Health inspection·October 19, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the electronic Medication Administration Record (eMAR) for the month of September 2023 for Resident #75 revealed the Hydralazine administration regimen as every day at 9:00 AM, 1:00PM and 8:00PM until the new order for 9/26/2023 with Resident #75 compliant with regimen. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 10/18/2023 at 12:49 PM. Staff G, LPN stated there is medication Resident #75 refuses to take in the morning, as Resident #75 does not want to be awoken early. Staff G, LPN stated we did not change the orders as it would not matter the timing, as the order is for every 8 hours. Therefore, the resident would have to be woken up in the evening. Staff G, LPN confirmed the medication times were never altered. A review of the facility's Grievance Logs revealed no grievances were filed for a change in medication times for Resident #75, during the months of July, August, September, or October 2023. An interview was conducted with the Social Service Director (SSD) on 10/18/2023 at 3:02 PM. The SSD confirmed there were no grievances filed for Resident #75 regarding medication administration times. The SSD stated the resident requests should be honored, if possible and be care planned. An interview was conducted with the Director of Nursing (DON) on 10/18/2023 at 3:15 PM. The DON stated she did not know the resident was refusing medications, due to the timing. Nor was she aware Resident #75 did not want to be woken up early. The DON continued to state, she did not know why the Resident's request was not facilitated. A policy for choices or accommodation of need was requested. No policies were produced upon exit of the survey team on 10/19/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 2 of 29 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 10/19/2023 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances and progress toward a resolution for concerns expressed in Resident Council Meetings by three residents (#63, #52, and #23) of 36 sampled residents. Residents Affected - Some Findings included: A review of the facility's the Resident Council Minutes from 9/12/2023 at 10:00 a.m. revealed the residents were voicing complaints regarding receiving clothing back from the laundry. (Photographic Evidence Obtained) An interview was conducted with Resident #63 on 10/16/23 at 10:10 a.m. During the interview Resident #63 stated, I had a lot of expensive stuff, now it's gone. They told me to write my name on my stuff, I did, and it didn't make a difference. Yes, I told them, and they said I needed to go to the clothing drive. I told them what's that got to do with my missing stuff. I don't trust them. I don't trust them when it comes to my clothes. An interview was conducted with Resident #52 on 10/16/23 at 11:35 a.m. During the interview Resident #52 stated, Oh, it's bad. You can ask anybody . They just keep saying that they are behind. This has been going on since I've been here .It's frustrating. As a woman it's frustrating because I have to wear the same thing every day. A Resident Council Meeting, conducted on 10/18/23 at 3:18 p.m., revealed residents voicing additional concerns regarding the facility's laundry service. During the meeting Resident #23 stated, It takes 6 weeks to get my laundry back. These findings were discussed and confirmed during an interview with Staff D, Environmental Supervisor, on 10/19/23 at 11:04 a.m. During the interview Staff E stated, The way personal laundry works is that when we get a new resident in the building, the CNAs ( Certified Nursing Assistants) are supposed to bag all their clothing , bring it to us and we label it. The issue that we are having is that clothing is not being brought to us to be labeled. I'm in the process of changing out this process .Yes, it's been bad but it's definitely getting better. It's been an ongoing issue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 3 of 29 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 10/19/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the admission Record for Resident #33 showed an admission date of 12/20/2019 with diagnoses of cerebrovascular disease (Stroke), peripheral vascular disease, muscle weakness and other co-morbidities. Residents Affected - Some A review of Resident #33's MDS with an Assessment Reference Date (ARD) of 8/14/2023 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. Resident #33 was observed in bed, covered with a sheet and arms above the sheet. Resident #33's right and left hands were folded at the metacarpophalangeal joints (MCP aka knuckles). During an interview on 10/17/2023 at 2:30 p.m. Resident #33 stated my hands have been like this for a while. The facility has not been working with me on moving them. Resident #33 continued to state; I can open my hands. At this time Resident #33 was able to bilaterally move his fingers from the MCP joints only, however, his middle to pinkie finger remained bent. Resident #33's second finger (pointer) and thumb moved up and down to touch each other and both hands were observed moving in this manner. During an interview on 10/18/2023 at 4:49 p.m. with Staff B, Certified Nursing Assistant (CNA) stated Resident #33's hands