Inspection·June 29, 2023

F 0641 4/28/2023 documented the resident's discharge status as 01- Community. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/28/2023 at 10:15 AM, the Director of Nursing (DON) stated that the discharge assessments for Residents #141 and #143 were inaccurately coded as to where they were discharged . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 2 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure residents received respiratory care services consistent with professional standards of practice for 2 out of 11 residents reviewed for respiratory services, Residents #114 and #38. Residents Affected - Few Findings include: 1. During an observation on 6/26/2023 at 9:53 AM, Resident #114 was lying in bed. There was a passive nebulizer mask on top of the drawer behind the nebulizer machine unbagged. During an observation on 6/27/2023 at 8:05 AM, Resident #114 was lying in bed with the passive nebulizer mask lying on top of the drawer behind the nebulizer machine unbagged. During an observation on 6/27/2023 at 12:18 PM with Staff D, License Practical Nurse (LPN), the nebulizer mask was behind the nebulizer machine unbagged. During an interview on 6/27/2023 at 12:18 PM, Staff D, LPN, stated, He does not require my attention. He is able to do a lot of stuff on his own. I could bag the mask, but he can remove it. Review of Resident #114's admission record showed the resident was admitted on [DATE] with diagnoses including pleural effusion in other conditions classified elsewhere, apraxia, pneumonia, asthma, and shortness of breath. During an interview on 6/28/2023 at 4:25 PM, the Director of Nursing (DON) stated, Mask should be bagged when not being used. During an interview on 6/29/2023 at 10:07 AM, the Infection Preventionist stated, Staff is responsible for ensuring that tubing and masks are stored in a bag when not in use. 2. During an observation on 6/26/2023 at 10:10 AM, Resident #38 was resting with the eyes closed. Oxygen was being administered at 5 liters per minute and continuous positive airway pressure (CPAP) mask was lying on top of the machine with no bag. During an observation on 6/27/2023 at 8:27 AM, Resident #38 was lying in bed and oxygen was being administered at 5 liters via nasal cannula and CPAP mask was on top of the drawer with no bag. During an interview on 6/27/2023 at 8:27 AM, Resident #38 stated, The nurses are the ones who adjust my oxygen flow rate. During an observation on 6/27/2023 at 12:25 PM with Staff D, LPN, Resident #38 was lying in bed with oxygen being administered via nasal cannula at 5 liters and CPAP mask being on top of the drawer unbagged. During an interview on 6/27/2023 at 12:25 PM, Staff D, LPN, stated, The CPAP mask does not need to be stored in a bag. He is being administered 5 liters of oxygen. He has orders for 3 liters of oxygen. [Resident #38's name] is not care planned for self-adjusting his oxygen flow rate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 3 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0695 Level of Harm - Minimal harm or potential for actual harm Review of Resident #38's physician order dated 6/7/023 read, CPAP QHS [once a day at bedtime] at bedtime for respiratory needs. Review of Resident #38's physician order dated 5/18/2023 read, Oxygen at 3 liters minute- NC [Nasal Cannula] every shift for oxygen. Residents Affected - Few During an interview on 6/28/2023 at 4:25 PM, the Director of Nursing (DON) stated, Oxygen should be administered as per doctor's orders. During an interview on 6/29/2023 at 10:07 AM, the Infection Preventionist stated, Staff is responsible for ensuring that oxygen is running at the rate ordered by the physician. Review of the policy and procedures titled Oxygen Administration last reviewed on 5/3/2023, read, Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 4 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals were secured in the facility. Findings include: 1. During an observation on 6/26/2023 at 9:43 AM, Resident #293 was lying in bed. There was one bottle of Tylenol, one bottle of Imodium and one bottle of melatonin on the drawer. During an interview on 6/26/2023 at 9:43 AM, Resident #293 stated, My husband brought these from home, so that I could take them. During an observation on 6/26/2023 at 10:03 AM, Resident #82 was lying in bed. There were three boxes of A&D ointment on the drawer. During an observation on 6/26/2023 at 10:06 AM, there was a normal saline syringe on the bedside table in Resident #135's room. During an interview on 6/26/2023 at 10:48 AM, Resident #135 stated, I used to have a wound and they would use that, but now I don't have a wound and they just left it here. During an interview on 6/29/2023 at 11:30 AM, the Director of Nursing (DON) stated, [names of Resident #293, #135, and #82] do not have an order in the system to self-administer medications. [Resident #293's name] could do it herself but right now it is not ideal. For the residents to be able to self-administer medication, they would have to have orders in place, self-administration assessment, and be care planned. None of the residents were. 2. During an observation on 6/26/2023 at 9:50 AM, Resident #132 was sitting in bed with a gastric tube noted on his abdomen. There was a syringe containing 0.9% sodium chloride, dated 6/23/2023, on top of the drawer. During an interview on 6/26/2023 at 9:50 AM, Resident #132 stated, I have a gastric tube for my cancer mediations. The nurses will administer the medications through the tube. During an interview on 6/27/2023 at 4:27 PM, the Director of Nursing (DON) stated, I know staff change syringes daily during the night shift. 3. During an observation on 6/26/2023 at 9:48 AM, there were medications on Resident #46's nightstand and bed, including one bottle of Hydrogen Peroxide Topical Solution, one tube of Hydrocortisone Cream, one tube of Diclofenac Sodium Topical Gel, and one tube of Ketoconazole Cream 2% (Photographic evidence obtained). Review of Resident #46's records revealed no physician order for self-administration of medications. During an interview on 6/27/2023 at 2:59 PM, Staff A, Licensed Practical Nurse (LPN), stated He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 5 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0761 [Resident #46] shouldn't have medications at his bedside. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/27/2023 at 3:06 PM, the Director of Nursing (DON) stated, It is my expectation that no medications are to be left at a resident's bedside. Residents Affected - Few Review of the policy and procedure titled Medication/Biological Storage lasted reviewed on 5/3/2023 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 6 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 Residents Affected - Few 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 ensure food was stored in accordance with professional standards for food service safety in the walk-in freezer (Photographic evidence obtained). Findings include: During the initial tour of the main kitchen on 6/26/2023 beginning at 9:00 AM with Staff F, Visiting Kitchen Manager, there were one opened box with an unsealed bag containing Cinnamon Roll Dough and breaded squash, and a plastic container of frozen pureed protein with the lid off and the contents expanded out of the container on the top wire shelf in the walk-in freezer. During an interview on 6/26/2023 at 9:28 AM, Staff F, Visiting Kitchen Manager, confirmed there were opened boxes of food in the freezer and stated, Those [the opened bags in the boxes] should have been closed and this [frozen protein] should have been thrown out. Review of the policy and procedure titled Refrigerated Storage dated 1/1/2022 and last reviewed on 5/3/2023 read, Policy: Foods and Nutrition Services (FNS) staff should maintain safe refrigerated storage areas. Refrigerated items should be properly stored, labeled and maintained by dietary staff . Procedure . 4. Dietary staff will label, date and monitor refrigerated food, including but not limited to leftovers to ensure use by use-by dates or frozen (where applicable) or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 7 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident records were complete and accurate for 2 out of 4 residents reviewed for assistance with activities of daily living, Residents #14, and #18. Findings include: 1. Review of Resident #14's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including encephalopathy, schizophrenia, muscle weakness, pain in right shoulder, type II diabetes mellitus, anxiety disorder, major depressive disorder, chronic pain syndrome, fibromyalgia, acute kidney failure, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, pseudobulbar affect, dementia, mood disorder, and hypertension. Review of Resident #14's Minimum Data Set (MDS)- Quarterly assessment dated [DATE] read, G0120. Bathing . A. Bathing: Self-performance . 4. Total Dependence . B. Bathing: Support provided . 2. One person physical assist. Review of Resident #14's shower task list documentation for June 2023 revealed no documentation for Wednesday 6/7, Monday 6/12 and Wednesday 6/14, and 97- not applicable for Monday 6/5, Friday 6/9, Monday 6/19 and Wednesday 6/21. 2. During an observation on 6/26/2023 at 11:00 AM, Resident #18 was lying in bed, with the resident's hair not combed and greasy. During an interview on 6/26/2023 at 11:01 AM, Resident #18 stated, I would love to have a shower and wash my hair. It feels dirty. Review of Resident #18's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic pain, cerebral infarction, hypertension, hemiplegia and hemiparesis following cerebral infarction, type II diabetes mellitus, dementia, dermatitis, anxiety disorder, end stage renal disease, and sleep apnea. Review of Resident #18's Minimum Data Set- Modification of Annual assessment dated [DATE] read, G0120. Bathing . A. Bathing: Self-performance . 