Health inspection·January 10, 2020

F 0656 to himself. Level of Harm - Minimal harm or potential for actual harm 11/23/19 13: 44 : In to the resident room to recheck BP, resident lying in the bed with (Resident 16) in the bed with him. The resident had his hands between the resident legs. (Resident 16) was escorted out of the resident room and back to her room. Resident was informed that he needs to keep his hands to himself. Incident was reported to the ADON. Residents Affected - Some 11/23/19 16: 58 : Progress note written by Director of Nursing (DON) : This writer was contacted and made aware that resident was found with a female resident lying next to him in bed., witnessed rubbing the female resident's inner thigh when the nurse entered the room. The resident was immediately put on a one to one until police were able to come and investigate the situation. Police were unable to determine intent for battery. Resident was given a warning from the police and placed on Q 15 minute checks by staff. AHCA immediate reporting completed and abuse registry was contacted. Abuse registry name was . Call to service number for police Will continue to monitor resident for behaviors. There were no progress notes for Resident #39 since 12/4/19. The DON states staff charts by exception. Review of the 11/13/19 MDS quarterly revealed no behaviors for Resident # 39. Review of care plans revealed no care plans related to the resident's behaviors with female residents and staff. On 1/10/20, the facility provided a Care Plan History for Resident # 39. Review of the care plan history revealed a problem area of ADL (Activities of Daily Living) Functional/Rehabilitation Potential, self care deficit as evidenced by: CVA (Cerebro Vascular Accident) sequela- Weakness which was started 10/18/19. The goal was stated as Will have reduced risk regarding complications related to decreased mobility and will be appropriately groomed and dressed Approaches (dated 10/31/19 ) included: ( Resident # 39) goes into female rooms when he is aware he should not be in these female rooms. Staff educates and reminds to stay out of these rooms, (Resident 39) inappropriately speaks to staff members and other female resident. Staff remind/ redirect as needed. Approaches dated 10/18/19 included encourage out of room dining and activities daily, invite encourage, remind and escort to activity programs, observe need for referral/screen and provide as indicated, provide ADL care to ensure daily needs are met. 2. The policy titled, Comprehensive Care Plans, reviewed and revised on 7/19/18, indicated a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the residents' medical, nursing, mental, and psychological needs is developed for each resident. The Guideline portion of the policy indicated the following: - The nurse/Interdisciplinary Team (IDT) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. - Each resident's Comprehensive Care Plan is designed to incorporate identified problem areas and risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and include any specialized services or specialized rehabilitative services, and reflect current recognized standards of practice for problem areas and condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 2 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #77 was admitted on [DATE] and 11/20/19. The face sheet included diagnoses not limited to Diabetes mellitus due to underlying condition with ketoacidosis without coma, unspecified chronic obstructive pulmonary disease, and unspecified stare of pressure ulcer of sacral region. An observation, on 1/7/20 at 11:45 a.m., revealed Resident #77 lying on a low air-loss mattress, watching television in an transmission-based precaution room. On 1/8/20 at 12:30 p.m., an interview was attempted with Resident #77, the resident was confused and non-interviewable, continued to be under transmission-based precautions. The care plan for Resident #77 indicated the resident was at risk for impaired skin integrity due to incontinence, requires assist with bed mobility and transfers and Diabetes, started and edited on 11/20/19. The approaches for this problem instructed staff to report changes in skin status to physician and to complete a weekly skin assessment. The care plan, titled Nutritional Status, started and edited on 11/20/19, identified Resident #77 required a mechanically-altered diet related to (r/t) swallowing/chewing problems, decreased albumin, pressure ulcer, Body Mass Index (BMI) was greater than 24.9%, and diagnosis