have been like that for a while now. Staff B, CNA stated I clean underneath the fingers and the palm the best I can as they are hard to move. I do not complete range of motion (ROM) with him. Resident #33 does not refuse care for me. During an interview on 10/18/2023 at 12:49 p.m. Staff G, Licensed Practical Nurse (LPN) stated Resident #33's right and left hands are contracted. I clean Resident #33's hands and clip the nails as this is hard for the CNA to complete due to the rigidity in the fingers. Resident #33 is very sweet and compliant with care for me. A review of Resident #33's physician order, dated 4/25/2023, revealed: May have restorative/maintenance programs as indicated. During an interview on 10/17/2023 at 2:36 p.m. the Regional Director of Rehabilitation (RDOR) stated he has been functioning as the Director of Rehabilitation at the facility. The RDOR stated therapy routinely screens residents on a quarterly basis, based on the MDS calendar. The RDOR was not able to provide a screening form completed on Resident #33, whose MDS was completed on 8/14/2023. The RDOR stated, I have not received a calendar for a while now. The RDOR stated I am unsure when Resident #33 was screened last, we don't have any documentation prior to July 1, 2023. An interview was conducted on 10/17/2023 at 2:41 p.m. with the RN MDS Coordinator and the Regional MDS Director. The RN MDS Coordinator stated the Inter Disciplinary Team is made aware of when the MDS for the residents are due by utilizing the computer software we have. The RN MDS Coordinator stated, I don't know why the screen would not have been completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 4 of 29 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 10/19/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview on 10/18/23 at 12:59 p.m. was conducted with the Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The DON stated Resident #33 is not compliant with care and maybe this is the reason no screening was performed. During an interview on 10/19/2023 at 1:20 p.m. the RN MDS Coordinator stated she was responsible for completing the section of the MDS that would indicate the resident's functional status. The RN MDS Coordinator verified Resident #33's functional status did not have any impairments noted. The RN MDS Coordinator stated there was no documentation of impairment in range of motion. No Policy and Procedure for Resident Assessments was provided to the survey team upon exit on 10/19/23. Based on observation, record review and interview the facility failed to accurately reflect each resident's status at the time of assessment on the minimum data set assessment (MDS) for three residents (#3, #40, and #33) out of thirty three sampled residents. Findings included: 1. A review of Resident #3's admission Record showed Resident# 3 was admitted to the facility on [DATE] with diagnoses of spinal bifida, paraplegia and atherosclerotic heart disease of native coronary artery with unspecified angina. A review of the Quarterly MDS, dated [DATE], Section N Medications, showed Resident #3 received anticoagulants for six days during the seven-day look back period. A review of Resident #3's current and discontinued physician orders showed no anticoagulant therapy. During an interview on 10/19/23 at 1:30 p.m. the Registered Nurse (RN) MDS Coordinator stated she reviewed anticoagulants on the Medication Administration Record (MAR) to ensure the medication was given. The RN MDS Coordinator reviewed Resident #3's MAR and stated she did not see an anticoagulant on the MAR. The RN MDS Coordinator reviewed Resident #3's current and discontinued physician orders and stated Resident #3 was never ordered or administered anticoagulants and the MDS was marked in error. 2. A review of Resident #40's admission Record showed Resident #40 was admitted to the facility on [DATE] with diagnoses of cerebrovascular disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and dysphasia. A review of Resident #40's Modification to Annual MDS, dated [DATE], Section K Swallowing Nutrition Status showed Yes was marked for weight loss. A review of Resident #40's weights and summary report as of 10/19/23 showed: 6/5/2023 - 106.5 pounds (Lbs) 7/4/2023- 111.5 Lbs 8/11/2023- 111.0 Lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 5 of 29 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 10/19/2023 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 0641 9/13/2023- 114.2 Lbs Level of Harm - Minimal harm or potential for actual harm 10/5/2023- 115.2 Lbs Residents Affected - Some On 06/05/2023, Resident #40 weighed 106.5 lbs. On 07/04/2023, Resident #40 weighed 111.5 pounds which was a 4.69 % gain. During an interview on 10/19/23 at 1:28 p.m. the RN MDS Coordinator reviewed Resident #40's Modification to Annual MDS, dated [DATE], Section K Swallowing Nutrition Status and weights. The RN MDS Coordinator stated that usually the Dietitian completes the MDS Section K but stated, I was the one who modified [Resident #40's] MDS to show weight loss. The RN MDS Coordinator stated, I looked at the dates wrong and modified the Dietitian's answer of weight gain to weight loss and that was an error as Resident #40 did not have weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 