4. Total Dependence . B. Bathing: Support provided . 2. One person physical assist. Review of Resident #18's activities of daily living task list for June 2023 showed the resident was scheduled to have a shower or bath three times a week and as needed on Mondays, Wednesdays, and Fridays on the day shift. Review of Resident #18's documentation of assistance with showering and/or bathing dated June 2023 showed no documentation for Monday 6/5 and Wednesday 6/14, and 97- not applicable for Friday 6/9, and Friday 6/23. During an interview on 6/27/2023 at 3:50 PM, the Director of Nursing (DON) stated, I expect the staff to document when they give a shower or for any reason do not do a shower. The DON confirmed that Resident #18's task list documentation for showers being given was not completed for two days and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 8 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented not applicable for two days in the month of June. She also confirmed that Resident #14's task list documentation for showers being given was not completed for three days and documented as not applicable for three days in June. During an interview on 6/29/2023 at 11:43 AM, Staff E, Certified Nursing Assistant (CNA), stated, If they receive a shower, I document it in PCC [Point Click Care] and if they refuse, we write refuse on the shower sheet and tell the nurse. Review of the policy and procedure titled Charting and Documentation dated 4/1/2022 and last reviewed on 5/3/2023 read, Policy: It is the policy of this facility that services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 9 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interviews and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to take actions to fully implement a developed plan of correction and Performance Improvement Plan (PIP), which resulted in the facility's failure to identify licensed staff was not following physicians' orders for notification of elevated blood sugars for 1 of 5 residents, Resident #13, and failure to identify medication errors for 3 of 5 residents, Residents #100, #4 and #5, who were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no glargine [Lantus/Detemir] and you have not given rapid acting insulin within the past 3-4 hours, it is likely that your body will make ketones and is at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) which as similar symptoms, causes, and treatments of DKA. DKA is caused by an overload of ketones present in your blood. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. HHS is a potentially fatal condition that can develop when diabetic medications are not administered as directed causing severe hyperglycemia and extreme dehydration leading to coma and death. Findings include: 1. Review of Resident #13's medical record documented the resident was admitted to the facility with the following diagnoses: acute on chronic systolic congestive heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease stage 3, acquired absence of left leg above knee, personal history of transient ischemic attack and cerebral infarction, cerebral infarction, subacute osteomyelitis left ankle and foot, depression, anemia, type 2 diabetes mellitus with diabetic polyneuropathy, secondary hypertension, hyperlipidemia, pressure ulcer unstageable, and pressure ulcer of sacral region. Review of Resident #13's physician orders dated 7/3/2023 read, Humalog Kwik-pen 100 units/ml [milliliter] solution pen-injector, Inject as per sliding scale: if BS [blood sugar] under 60 call MD [medical doctor], 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, if BS > 400 call MD. Review of Resident #13's July 2023 Medication Administrator Record (MAR) revealed on 7/4/2023 at 11:30 AM no information was documented for blood sugar, and on 7/11/2023 at 6:30 AM blood sugar of 461 was documented with a chart code of 9 (other/see nurses notes). Review of the progress notes on and about 7/11/2023 did not document a nurses note. Review of Resident #13's July 2023 MAR revealed a blood sugar of 424 and a chart code of 9 (other/see nurses notes) was documented on 7/18/2023 at 6:30 AM. Review of the progress notes on and about 7/18/2023 did not document a nurses note. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 10 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0867 Review of Resident 13's August 2023 MAR revealed a blood sugar of 527 and a chart code of 9 (other/see nurses notes) was documented on 8/2/2023 at 6:30 AM. Level of Harm - Immediate jeopardy to resident health or safety Review of the progress notes on and about 8/2/2023 did not document a nurses note. Residents Affected - Some Review of Resident #13's August 2023 MAR revealed a blood sugar of 542 and a chart code of 9 (other/see nurses notes) was documented on 8/4/2023 at 6:30 AM. Review of the progress notes on and about 8/4/2023 did not document a nurses note. Review of Resident 13's August 2023 MAR revealed a blood sugar of 531 and a chart code of 9 (other/see nurses notes) was documented on 8/12/2023 at 6:30 AM. Review of the progress notes on and about 8/12/2023 did not document a nurses note. 2. Review of Resident #100's medical record documented diagnoses that included encephalopathy, unspecified visual field defects, type 2 diabetes mellitus without complications, essential primary hypertension, and cerebral infarction (a stroke). Review of the physician orders for Resident #100 dated 4/5/2023 read, Insulin Detemir Solution 100 Unit/ml [milliliter]. Inject 20 units subcutaneously at bedtime for diabetes. Review of the Medication Administration Record (MAR) for Resident #100 for the period of 5/1/2023 through 8/30/2023 revealed on 5/1/2023 at 9:00 PM Staff A, Licensed Practical Nurse (LPN) documented 14 (insulin coverage not needed) for Insulin Detemir 20 units, on 5/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) Detemir 20 units, on 5/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/4/2023 at 9:00 PM Staff C, LPN documented 4 (held per parameters) for Insulin Detemir 20 units, on 5/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/10/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/11/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/19/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/20/2023 at 9:00 PM Staff B documented 4 (held per parameters) for Detemir 20 units, on 5/21/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/24/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 5/30/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 5/31/2023 at 9:00 PM Staff B, LPN documented 11 (held per parameters) for Detemir 20 units, on 6/2/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/3/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/7/2023 at 9:00 PM, there was no documentation on the MAR for the administration of Detemir 20 units, the box to indicate administration was blank, on 6/13/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 6/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/1/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/5/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/12/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/15/2023 at 9:00 PM Staff B, LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 11 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some documented 4 (held per parameters) for Detemir 20 units, on 7/16/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/18/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/28/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 7/30/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/9/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/10/2023 at 9:00 PM Staff C LPN documented 14 (insulin not required) for Detemir 20 units, on 8/22/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/23/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/25/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, on 8/27/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units, and on 8/29/2023 at 9:00 PM Staff B, LPN documented 4 (held per parameters) for Detemir 20 units. 3. Review Resident #4's medical record documented diagnoses that included cerebral infarction due to occlusion or stenosis of small artery (a stroke), chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and end stage renal disease. Review of the physician orders for Resident #4 dated 2/14/2023 read, Insulin Detemir Solution 100 unit/ml, Inject 38 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 8/1/2023 through 8/30/2023 revealed on 8/6/2023 at 9:00 PM Staff D, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/8/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/12/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units, on 8/14/2023 at 9:00 PM Staff C, LPN documented 14 (insulin not required) for Detemir 38 units, and on 8/17/2023 at 9:00 PM Staff E, LPN documented 4 (held per parameters) for Detemir 38 units. 4. Review of Resident #5's medical record documented diagnoses that included anoxic brain damage, type 2 diabetes mellitus with diabetic neuropathy, and secondary hypertension. Review of the physician orders for Resident #5 dated 6/22/2023 read, Lantus Solution 100 unit/ml [insulin glargine] inject 15 units subcutaneously two times a day related to type 2 diabetes mellitus without complication. Review of the MAR for Resident #5 for the period of 8/1/2023 through 8/30/2023 revealed on 8/3/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus Insulin 15 units, on 8/5/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/8/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/13/2023 at 9:00 PM Staff G, LPN documented 14 (insulin not required) for Lantus 15 units, on 8/17/2023 at 6:00 AM Staff H, LPN documented 14 (insulin not required) for Lantus 15 units, and on 8/21/2023 at 6:00 AM Staff I, LPN documented 4 (held per parameters) for Lantus 15 units. During an interview on 8/31/2023 at 9:55 AM, Staff J, Regional Nurse Consultant stated, We have done a PIP [performance improvement plan] for insulin administration. We did this about a week ago and we have been auditing. We did a whole house audit of all residents who are being administered insulin. I will get that for you. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 12 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the document titled Performance Improvement Plan dated 8/23/23 read, Objective and goal: Insulin administration/following physician orders. The facility will respond with the development of a charter PIP as well as an investigation. Initiative: 1. Immediate corrections to ensure safety of affected resident(s). 2. Identification of any other residents who may be affected or at risk. 3: Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: During a quality system review, it was identified that physician's orders, as it pertains to insulin administration were not followed at times or action taken related to variation from physician orders were not documented in the clinical record. A comprehensive audit of active residents in the facility with orders for insulin administration was conducted to identify concerns related to insulin administration in accordance with physician orders 30 days no concerns. Responsible person(s): DNS/designee. Target date: 8/23/23. Status: Completed. Review of a Full House audit titled Diabetes Insulin dated 8/23/23 was completed and included: 1. MD [Medical Doctor] order with dx [diagnosis] for insulin. **** Sliding scale orders should include instructions such as MD notification for BG [blood glucose] > 400 or < 70. 2. MD order for hypoglycemia emergency response. 3. Nurse assigned to patient can verbalize the s/s [signs and symptoms] of hypoglycemia. 4. MAR documentation supports appropriate administration. (i.e., . MD notified for BG > 400 or < 70). [Long-acting insulins were not included in this audit]. During an interview on 8/31/2023 at 10:54 AM, the Medical Director stated, I was not aware that the nurses were holding long-acting insulins. I should be notified when the nurses are holding insulin, long-acting insulin. I should be notified if blood sugars are below 60 or above 400 unless there are different parameters I have set. Long-acting insulin does not have any parameters for holding, so I expect to be called. I do not think that any of my residents have had to be hospitalized due to hyperglycemia. There are concerns with holding insulins, the elderly are not as resilient and can decompensate quickly if they have any underlying illness. I should be notified if insulin is not administered. Nurses should follow orders and call if they have any concerns about giving the insulin. During an interview on 8/31/2023 at 11:50 AM, the Administrator stated, We did meet and discuss the concerns about insulin and have been working on a plan of correction. I guess we should have found this when we looked at the insulin administration. We did not complete an RCA [root cause analysis] to determine if there were any other problems related to insulin administration. I assumed that all insulin was being looked at. We were focusing on the recertification survey, revisit, and complaint surveys. We should have looked at this and found that this was happening during our audits. We should have notified the doctors that the long-acting insulin was not administered. I don't know why; I don't have an answer as to why this was not addressed. Nurses should administer insulin when ordered by the doctor or call if they have any concerns about administering it [the insulin]. During an interview on 8/31/2023 at 11:57 AM, Staff J, Regional Nurse Consultant stated, Each time 4 or 14 is documented the medication was not given per the doctors' order. The nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I just don't know why they did this. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. The nurses were not following our policies for medication administration, notifying doctors of changes in condition. They should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 13 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some have called the doctor if they had any concerns at all. I don't know why they did not administer the insulin. I have not asked them or investigated why they did not give it. I was not aware that long-acting insulin wasn't being given. I don't know what the DON [Director of Nursing] knew or investigated. I did the audits of all the residents on insulin. I did audits for what is documented on the audits, doctors' orders for insulin, orders for hypoglycemia protocol, that nurses can verbalize the signs and symptoms of hypoglycemia and that the MARs reflect appropriate administration. I don't recall seeing documentation for holding long-acting insulin. I don't recall whether I saw this or not. We did training with staff about insulin administration and that did include types of insulin. I was not aware that we still have staff not administering the long-acting insulin. I really can't say if I looked at the long-acting insulin or just that the accuchecks [an easy way to measure blood sugar] were being called and if they were documenting them correctly. I don't know exactly how the education was completed. What exactly they went over. We did not document whether or not we looked at the long-acting insulin when we did the PIP. I was not involved in the PIP, and I can't say. We should have identified it as a problem [long-acting insulin administration] and evaluated whether the staff were administering it per orders. Long-acting insulin does not have parameters for holding them. Nurses should have called the doctor if they had concerns about administering the insulin and documented that they called the doctor. Review of the PIP with the Regional Nurse Consultant, the PIP did not document identification of long-acting insulin not being administered. Review of the education provided to licensed staff dated 8/16/2023 read, F842 following physician orders and notifying physician of CIC [change in condition] as indicated. Ensure you complete all PCC [Point Click Care] documentation before the end of your shift. During a telephone interview on 8/31/2023 at 4:35 PM, Staff H, LPN stated, I did hold the insulin. It was long-acting insulin. The blood sugar was below 150. I always hold the Lantus when that happens. I did not call the doctor or text him. I thought that I was doing the right thing. I was not following doctors' orders for that administration. There are no parameters in the order to hold the insulin. If I was concerned, I should have called the doctor. During a telephone interview on 9/1/2023 at 8:06 AM, Staff I, LPN stated, I did hold the insulin. I guess I wasn't understanding that I needed to give it. I should not have held the insulin. I should have let the doctor know I was holding the insulin. I was not following doctor's orders when I held the long-acting insulin. During a telephone interview on 9/1/2023 at 8:16 AM, Staff B, LPN stated, So, I guess I had a misunderstanding of what long-acting insulin does and I would hold this for the sliding scale parameters. I didn't understand that I shouldn't or that I wasn't following doctors' orders. I should have given the insulin. I was not following the policies for medication administration; I was not following the doctor orders when I held the insulin. There are no parameters to hold long-acting insulin. During an interview on 9/1/2023 at 8:26 AM, Staff K, Regional Nurse Consultant stated, I do not have any evidence for the dates the insulin was not administered that the doctor was notified, no texts and no progress notes. During an interview on 9/1/2023 at 11:10 AM, Staff D, LPN stated, I did hold insulin based on the short acting insulin scale and I shouldn't have. I should have either given the insulin or called the doctor if I was concerned about the resident's blood sugars. I just thought I was doing the right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 14 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some thing for the resident. I really should have called the doctor. I did not follow the doctor's orders. I was not following our policies for calling the doctor or administering medications. Review of the policy and procedure titled P&P ANE [Abuse, Neglect, Exploitation] and Investigation issued on 4/1/2022 read, It will be the policy of this facility to honor resident rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporeal punishment, misappropriation of residents property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure . 3. Prevention: Staff, residents and resident representatives will be instructed of how to identify and report concerns, events, & grievances. The facility will monitor reported events to determine any pattern, trend, or frequency exists to attempt to minimize the occurrence of injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. 5. Investigation: The facility will conduct their own internal investigation including but not limited to staff (work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident's representative and physician should be notified that there is an on-going investigation regarding the alleged incident. Review of the policy and procedure titled P&P Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 read, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility: address all systems of care and management practices, include clinical care, quality of life, and resident choice; utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations; reflect the complexities, unique care, and services that the facility provides. 