Health inspection·November 5, 2021

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, The nurse must be in the room with the resident during administration of a medication, and until the medication is completed. The DON confirmed Resident #250 did not have a physician order to self-administer a respiratory (nebulizer) treatment. Review of the facility's policy titled Oral Inhalation Administration, Pharm script Policy #9.8 with revision date of 08/2020, Page 156, 158 and 159, read under Policy Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer medications that are orally inhaled. IV. NEBULIZERS: 12. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. 18. Administer Therapy until medication is gone (mist has stopped or until the designated time of treatment has been reached. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 2 of 5 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 11/05/2021 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility failed to ensure a clean and sanitary living environment was provided during three (11/02/21, 11/03/21 and 11/04/21) of four days observed, and for two (#39 and #84) of two residents in room [ROOM NUMBER]. Findings included: During a facility tour on 11/02/21 at 10:48 a.m., Resident #39 and #84's room (room [ROOM NUMBER]) was observed with brown stains on wall by trash can with an appearance of human waste matter. The floor around Resident #39's bed was noted with sticky dirt and debris around the fall mats, which were positioned on both sides of the bed. The area in front of Resident #39's bed side table was noted with black spots, stains and dust. A subsequent observation on 11/02/21 at 1:26pm revealed no change in the cleanliness of the resident room. Photographic evidence was obtained. On 11/03/21 at 09:19 a.m., room [ROOM NUMBER] was observed with the same brown stains on wall, dirt on the floors, stains on floors and an overflowing trash can. A tour of a bathroom inside room [ROOM NUMBER] revealed a toilet with yellow streak stains and a base covered with brown and yellow debris. The bathroom floors were noted sticky and with dried yellow liquid. A piece of rusted metal pipe extended to the front of the toilet next to Resident #84's walker. A trash can underneath the hand washing sink was noted with overflowing trash. A loose pipe was observed underneath the sink on the floor. Photographic evidence was obtained. A review of the clinical record for Resident #39 revealed she was readmitted to the facility on [DATE] with a primary diagnosis of other osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing. A quarterly MDS (minimum data set) dated 09/20/21, section C showed a BIMS (brief interview for mental status) score of 14, indicating intact cognition. Section G revealed Resident #39 was totally dependent for ADLs (activities of daily living). A review of the clinical record for Resident #84 revealed admission to the facility on [DATE] with a primary diagnosis of unspecified fracture of shaft tibia, subsequent encounter for closed fracture with routine healing. A quarterly MDS dated [DATE], section C showed a BIMS score of 15, indicating intact cognition. Section G showed Resident #84 was totally dependent for ADLs. On 11/03/21 at 09:18 a.m., an interview was conducted with Staff F, Housekeeping. Staff F was observed sweeping the hallway floors outside room [ROOM NUMBER]. Staff F stated that he cleans resident rooms every day. Staff F stated that he was sweeping floors but would be cleaning resident rooms later. Staff F confirmed there are at least four housekeeping staff on duty daily. On 11/03/21 at 09:22 a.m. an interview was conducted with Resident #39. She stated the stains on the wall in front of her bed had been there a while. Resident #39 said, too bad I have to look at that every day. On 11/04/21 at 08:47 a.m., room [ROOM NUMBER] was observed in the same condition as the previous observations on 11/02/21 and 11/03/21 showing the same brown stains on the walls, bathroom floors and the bedside floor areas with dirt, dust, and debris. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 3 of 5 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 11/05/2021 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Resident #84 on 11/04/21 at 10.22 a.m. Resident #84 stated she uses the bathroom inside her room every day. Resident #84 stated staff assist her with transfers and said she did not know why the floors are never cleaned. On 11/04/21 at 12:25 p.m., Resident #39 was observed laying in her bed, waiting for lunch. The room was noted dirty, with trash overflowing, bathroom floors stained, and drops of brown matter were observed near the trash can, noted extending towards the doorway. An interview was conducted on 11/04/21 at 12:30 p.m. with Staff B, CNA (certified nurse's aide). Staff B looked at room [ROOM NUMBER] and said, this room is not clean. At 12:34 pm, Staff C, CNA who was standing outside the door also proceeded to look at room [ROOM NUMBER]. Staff C said, looks like [bowel movement]. The housekeeper should clean it. Staff C stated she saw the stained walls before and forgot to say something. On 11/04/21 at 12:33 p.m., an interview was conducted with Staff E, CNA who worked that hallway during the three days of observation. Staff E said, I would not have my family use that restroom. On 11/04/21 at 12:35 p.m., an interview was conducted with Staff D, LPN (licensed practical nurse). Staff D observed the bathroom and said, the brown stains on wall and floors looks bad. Staff D stated she thought the expectation was that Housekeeping should clean resident rooms daily. A follow-up was conducted on 11/04/21 at 01:00 p.m. with the Housekeeping Director (HD). The HD observed room [ROOM NUMBER] and stated, this is absolutely unacceptable, looks like feces on walls and on the floor. The HD stated the CNAs should be wiping off the immediate bowel movement and then Housekeeping staff can disinfect it. The HD stated the resident rooms are cleaned daily, and said, No residents should use a restroom that looks like that. I will clean it myself right after lunch. The HD stated the expectation is for the resident living areas to be cleaned daily. On 11/05/21 at 08:24 a.m. an observation of room [ROOM NUMBER] confirmed the room and bathroom was clean. A follow -up interview was conducted on 11/05/21 at 08:40 a.m., with the director of nursing (DON). The DON stated she was informed to the condition of room [ROOM NUMBER], and said it was cleaned right away. The DON said, Residents should live in a clean room. Review of an undated facility policy titled, [company name] Daily resident/patient room cleaning, showed that room cleaning tasks should be performed in the following order: 1. Straighten up resident's room. 2. Dust all surfaces, and spot clean all necessary areas. 3. Dust mop the floor and sweep trash and debris to the door and pick it up with the dust pan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 4 of 5 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 11/05/2021 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 0584 4. Level of Harm - Minimal harm or potential for actual harm Empty and clean the trashcan and put in a new liner if necessary. 5. Residents Affected - Few Wet mop the room using disinfectant. Under title, Restroom Cleaning the policy showed the restroom cleaning tasks should be performed in the following order: 2. Dust mop the room and spot clean all necessary areas, such as walls. 3. Disinfect the sinks, mirrors, all lights, fixtures, and pipes. 4. Disinfect and clean all parts of the toilet. 5. Damp mop the room using disinfectant. Under title, Method of cleaning, the policy showed to: Move furniture around and clean behind not commonly used furnishings. Restrooms: pay close attention to the sink and commode. Check overall condition of the room Remove all debris from floors, counters, and edges. Remove all trash and replace liners as needed. Mop floors using disinfecting neutral floor cleaner or disinfectant cleaner. Review of an environmental specialist job description titled, Environmental specialist, with a revised date 06/2020, showed that the goal is to create a clean and orderly environment for the residents that will become a critical factor in maintaining and strengthening their reputation. Responsibilities included to: Ensure all clean and soiled rooms are cared for and inspected according to standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105166 If continuation sheet Page 5 of 5