6 of 29 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 10/19/2023 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to develop and implement a care plan related to: 1. smoking for one resident (#82), 2. lack of range of motion for one resident (#33), and 3. related to the changes in one resident's (#78) mood, behavior and new medications for depression and anxiety out of thirty-three sampled residents. Findings included: 1. An observation and interview was conducted on 10/16/23 at 10:51 a.m. with Resident #82. The resident confirmed he smoked while at the facility. The resident stated staff members are always with the residents while smoking and the facility keep all cigarettes and lighters. On 10/18/23 at 10:49 a.m. Resident #82 was observed walking the facility's hallway. A review of the admission Record for Resident #82 revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record showed the resident had diagnoses not limited to other encephalopathy, fracture of unspecified part of neck of unspecified femur subsequent encounter for closed fracture with routine healing, uncomplicated alcohol abuse, and unspecified nutritional anemia. Review of Resident #82's Minimum Data Set, dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition. Section J Health Conditions revealed the resident did not use tobacco. A review of a Smoking Evaluation, dated 9/5/23, for Resident #82 identified the resident did smoke, was determined a safe smoker, and supervision was not needed. Review of Resident #82's Smoking Evaluation, dated 9/21/23, identified the resident did smoke and was determined to be a safe smoker. The evaluation did not reveal if the resident needed supervision while smoking. Review of Resident #82's active care plan with the last review date of 10/16/23 revealed there was no focus, goal, or intervention regarding the resident's choice to smoke. An interview was conducted with the Registered Nurse Minimum Data Set Coordinator (RN MDS Coordinator) on 10/19/23 at 1:52 p.m. The RN MDS Coordinator stated residents should absolutely have a care plan for smoking if they had gotten to their comprehensive assessment. The RN MDS Coordinator reviewed Resident #82's care plan, the options available, and confirmed the resident did not have a care plan for smoking. The staff member stated she must have been unaware Resident #82 was smoking and finds out if a resident was a smoker generally there is a smoking assessment in the electronic clinical record. On 10/19/23 at 2:03 p.m. Resident #82 confirmed smoking and being out there (smoking patio) every day. 2. A review of the admission Record for Resident #33 showed an admission date of 12/20/2019 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 7 of 29 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 10/19/2023 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 - Few diagnoses of cerebrovascular disease (Stroke), peripheral vascular disease, muscle weakness and other co-morbidities. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. Resident #33 was observed in bed, covered with a sheet and arms above the sheet. Resident #33's right and left hands were folded at the metacarpophalangeal joints (MCP aka knuckles). During an interview on 10/17/2023 at 2:30 p.m. Resident #33 stated my hands have been like this for a while. The facility has not been working with me on moving them. Resident #33 continued to state; I can open my hands. At this time Resident #33 was able to bilaterally move his fingers from the MCP joints only, however, his middle to pinkie finger remained bent. Resident #33's second finger (pointer) and thumb moved up and down to touch each other and both hands were observed moving in this manner. During an interview on 10/18/2023 at 4:49 p.m. with Staff B, Certified Nursing Assistant (CNA) stated Resident #33's hands have been like that for a while now. Staff B, CNA stated I clean underneath the fingers and the palm the best I can as they are hard to move. I do not complete range of motion (ROM) with him. Resident #33 does not refuse care for me. During an interview on 10/18/2023 at 12:49 p.m. Staff G, Licensed Practical Nurse (LPN) stated Resident #33's right and left hands are contracted. I clean Resident #33's hands and clip the nails as this is hard for the CNA to complete due to the rigidity in the fingers. Resident #33 is very sweet and compliant with care for me. A review of Resident #33's physician order, dated 4/25/2023, revealed: May have restorative/maintenance programs as indicated. A review of Resident #33's MDS with an Assessment Reference Date (ARD) of 8/14/2023 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. During an interview on 10/17/2023 at 2:36 p.m. the Regional Director of Rehabilitation (RDOR) stated he has been functioning as the Director of Rehabilitation at the facility. The RDOR stated therapy routinely screens residents on a quarterly basis, based on the MDS calendar. The RDOR was not able to provide a screening form completed on Resident #33, whose MDS was completed on 8/14/2023. The RDOR stated, I have not received a calendar for a while now. The RDOR stated I am unsure when Resident #33 was screened last, we don't have any documentation prior to July 1, 2023. An