of Diabetes. The approaches related to the resident's nutritional risk did not include care of a pressure ulcer. Resident #77's care plan did not identify the resident had actual pressure ulcers or instruct staff in the care of the existing pressure ulcers. A review of the active physician orders for Resident #77 revealed the following: - Cleanse wound to sacrum with normal saline (NS), pat dry, pack with Dakins soaked gauze, and cover with a clean dry dressing daily and as needed (prn), if soiled or missing dressing. Special instructions: cleanse wound to sacrum with NS, pat dry, pack with Dakin soaked gauze, and cover with a clean dry dressing daily and prn if soiled or missing dressing. Two identical orders were reviewed, one for prn and one for daily application of dressing during the 23:00 - 07:00 shift. The orders started on 11/2/19 with an open end date. The Treatment Administration Record (TAR), dated 12/11/19 - 1/10/20, indicated staff had applied a dressing to Resident #77's sacrum area daily. A review of a wound care vendor progress note, dated 11/21/19, identified Resident #77 had a stage 4 pressure ulcer of sacral region and an unstageable pressure area to the right heel. The wound care vendor note, dated 11/28/19, indicated the resident had a stage 4 pressure ulcer to the sacrum/coccyx, an unstageable area to the right heel, a deep tissue injury to the left heel, and an unstageable to the right forearm. The nursing observation of Resident #77, dated 1/6/20, identified pressure ulcers to the right and left buttocks. The observation documentation, dated 12/30/19, indicated bilateral buttock pressure areas. The posterior skin evaluation, dated 12/23/19, indicated Resident #77 had pressure areas to the left and right buttocks. During an interview, on 1/9/20 at 5:33 p.m., the Director of Nursing (DON) confirmed Resident #77 had a large wound to her bottom area. On 1/10/20 at 1:04 p.m., the DON stated she did not need to review the care plan as she believed the findings of this writer. She stated the care plan should reflect that Resident #77 had an actual wound and should include interventions related to the wound. 3. Resident #45 was admitted on [DATE] and 11/16/19. The face sheet included Parkinson's disease, left hand contracture, left elbow contracture, and right hand contracture. The quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had no functional Range of Motion (ROM) limitation to bilateral upper and/or lower extremities and did have a indwelling catheter. Resident #45's care plan indicated the resident had a problem with Activities of Daily Living (ADL) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 3 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Functional/ Rehabilitation potential. The problem described that the resident had a self-care deficit as evidenced related to (r/t) Parkinson's disease, Alzheimers, and weakness. The approaches, start date 10/23/19, indicated nursing and Certified Nursing Assistant (CNA)'s were responsible for the application of right (rt) and left (lt) hand splint applied as tolerated, and to check skin integrity every shift. The care plan did not include an approach related to Resident #45's indwelling catheter. The care plan did indicate the resident did have a problem, started 9/2/19 and edited 11/6/19, related to elimination. The problem of elimination indicated Resident #45 was not a candidate for bowel or bladder retraining as evidence by severe cognitive deficit. The approaches revealed staff were to check resident every (q) 2 to 3 hours and as needed (prn) for incontinent episodes and to provide incontinent/peri-care after each incontinent episode. An observation, on 1/7/20 at 11:58 a.m., revealed an elderly resident sitting in a reclining wheelchair. The resident appeared to have bilateral hand contractures and was not wearing any splints or braces. On 1/8/20 at 8:08 a.m., Resident #45 was sitting in the Dining Room after being assisted with breakfast, no splints were observed on either hands. At 12:14 p.m. on 1/8/20, hand splints were observed lying atop of Resident #45's bedside dresser and the resident was holding a teddy bear. On 1/9/20 at 2:57 p.m., Resident #45 was observed lying in bed, a urinary drainage bag was hanging from the frame of the bed. An observation, on 1/10/20 at 9:10 a.m., revealed the resident was sitting in a reclined wheelchair and urinary catheter tubing was visible coming from the resident's pant leg and a privacy bag was hanging from the leg rest of the chair. The