5. The governing body and/or executive leadership (or organized group or individual who assumes full authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information; corrective actions address gaps in systems and are evaluated for effectiveness. The Immediate Jeopardy was removed on site on 9/1/2023 after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of the immediate jeopardy to prevent the likelihood of harm and/or possible death as evidenced by the following: On 8/31/2023 the facility assessed all residents involved in the IJ situation and conducted a facility wide audit of all residents receiving insulin to identify possible harm, side effects or injury due to holding the insulin. The facility held an Ad Hoc QAPI meeting to discuss staff holding long-acting insulin without parameters and conducted a root cause analysis. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 15 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 8/31/2023 and 9/1/2023 the Regional Nurse Consultant provided education to the licensed nursing staff on long and short acting insulin administration, medication errors, following physician orders, changes in condition and abuse and neglect for 39 out of 41 licensed staff. On 8/31/2023 the Regional Nurse Consultant provided education and training to the facility administration on QAPI/QAA policy and abuse and neglect policy. On 8/31/2023 and 9/1/2023 interviews were conducted with eight licensed nursing staff who verified training was provided for abuse and neglect, long and short acting insulin administration, following physician orders, medication errors, and change in condition notification. Interview with the Administrator on 9/1/2023 verified that training on abuse and neglect and on quality assurance. Event ID: Facility ID: 105193 If continuation sheet Page 16 of 17 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 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 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 ensure staff followed the accepted infection control practice standards during tracheostomy care to prevent the possible development and transmission of communicable diseases and infections for 1 out 2 residents with tracheostomy, Resident #82. Residents Affected - Few Findings include: During an observation on 6/26/2023 at 10:00 AM, Resident #82 was lying in bed with the eyes closed. Tracheostomy site did not have gauze and there was yellow drainage underneath the trach plate. During an observation on 6/27/2023 at 3:02 PM, Staff C, License Practical Nurse (LPN), entered Resident #82's room and washed her hands and proceeded to open tracheostomy kit placed on Resident #82 drawer. Staff C removed sterile glove package and placed them on top of Resident #82's bed linen. Staff C donned sterile gloves and proceeded to place sterile drape on top of Resident #82's abdominal area. Resident #82 started to move his arms and dragged sterile drape under his left arm. Staff C touched Resident #82's arm with both hands using sterile gloves and removed the contaminated drape, repositioning the resident and the drape. Staff C did not change her gloves and proceeded to clean tracheostomy site and trach plate. Staff C removed inner cannula form the outer cannula and disposed of it. Staff C opened a new inner cannula and placed it on Resident #82 without changing her gloves. During an interview on 6/27/2023 at 3:21 PM, Staff C, LPN, stated, I kind of went backwards. I should have made sure I kept sterile procedure, so that I am not giving him any germs in the air way. During an interview on 6/28/2023 at 3:15 PM, the Director of Nursing (DON) stated, I expect them to follow the tracheostomy policy we have provided. During an interview on 6/29/2023 at 10:08 AM, the Infection Preventionist stated, Staff should keep sterile throughout the tracheostomy care. If they break the sterility, they need to stop and recollect items and they need to start over. This is important due to prevention of infection. Gastric tubes syringes should be changed daily since they are a vector for infection. Review of the policy and procedures titled Respiratory Care last reviewed on 5/3/2023 read, Procedure . 5. Trach care and suctioning and chest tube/PleurX care should be provided per physician orders and as needed. Supplies and tubing should be changed out to maintain infection control quality weekly and as needed. It is important that the nurse maintain proper sterile vs clean technique when providing trach care and suctioning. Suctioning machines should be maintained in good condition at bedside for ease of use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 17 of 17