interview was conducted on 10/17/2023 at 2:41 p.m. with the RN MDS Coordinator and the Regional MDS Director. The RN MDS Coordinator stated the Inter Disciplinary Team is made aware of when the MDS for the residents are due by utilizing the computer software we have. The RN MDS Coordinator stated, I don't know why the screen would not have been completed. An interview on 10/18/23 at 12:59 p.m. was conducted with the Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The RCN stated we do have a restorative maintenance program. Residents are placed on the program by either a therapy or nursing referral. Residents stay on this program for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 8 of 29 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 10/19/2023 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 - Few about 6-8 weeks. Resident #33 is not on restorative. The DON stated Resident #33 is not compliant with care and maybe this is the reason no screening was performed. During an interview on 10/19/2023 at 1:20 p.m. the RN MDS Coordinator stated she was responsible for completing the section of the MDS that would indicate the resident's functional status. The RN MDS Coordinator verified Resident #33's functional status did not have any impairments noted. The RN MDS Coordinator stated there was no documentation of impairment in range of motion. The RN MDS Coordinator stated Resident #33 refused to speak with me. A review of Resident #33's care plan with last care plan review completed 8/29/2023 showed: *Focus: [Resident #33] has an Activity of Daily Living self-care deficit related to muscle weakness, decreased mobility, obsessive compulsive disorder, depression, bipolar, cerebral vascular disease, adult failure to thrive. [Resident #33] prefers to stay in bed and declines staff request to transfer out of bed and into the wheelchair. [Resident #33] has a history of refusing care, declining showers, and declining to be weighed. Goal: The resident will maintain current level of function through next review date. Interventions: Bathing/Showering: assist of one staff. Bathing/Showering: check nail length and trim and clean on bath day as necessary, report any changes to the nurse. Bed mobility: assist of two staff. Bed fast: the resident is bed fast all or most of the time per his preference. Dressing: assist of one staff. Eating: the resident is able to feed self with setup. Personal hygiene: assist of one staff. Toilet use: assist of one staff. Transfer: requires mechanical lift [name brand] with two staff assistance for transfers. Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use the call bell for assistance. Praise all efforts at self-care. Physical Therapy and Occupational Therapy evaluation and treatment as per Medical Doctor orders. *Focus: [Resident #33] prefers to stay in bed and declines staff request to transfer out of bed and into the wheelchair. [Resident #33] has a history of refusing care, wound care, declining showers and/or bed baths, refuses nail care, declining to reposition and declining to be weighed. Goal: The resident will cooperate with care through the next review date. Interventions: Allow the resident to make decisions about treatment regimen, to provide sense of control. Arrange for psych evaluation if resident continues to decline care on a consistent basis, and the root cause of resident's decline for assistance cannot be determined. Educate resident/resident's representative/caregivers of possible outcome(s) of not complying with treatment care. Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all activities prior to and as they occur during each contact. If resident does not cooperate with ADL's (activities of daily living), reassure the resident, leave, and return later and try again. Notify physician as needed of frequent denials to assist with care. Praise the resident when behavior is appropriate. Provide consistency and care to promote comfort with ADLs. Maintain consistency and timing of ADLs, caregivers, and routine, as much as possible. Provide the resident with opportunities for choice during care provision. Resident #33's care plan was silent of a focus, goal or interventions related to the lack of range of motion for the resident's hands. 3. Review of Resident #78's Minimum Data Set (MDS) assessments showed the resident returned to the facility on 9/27/2023, had an unplanned transfer to the hospital on 9/30/2023, and was readmitted to the facility a 3rd time on 10/10/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 9 of 29 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 10/19/2023 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 Review of Resident #78's Nursing Progress notes dated 9/30/2023 at 5:45 AM (just prior to the most recent hospitalization) showed, Resident #78 called a family member and stated I am giving up. Review of the admission Record showed new diagnoses in October of 2023 to include major depressive disorder and anxiety. Residents Affected - Few On 10/16/2023 at 9:53 AM, Resident #78 was observed in bed under the blankets with the lights off. Resident #78 stated I just don't want to get up. On 10/17/2023 at 3:30 PM, Resident #78 was observed in bed under the blankets with the lights off, and on 10/18/2023 