physician order report identified patient (pt) to wear right (rt) resting hand splint during daytime as tolerated for contraction management twice daily, start date 6/18/19 and open ended. The Treatment Administration Record (TAR), dated 12/11/19 through 1/10/20, indicated staff documented the right hand splint twice daily. The TAR indicated during the 7:00 a.m. to 3 p.m. shift, Resident #45 refused the splint on 12/13, 12/16, 12/18, 12/20, 12/21, 12/22, 12/25, 12/26, and 12/27/19. The TAR did not indicate Resident #45 refused the application of splint during the 3:00 p.m. - 11:00 p.m. shift. The Plan of Care, dated 1/10/20, indicated the resident received Restorative splint or brace assistance. The Occupational Therapy Discharge Summary indicated Resident #45 was discharged from therapy on 1/4/20 and referred to the Restorative Nursing Program (RNP). The summary indicated the resident was tolerating bilateral finger separators for 2 hours and the short-term goal had been met. The Occupational Therapy note, dated 1/2/20, indicated caregiver instruction was done in proper use, care and wearing time of hand and elbow splints and assessment of patient (pt) tolerance to splint wear with pt wearing splints x2 hours with no adverse reactions noted. The physician order report did not include orders for the care of Resident #45's indwelling catheter. The TAR did not reveal indwelling catheter care had been completed. The progress notes, dated 12/2/19 through 1/8/20, did not include any mention of Resident #45's indwelling catheter. A progress note, dated 11/16/19, indicated the resident was re-admitted from the hospital with a Foley urinary catheter. During an interview, on 1/10/20 at 9:27 a.m., Staff Member C, Registered Nurse (RN) stated Physical Therapy puts splints on Resident #45 after range of motion and the resident sometimes refuses to wear them. The Director of Therapy stated, on 1/10/20 at 9:39 a.m., therapy does not apply splints on the resident, they had trained staff to put them (splints) on. On 1/10/20 at 9:41 a.m., Staff Member C stated nursing charts whether the resident has splints on or not and if the resident refuses them. On 1/10/20 at 9:48 a.m., Staff Member D, Certified Nursing Assistant (CNA), stated she did not put splints on Resident #45 as resident was going from therapy to restorative. The staff member stated she had spoken with the restorative nurse yesterday about the splints. The CNA explained about being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 4 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transferred from the restorative department to the floor this week and had been training with therapy during the week. The Director of Nursing (DON) stated, on 1/10/20 at 1:15 p.m., the aides are responsible for putting splints on the resident and believed she was in between therapy and restorative. The DON explained when staff set up orders they need to tie the order into the Plan of Care and if they do not tie it up the aides are unable to document on the order. She stated the order for splints was not put in correctly so the aides were unable to document for the application of splints. After a review of the MAR and TAR, she stated if the resident had refused to wear splints her expectation was for staff to document the refusal. A review of Resident #45's progress notes was completed and the DON confirmed staff had not documented splint refusals. The Director of Nursing verified the indwelling urinary catheter was not a part of the resident's care plan. 4. Resident #51 was admitted on [DATE]. The face sheet included diagnoses not limited to other sequelae of cerebral infarction and contracture of left hand. The Annual Minimum Data Set (MDS), dated [DATE], indicated resident had no functional limitation of range of motion in lower or upper extremities. The quarterly MDS, dated [DATE], indicated Resident #51 had range of motion limitation on one side of the upper extremities. Resident #51's annual Brief Interview of Mental Status, dated 11/25/19, indicated no score as the resident was rarely/never understood. An observation, on 1/7/20 at 3:42 p.m., revealed Resident #51 was not wearing a hand splint/brace to a left hand contracture. At 1/8/20 on 2:10 p.m., the resident was observed sitting in wheelchair, across from nursing station, wearing white tube socks and no splint to left hand. At 9:22 a.m. on 1/10/20, the resident was observed lying in bed and was not wearing hand splint or bilateral boots. At 11:58 a.m. on 1/10/20, Resident #51 was