on 2/14/20 at 11:14 a.m. the consultant pharmacist stated that he visited the facility monthly. On his visit he reviewed the resident's medication orders and Medication Administration Records. He stated that he would expect to see behavioral monitoring for residents on psychotropics. He stated that he would expect to see monitoring for Lexapro, Lorazepam and Trazodone. Record review of the facility's policy, Behavior Assessment and Monitoring, revised April 2007, showed Assessment: the nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including: onset, duration and frequency of problematic behaviors or changes in behavior, cognition, or mood; any precipitating or relevant factors. Management: The staff will identify and discuss with the practitioner situations where nonpharmacological (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 8 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete approaches are indicated, and will institute such measures to the extent possible. Monitoring: If the resident is being treated for problematic behavior or mood, the staff and physician will obtain and document ongoing assessments of changes in the individual's behavior, mood and function The staff will document the following information about specific problem behaviors: number and frequency of episodes; preceding or precipitating factors; interventions attempted; and outcomes associated with interventions. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. Event ID: Facility ID: 105166 If continuation sheet Page 9 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow infection control practices related to adequately cleaning blood glucose meters for two residents (#7 and #99) of two residents observed for glucose monitoring. Residents Affected - Few Findings included: 1. An observation on 2/11/20 at 4:55 p.m. revealed Staff A, Licensed Practical Nurse (LPN) removed the blood glucose meter from the top drawer of the medication cart and set it on the top of the cart. She also placed a lancet and alcohol wipes on top of the cart also (no barrier). Staff A stated that she had one more blood glucose monitoring to perform. She donned two gloves and entered Resident #7's room with the supplies. She placed the items on the overbed table. She cleaned the right ring finger with an alcohol wipe. She pricked his finger with a lancet. A drop of blood was added to the strip and placed in the meter. She removed her gloves. She informed the resident the results were 208. She placed the lancet into the biohazard container. She placed the blood glucose meter on the top of the medication cart. She washed her hands. She drew the required amount of insulin. She donned her gloves and administered the insulin. Staff A, LPN removed her gloves and washed her hands. She moved the blood glucose meter with her bare hand. She administered the rest of Resident #7's medications. She washed her hands. She opened the top drawer of the medication cart and placed the uncleaned blood glucose meter inside. When asked about cleaning of the machine she stated that she would clean it with an alcohol wipe. She removed the uncleaned machine from the drawer and cleaned it with multiple alcohol wipes. She stated that she would clean it and leave it out to air dry for 2-3 minutes. She put it back in the drawer after a few moments. 2. An observation on 2/11/20 at 6:00 p.m. revealed Staff B, Registered Nurse (RN) had two blood glucose meters sitting on top of her medication cart in plastic cups. She stated that after she cleans the meters, she places them in the cup to dry. She placed a barrier/Styrofoam plate on the medication cart and placed the blood glucose meter on it, including alcohol wipes and a lancet. She entered Resident #99's room and placed a paper towel on the over bed table and placed the items on the barrier on the bedside table. She washed her hands and donned gloved. Staff B used the alcohol wipe to right forefinger of Resident #99. She then used the lancet. The results showed 261. She placed the lancet in the biohazard container. She removed her gloves and placed the meter into a cup on the medication cart. She administered the required Humulin R insulin, 2 units, in the abdomen post the use of an alcohol wipe. She placed the used syringe in the biohazard container. Staff B, RN wiped the meter with bleach wipes and placed in the cup on the medication cart. Staff B stated that she wipes the meter with a bleach wipe and leaves it in the cup for about 3 minutes before replacing in the drawer. During an interview on 2/11/20 at 6:20 p.m. the Director of Nursing (DON) stated that they were supposed to use bleach wipes after blood glucose meter use. They were to wipe the meter and put it in a cup until it is dry. She stated that she will educate the nurses about using a bleach wipe not an alcohol wipe to clean the meters. The DON stated that she had not reviewed the directions or contact time on the bleach wipe container. They instructed the nursing staff to wipe the blood glucose meter and leave it in a cup until it dries. A review of the directions for the bleach wipes showed a 30 second contact time is required to kill all the bacteria and viruses on the label except a 1-minute contact time is required to kill Trichophyton mentagrophytes and a 3-minute contact is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains wet the entire contact time. Allow surface to air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 10 of 11 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 105166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Pointe Care Center 6020 Indiana Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dry and discard used wipe and empty canister. The DON stated that the nurses needed to wipe the meter top to bottom and front to back and leave the bleach wipe wrapped around the meter until it dries to meet the direction requirements. She stated that they would instruct the nurses again. Record review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, revised October 2011, showed always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Record review of Brand Name Bleach Wipe showed: apply towelette and wipe desired surface to be disinfected. A 30 second contact time is required to kill all the bacteria and viruses on the label except a 1-minute contact time is required to kill Trichophyton mentagrophytes and a 3-minute contact is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains wet the entire contact time. Allow surface to air dry and discard used wipe and empty canister. Contact time: allow surface to remain wet for 30 seconds to kill bacteria and viruses on the label except a 1-minute contact time is required to kill Trichophyton mentagrophytes and a 3-minute contact time is required to kill Clostridium difficile spores. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 11 of 11