at 11:36 AM, Resident #78 was observed a third time in the same state. During the 10/18/2023 observation, Resident #78 stated I went to therapy today. Outside of that, I am going to stay in bed with the lights off. I don't feel like doing anything. Interview on 10/18/2023 at 11:40 AM with Staff E, Certified Nursing Assistant (CNA) revealed Resident #78's only goes to therapy and then lays in the bed with the lights off. Interview on 10/18/2023 at 12:52 PM with Staff G, Licensed Practical Nurse (LPN) revealed it was the resident's choice to stay in bed. Staff G reported Resident #78 was not like this on her prior admissions. Review of Resident #78's physician orders revealed the resident was receiving: Mirtazapine oral tablet 15 mg - give one tablet at bedtime for depression with appetite loss (order and start date 10/10/2023) Paroxetine HCI oral tablet 20 mg - give 1 capsule one time a day for depression related to major depressive disorder, single episode, unspecified (order date 10/4/2023, start date 10/5/2023) Alprazolam oral tablet 0.5 mg - give 1 tablet every 8 hours as needed 3 times daily for anxiety disorder, unspecified for 14 days (order and start date 10/12/2023) Review of Resident #78's care plan revealed no plan of care was developed related to the changes in the resident's mood, behavior and new medications for depression and anxiety. On 10/18/2023 at 3:05 PM, the Social Services Director (SSD) reported Resident #78 should have been care planned for depression, especially since the resident doesn't come out of her room. On 10/18/2023 at 3:15 PM, the Director of Nursing (DON) stated the expectation is medications for mood and behavior receive a care plan. Review of the policy and procedure titled, Care Plans, dated 8/2022, revealed: Intent: it is the policy of the facility to create care plans in accordance with state and federal regulations. Definition: Resident care plan means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident, the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being, a listing of services provided within or outside the facility to meet those needs, and an explanation of service goals. Procedure: 1. Each resident admitted to the nursing home facility shall have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 10 of 29 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 10/19/2023 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a plan of care. 2. The plan of care must consist of: a. Physician's orders, diagnosis, medical history, physical exam, and rehabilitative or restorative potential. 3. A preliminary nursing evaluation with physician's orders for immediate care, completed upon admission. 4. A complete, comprehensive, accurate, and reproducible assessment of each resident's functional capacity which is standardized in the facility and is completed within 14 days of the resident's admission to the facility, and every 12 months thereafter. 5. The assessment must be: a. Reviewed no less than once every three months, b. Reviewed promptly after a significant change, which is in need to stop a form of treatment because of adverse consequences (e. g., an adverse drug reaction), or commence a new form of treatment to deal with a problem in the resident's physical or mental condition; and c. Revised as appropriate to assure the continued accuracy of the assessment. 6. The facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. 7. The care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. 8. The care plan will be completed within seven days after completion of the resident's assessment. 9. At the resident's option, every effort must be made to include the resident and family or responsible party, including private duty nurse or nursing assistant, in the development, implementation, maintenance, and evaluation of the resident's plan of care. 10. All staff personnel who provide care, and at the resident's option, private duty nurses or personnel who are not employees of the facility, will be knowledgeable of, and have access to, the resident's plan of care. 11. A summary of the residence plan of care and a copy of any advanced directives must accompany each resident discharge or transferred to another healthcare facility, licensed under chapter 395 or 400, F. S., or must be forwarded to the receiving facility as soon as possible consistent with good medical practice. Event ID: Facility ID: 105275 If continuation sheet Page 11 of 29 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 10/19/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observations, interviews, and record reviews the facility failed to ensure one resident (#33) of two sampled residents received treatment and services to prevent further decrease in range of motion. Residents Affected - Few Findings included: A review of the admission Record for Resident #33 showed an admission date of 12/20/2019 with diagnoses of cerebrovascular disease (stroke), peripheral vascular disease, muscle weakness and other co-morbidities. A review of Resident #33's Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 8/14/2023, revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. Resident #33 was observed in bed, covered with a sheet and arms above the sheet. Resident #33's right