observed sitting in chair, wearing bilateral boots and removing splint from left hand. Resident #51's care plan indicated a problem of an actual contracture/impaired functional range of motion of left hand related to (r/t) history of Cerebrovascular Accident (CVA), started and edited on 9/3/19. The approaches included: apply at (blank) pm/am, remove at (blank) pm/am; started and created on 9/3/19, on (blank) hours/off (blank) hours; started and created 9/3/19, continuous (may remove for bathing or personal care activities); created and started 9/3/19, splint type: (blank), apply to: (blank); created and started 9/3/19. The care plan identified Resident #51 had a self-care deficit as evidenced by weakness, impaired mobility, and incontinence. The approaches included the nurse was to ensure that resident was wearing her boots to prevent foot drop every shift, start date 9/3/19 and edited 1/7/20. The physician order report revealed the following: - start date 6/13/19: Left hand splint to be applied as tolerated for contracture prevention. Check skin for redness and edema every shift; days, evenings, and nights. - start date 12/9/19: nurse to ensure that resident is wearing her boots to prevent foot drop every shift. Every shift; days, evenings, and nights. The Treatment Administration Record (TAR), dated 12/11/19 - 1/10/20, indicated there resident refused the left hand splint on 12/11-12/13, 12/16, 12/18, 12/20-12/22, and 12/25/19 during the day shift. The TAR did not indicate Resident #51 refused the left hand splint on evening or night shift. The TAR indicated the resident did not refuse to wear bilateral boots during day, evening, or night (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 5 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0656 shift. Level of Harm - Minimal harm or potential for actual harm During an interview, on 1/10/20 at 1:35 p.m., the Director of Nursing stated the floor aides are responsible for applying the splints. She verified the approach regarding the left hand contracture did not indicate what and when to apply and when to remove. She stated there should be a progress note that says Resident #51 removes the splint and the care plan should reflect that the resident has a behavior of removing the splint. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 6 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 revise the comprehensive care plans for one resident of forty-three residents sampled related to Resident #242's safe smoking ability. Findings included: Resident #242 was admitted on [DATE] with multiple diagnoses that included Pulmonary Embolism without acute cor pulmonale, Dysphagia oropharyngeal phase, Conversion disorder with seizures or convulsions and Exocrine pancreatic insufficiency, Nicotine dependence, other tobacco product, with withdrawal. A record review identified the Quarterly Minimum Data Set (MDS) dated [DATE], for Resident # 242 to have a Brief Interview of Mental Status (BIMS) Score of 15 (on a 1-15 score range) indicating the resident to be cognitively intact. Review of the clinical record revealed Resident #242's most recent smoking evaluation (observation detail report) was dated 12/24/19, which indicated the resident was a safe smoker and did not require supervision while smoking. The comprehensive care-plan with last revision date of 12/27/19 for Resident #242 included a problem area which read Smokes and at risk for safety concerns related to:__ Desires to smoke and is designated as a __Safe Smoker, __Impaired Smoker,___Resident needs the following while smoking___ Protective Gear. (the blanks were not filled in) The Approaches section included: Resident #242 will be supervised while smoking at all times. During an interview conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 1/08/20 at 1:45 p.m., they were both shown the resident's comprehensive care plan and the smoking evaluation (observation detail report). Both the DON and NHA confirmed that the comprehensive care-plan Problem area was not filled in or checked for smoking status, and that the smoking evaluation (observation) was different than what the Approaches indicated on the comprehensive care plan. The DON stated It contradicts each other, I see what the issue is, there is supposed to be something checked in the problem area under categories. I see the care-plan states she should be supervised in the approaches section. A review of Facility Policy Titled Comprehensive Care Plans, Revision Date: 7/19/18, Page 01 and 02 of Page 03, showed the following under Guidelines: 4. Each resident's Comprehensive Care Plan is designed to: a. Incorporate identified areas; b. Incorporate Risk factors associated with identified problems; e. Reflect treatment goals, timetables and objectives in measurable outcomes; j. Reflect currently recognized standards of practice for problem areas and conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 7 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 13. Care plans are ongoing and revised as information about the resident and the resident's condition change. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 8 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and twenty-eight errors were identified for three (#72, #88, and #33) of five residents observed. These errors constituted a 75.68% medication error rate. Residents Affected - Few Findings included: 1. On 1/9/20 at 11:19 a.m., an observation of medication administration with Staff Member F, Registered Nurse (RN), was conducted with Resident #72. Staff Member F, RN was observed administering the following medications: - Hydrocodone-Acetaminophen 7.5-325 milligram (mg) tablet orally - Alprazolam 0.25 mg tablet orally - Acidophilus tablet orally - Iron 325 mg tablet orally - Vitamin D3 5000 international unit (iu) tablet orally - Breo-Ellipta 100 microgram/25 microgram (mcg/mcg) inhaler, one puff inhaled - Fluticasone Propionate 50 mcg nasal spray, one spray bilateral nares - Lisinopril 10 mg orally - Myrbetriq Extended Release (ER) 50 mg tablet orally - Sertraline Hydrochloride (HCl) 100 mg tablet orally - Vitamin B12 500 mcg tablet orally - Vitamin E 400 units (u) softgel orally When asked why the Resident profile was colored red, Staff Member F confirmed the medications were due at 11:00 a.m. Staff Member F entered Resident #72's room at 11:33 a.m. to administer the above medications. A review of the Medication Administration Record (MAR) for Resident #72 revealed the above medications were scheduled to be administered: - Alprazolam at 9:00 a.m. - Acidophilus at 7:00 - 11:00 a.m. - Iron (Ferrous Sulfate) at 7:00 - 11:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 9 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0759 - Vitamin D3 at 7:00 - 11:00 a.m. Level of Harm - Minimal harm or potential for actual harm - Med Pass No added sugar at 07:00 - 11:00 a.m. - Breo-Ellipta at 7:15 - 11:00 a.m. Residents Affected - Few - Fluticasone at 7:15 - 11:00 a.m. - Lisinopril at 7:15 - 11:00 a.m. - Myrbetriq at 7:15 - 11:00 a.m. - Sertraline at 7:15 - 11:00 a.m. - Vitamin B12 at 7:15 - 11:00 a.m. - Vitamin E at 7:15 - 11:00 a.m. - Folic Acid at 7:15 - 11:00 a.m. - Xyzal at 7:15 - 11:00 Staff Member F stated, on 1/9/20 at 11:27 a.m., that she needed to look into the overflow for the residents' folic acid. Resident #72's ordered medication of Folic Acid and Xyzal were not administered during the observation. 2. On 1/9/20 at 11:57 a.m., an observation of medication administration with Staff Member F, RN, was conducted with Resident #88. The electronic profile for Resident #88 was colored red. Staff Member F was observed administering the following medications: - Gabapentin 300 mg capsule orally - Glipizide 5 mg tablet orally - Lisinopril 30 mg tablet orally - Oxybutnin chloride Extended Release (ER) 10 mg tablet orally - Furosemide 20 mg tablet orally - Sertraline 50 mg tablet orally - Sertraline 25 mg tablet orally - Iron (Ferrous Sulfate) 325 mg tablet orally - Artificial Tears eye drops A review of the Medication Administration Record (MAR) for Resident #88 revealed the above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 10 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0759 medications were scheduled to be administered by 11:00 a.m. A review of the Physician's orders for Resident #88 revealed the following medication orders: Level of Harm - Minimal harm or potential for actual harm - Gabapentin 300 mg capsule orally twice daily at 7:00-11:00 a.m. Residents Affected - Few - Glipizide 5 mg tablet orally once a day at 7:15-11:00 a.m. - Lisinopril 30 mg tablet orally once a day at 7:15-11:00 a.m. - Oxybutynin chloride ER 10 mg tablet one time daily at 7:15-11:00 a.m. - Furosemide 20 mg tablet once a day at 7:15-11:00 a.m. - Sertraline 50 mg tablet once a day with 25 mg to equal 75 mg at 7:15-11:00 a.m. - Sertraline 25 mg tablet once a day with 50 mg to equal 75 mg at 7:15-11:00 a.m. - Ferrous Sulfate 325 mg tablet three times dailyc at 9:15-11:00 a.m. - Artifical Tear 1.4% drop in both eyes four times daily at 7:00-11:00 a.m. Staff Member F documented on the MAR the above medications were administered late. 3. On 1/9/20 at 11:57 a.m., an observation of medication administration with Staff Member F, RN, was conducted with Resident #33. The observation revealed Resident #33's medication profile was colored red. Staff Member F was observed administering the following medications: - Aspirin 81 mg Enteric Coated (EC) tablet orally - Furosemide 20 mg one half tablet orally - Escitalopram Oxalate 10 mg tablet orally - Escitalopram Oxalate 10 mg tablet orally - Famotidine 20 mg tablet orally - Lisinopril 20 mg tablet orally A review of the Medication Administration Record (MAR) for Resident #33 revealed the above medications were scheduled to be administered at 7:15 - 11:00 a.m. A review of the Physician's orders for Resident #33 revealed the following medication orders: - Aspirin 81 mg chewable tablet once a day by mouth - Furosemide 20 mg tablet: 10 mg tablet once a day oral - Lexapro (escitalopram oxalate) 10 mg: 20 mg once a day oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 11 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 0759 - Pepcid (famotidine) 20 mg once a day oral Level of Harm - Minimal harm or potential for actual harm - Lisinopril 20 mg tablet once a day by mouth Residents Affected - Few On 1/9/20 at 11:45 a.m., Staff Member F was asked why medications for residents were late, the staff member stated a physician order needed to be put into the computer right away and a Vancomycin lab draw needed to be done. At 12:18 p.m. on 1/9/20, Staff Member F reviewed the resident sheets and stated seven (7) residents still had 7:00 - 11:00 a.m. medications to be administered. When asked what the process was for administering late medications, the RN stated the process for late medications were to keep going, if we stopped we would run into the 1 or 2 o'clock meds (medications). At 4:52 p.m. on 1/10/20, the Director of Nursing (DON) stated due to the open medication pass medications administered outside of the administration times were considered late. She confirmed, when asked for a clarification, if a medication was to be administered, for example: between 7:00 - 11:00 a.m., any medication administered after 11:00 a.m. would be considered late. The DON explained that after a medication error event was documented, the physician and the resident and/or resident representative would be notified. The policy titled, Medication Administration: General Guidelines, dated 09/18, indicated medications are administered with good nursing principles and practices. The policy directed staff to review and confirm medication orders prior to administration and to verify medication was correct three (3) times before administering the medication. The guidelines identified medication administration timing parameters included any facility specific policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 12 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 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, policy review, and interviews the facility failed to ensure expired medications were removed from two of four medication carts, medication ointment was labeled with a resident name in one of two treatment carts, and one of two treatment carts were locked when left unattended. Findings included: An observation, on 1/8/20 at 3:58 p.m., was conducted with Staff Member E, Licensed Practical Nurse (LPN), of the D-wing medication cart. The D-cart contained a 100 unit/milliliter (u/mL) vial of Humulin R insulin which the label identified as being opened 12/7/20 and expired on 1/7/20, one 100 u/mL vial of Lantus which the label identified as being opened 12/7/19 and expired on 1/7/20. The D-wing medication cart contained six (6) 14 milligram (mg) Nicotine Transdermal System patches which the packaging indicated had expired in August (Aug) 2019. A 4 fluid ounce bottle of Tearless Baby Shampoo was observed to be stored with mulitple bottles of oral over-the-counter medications. Photographic evidence was obtained. The Consulting Pharmacist stated, on 1/8/20 at 4:01 p.m., he checks the medication carts every couple of months and the insulin should have been removed. On 1/10/20 at 5:02 p.m., the Director of Nursing (DON) confirmed an opened tube of Triamincolone Acetonide 0.5%, observed in the A and B -wings treatment cart, was unlabeled with a residents name or pharmacy information. At 5:27 p.m. on 1/10/20, as the DON and surveyor were walking past the C and D-wing nursing station, it was noted that the C and D wings' treatment cart was unlocked and unattended. The treatment cart contained multiple containers of topically ointments in clear bags. The DON asked, was that unlocked? and shook her head. An observation was conducted with the DON and Staff Member G, LPN, of the medication cart on C-wing at that time. The observation revealed a Lantus Solostar insulin pen, opened 11/27/19 and expired 12/25/19. Photographic evidence was obtained. Staff Member G confirmed the expiration date of the Lantus insulin pen and removed it from the cart. The policy titled, Medication Storage: Storage of Medication, dated 09/18, indicated medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration, and the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The procedures of the policy identified medication rooms, cabinets, adn medication supplies should remain locked when not in use or attended by persons with authorized access. The procedure revealed internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories. Procedure #14 of the policy indicated outdated, contaminated, discontinued, or deteriorated medications and those that are cracked, soiled, or without secure closures are immediately removed from stock. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 13 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation was conducted, on 11/9/20 at 11:33 a.m., with Staff Member F, Registered Nurse (RN) of the administration of medications. The staff member dispensed medications for Resident #72 at the medication cart, entered the resident's room, and handed the medication cup to the resident. Staff Member F donned gloves (without performing hand hygiene), administered nasal spray for Resident #72. The staff member placed the cap back on the bottle, returned to the medication cart, and documented the administration of the medication. The staff member was called to the telephone, which was answered in the unit hallway, and left the area to finalize the telephone call. Residents Affected - Few At 11:46 a.m. on 11/9/20, Staff Member F began to dispense medications for Resident #91. The staff member placed all medications into one medication cup, entered the resident's room, and administered the medications. After leaving Resident #91's room, Staff Member F returned to the cart and signed the medications as administered, then left to verify location of other residents. The staff member did not perform hand hygiene after the dispensing or administration of medications to Resident #91. On 1/9/20 at 11:57 a.m., an observation with Staff Member F administer medications to Resident #88. The staff member did not perform hand hygiene prior to or after dispensing the medications for Resident #88. Resident #88 asked the staff member for eye drops. Staff F returned to the medication cart, retrieved the resident's eye drops, and re-entered Resident #88's room. Staff Member F applied gloves and administered one drop into each eye, removed gloves, and returned to the medication cart. The RN did not perform hand hygiene before dispensing medications or prior to applying gloves for the administration of eye drops. The staff member pulled down the lid of the resident's right eye and administered one drop of Artificial Tears, then without removing gloves or performing hand hygiene and re-applying gloves, Staff Member F pulled the lid of the left eye down and administered one drop. The staff member removed gloves and returned to the medication cart in the hallway, without performing hand hygiene. At 12:08 p.m. on 1/9/20, Staff Member F dispensed medications for Resident #33, without performing hand hygiene after the administration of medications for Resident #88. At 12:13 p.m., the staff member entered the resident's room, assisted the resident to a sitting position by the allowing him to hold her hand, then administered the medications to Resident #33. After the administration, Staff Member F returned to the medication cart and signed out the medications as administered in the electronic record. Staff Member did not perform hand hygiene prior to the dispensing of the medications or after the administration. The policy titled, Standard Precautions, dated October 2018, indicated standard precautions, such as hand hygiene, was to be performed before and after contact with resident, after removing gloves, and before and after contact with items in the resident's room. The policy revealed gloves are to be changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another and after gloves are removed, hands are to be washed immediately to avoid transfer of microorganisms to the other residents or environments. Based on observation, interview, and record review, the facility failed to ensure the indwelling catheter tubing and bag were appropriately maintained for Resident #55 for three of four days observed (1/8/20, 1/9/20 and 1/10/20); and failed to perform hand hygiene during the task of medication administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 14 of 15 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 105275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Pines Nursing Center 6140 Congress St 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 Findings included: Level of Harm - Minimal harm or potential for actual harm 1. On 1/8/20 at 9:54 a.m., Resident #55 was observed to be seated in a wheelchair located on the smoking patio. The resident's indwelling catheter was inside a privacy bag, that was dragging on the ground along with the catheter tubing when the resident self-propelled in the wheelchair. Resident #55 was immediately interview and he indicated that the Certified Nursing Assistant's (CNA), put his indwelling catheter bag inside the privacy bag. Residents Affected - Few On 1/9/20 at 08:11 a.m. Resident #55 was observed to be sitting in a wheelchair in the main dining room, holding a large Styrofoam cup filled with coffee. The resident's indwelling catheter tubing was on the floor, and the catheter bag was contained in a privacy bag that was dragging on the floor when the resident self-propelled in the wheelchair. On 1/10/20 at 08:10 a.m., Resident #55 was observed to be in the dining area drinking from a large Styrofoam cup. The catheter bag was observed to be in a privacy bag which was located on the floor next to the catheter tubing. When Resident #55 self-propelled around the dining room table in the wheelchair, it was observed that his privacy catheter bag was dragging along with the catheter tubing on the floor. The resident was asked if any staff had assisted him with inserting the indwelling catheter in the privacy bag and affixing it to the wheelchair when he transferred into it. Resident #55 pleasantly stated I use a walker to transfer but Staff A Certified Nursing Assistant (CNA), put the indwelling catheter in the bag and helped me with everything else. The resident was asked if he was aware that his catheter privacy bag and catheter tubing were dragging each time he self-propelled in his wheelchair around the facility. The resident indicated that he did know that it was and said he would tell Staff B (CNA) when he saw her again. A record review for Resident #55 revealed Physician Order dated 1/07/20 for indwelling catheter (Foley) insertion. Nursing progress note date and time of 1/7/20 at 23:21 p.m., read Foley catheter reinserted patient tolerated well, amber urine in drainage bag, patient tolerated well. A record review identified the Quarterly Minimum Data Set (MDS) dated [DATE], for Resident # 55 to have a Brief Interview of Mental Status (BIMS) Score of 15 (on a 1-15 score range) indicating the resident to be cognitively intact. An interview was conducted with the Director of Nursing (DON) on 01/10/20 at 08:16 a.m. During the interview the DON was informed all observations of the resident's catheter tubing and privacy catheter bag being on the floor or dragging on the floor while the resident self-propelled in his wheelchair around the facility premises. The DON confirmed the catheter tubing was on the dining room floor, and that it was an infection control issue from what she could see, that needed to be addressed immediately. The DON stated, I will get the CNA to empty the catheter, and of course you can't have the catheter privacy bag dragging on the floor at any time. During a random follow-up observation on 1/10/20 at 09:04 a.m., Resident # 55 was observed to be sitting in his wheelchair on the smoking patio. The indwelling catheter's tubing was inserted into the privacy catheter bag, which was located on the ground on the smoking patio. (Photographic Evidenced Obtained.) Resident #55 smiled and politely stated Yes, they fixed it. On 1/10/20 at 09:07 a.m., an immediate interview was conducted with the DON. The DON was shown the photographic evidence obtained of Resident #55's indwelling catheter privacy bag being on the ground during the 09:04 a.m. observation. The DON revealed she would take care of it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 15 of 15