and left hands were folded at the metacarpophalangeal joints (MCPaka knuckles). During an interview on 10/17/2023 at 2:30 p.m. Resident #33 stated my hands have been like this for a while. The facility has not been working with me on moving them. Resident #33 continued to state; I can open my hands. At this time Resident #33 was able to bilaterally move his fingers from the MCP joints only, however, his middle to pinkie finger remained bent. Resident #33's second finger (pointer) and thumb moved up and down to touch each other and both hands were observed moving in this manner. During an interview on 10/18/2023 at 4:49 p.m. with Staff B, Certified Nursing Assistant (CNA) stated Resident #33's hands have been like that for a while now. Staff B, CNA stated I clean underneath the fingers and the palm the best I can as they are hard to move. I do not complete range of motion (ROM) with him. Resident #33 does not refuse care for me. During an interview on 10/18/2023 at 12:49 p.m. Staff G, Licensed Practical Nurse (LPN) stated Resident #33's right and left hands are contracted. I clean Resident #33's hands and clip the nails as this is hard for the CNA to complete due to the rigidity in the fingers. Resident #33 is very sweet and compliant with care for me. A review of Resident #33's physician order, dated 4/25/2023, revealed: May have restorative/maintenance programs as indicated. During an interview on 10/17/2023 at 2:36 p.m. the Regional Director of Rehabilitation (RDOR) stated he has been functioning as the Director of Rehabilitation at the facility. The RDOR stated therapy routinely screens residents on a quarterly basis, based on the MDS calendar. The RDOR was not able to provide a screening form completed on Resident #33, whose MDS was completed on 8/14/2023. The RDOR stated, I have not received a calendar for a while now. The RDOR stated I am unsure when Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 12 of 29 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 10/19/2023 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 0688 #33 was screened last, we don't have any documentation prior to July 1, 2023. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 10/17/2023 at 2:41 p.m. with the Registered Nurse (RN) MDS Coordinator and the Regional MDS Director. The RN MDS Coordinator stated the Inter Disciplinary Team is made aware of when the MDS for the residents are due by utilizing the computer software we have. The RN MDS Coordinator stated, I don't know why the screen would not have been completed. Residents Affected - Few An interview on 10/18/23 at 12:59 p.m. was conducted with the Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The DON stated Resident #33 is not compliant with care and maybe this is the reason no screening was performed. During an interview on 10/19/2023 at 1:20 p.m. the RN MDS Coordinator stated she was responsible for completing the section of the MDS that would indicate the resident's functional status. The RN MDS Coordinator verified Resident #33's functional status did not have any impairments noted. The RN MDS Coordinator stated there was no documentation of impairment in range of motion. Review of Resident #33's care plan with the last care plan review completed 8/29/2023 showed: *Focus: Resident #33 has an Activity of Daily Living self-care deficit related to muscle weakness, decreased mobility, obsessive compulsive disorder, depression, bipolar, cerebral vascular disease, adult failure to thrive. Resident #33 prefers to stay in bed and declines staff request to transfer out of bed and into the wheelchair. Resident #33 has a history of refusing care, declining showers, and declining to be weighed. Interventions included: Bathing/Showering: check nail length and trim and clean on bath day as necessary, report any changes to the nurse. Physical Therapy and Occupational Therapy evaluation and treatment as per Medical Doctor orders. *Focus: . Resident #33 has a history of refusing care, wound care, declining showers and/or bed baths, refuses nail care, declining to reposition and declining to be weighed. Goal: The resident will cooperate with care through the next review date. Interventions included: Allow the resident to make decisions about treatment regimen, to provide sense of control. Resident #33's care plan was silent of a focus, a goal or interventions related to the lack of range of motion for the resident's hands. Review of the facilities policy titled, Mobility/Range of Motion, dated April 2022, showed: it is the policy of the facility to ensure that the residents receive range of motion, in accordance with state and federal regulations. Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: a. that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and b. a resident with limited range of motion receives appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. c. a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 2. The facility will ensure that the resident reaches and maintains his or her highest level of range of motion and to prevent avoidable decline of range of motion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 13 of 29 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 10/19/2023 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 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 observations, record reviews, and interviews the facility failed to ensure respiratory equipment was changed and maintained in a sanitary manner for one resident (#60) out of one resident sampled for receiving respiratory therapy. Residents Affected - Few Findings included: On 10/16/23 at 10:01 a.m. Resident #60 was observed wearing a nasal cannula which was attached to an oxygen concentrator. The concentrator showed the resident was receiving 3 liters per minute (lpm) of oxygen. An additional observation of the nebulizer machine on the table next to the resident's bed revealed tubing attached to the machine with an aerosol mask. The tubing was dated 10/01/23. The mask was lying directly on the table and not in a storage bag or standing in the slot provided on the machine. On 10/17/23 at 10:39 a.m. Resident #60 was observed sitting in a wheelchair next to the bed wearing a nasal cannula, and the nebulizer mask was sitting on the round table in front of the resident. On 10/19/23 at 8:42 a.m. Resident #60 was observed lying in bed with the aerosol mask standing up on the nebulizer machine. Review of Resident #60's admission Record showed the resident was admitted on [DATE] and diagnoses included heart failure, unspecified anxiety disorder, and unspecified dyspnea. An interview was conducted with Staff I, Certified Nursing Assistant (CNA) on 10/19/23 at 3:50 p.m. Staff I confirmed the tubing attached to the nebulizer and the tubing attached to the oxygen concentrator was dated 10/01/23. (Photographic Evidence Obtained) A review of Resident #60's physician orders included an order, dated 9/19/23, for Oxygen as needed PRN (as needed) for Shortness of Breath (SOB). The order did not identify the amount of oxygen to be delivered per minute. This order was discontinued on 10/19/23 at 6:02 p.m. An order, dated 10/19/23 at 6:15 pm, revealed the resident was to receive oxygen at 2 lpm as needed for Shortness of Breath. Review of the Resident #60's October 2023 Medication and Treatment Administration Records (MAR/TAR) did not reveal an order to change oxygen and nebulizer tubing. A further review of the resident's October MAR revealed the resident did not have an active nebulizer medication order. The order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligram (mg)/3 milliliter (mL) was discontinued on 10/1/23. During an interview on 10/19/23 at 6:03 p.m. the Director of Nursing (DON) stated oxygen orders should identify the liters per minute (lpm) to be delivered and the oxygen/nebulizer tubing should be changed weekly and listed on the MAR/TAR. The facility provided the policy titled, Physical Environment - Space and Environment, undated. A review of the policy revealed, It is the policy of the facility to provide areas large enough to comfortably accommodate the needs of the residents who usually occupy this space and equipment maintained in safe and working order, in accordance to state and federal regulations. The procedure portion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 14 of 29 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 10/19/2023 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 0695 of the policy showed: Level of Harm - Minimal harm or potential for actual harm - 3. The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition. Residents Affected - Few - 4. Equipment will be maintained according to manufacturer's recommendations. In review the Cleveland Clinic, located at https://my.clevelandclinic.org/health/treatments/25187-nasal-cannula, identified if using oxygen therapy at home people should take care of the equipment and the nasal cannula be changed at least once a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 15 of 29 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 10/19/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide psychological and behavioral health care services to maintain the highest practicable mental and psychosocial well-being for one resident (#60) out of three residents sampled for emotional and mood behaviors. Findings included: An observation and interview was conducted on 10/16/23 at 9:55 a.m., with Resident #60. The resident was very hard of hearing and stated, This is no way to live, and for the last couple of weeks felt if only he had a Couple white pills. The resident stated, Should talk to a mental health specialist. The resident did report he informed others of suicidal thoughts. On 10/16/23 at 10:14 a.m. an interview was conducted with Resident #60's assigned nurse, Staff J, Licensed Practical Nurse (LPN). Staff J stated the resident had not previously voiced the suicidal thoughts. Staff J stated the psychiatric provider was in the facility and would be notified. On 10/16/23 at 10:33 a.m. Staff J, LPN stated the facility notified Resident #60's Hospice provider and the resident had voiced the same to the Hospice nurse. A Hospice Social Worker (HSW) consult had been made for the resident. The Social Service Director (SSD) stated the resident thought it was a joke to report (regarding the white pills). On 10/19/23 at 2:36 p.m. an interview was conducted with a psychiatric provider, Staff K, Psychiatric Nurse Practitioner (NP). Staff K reported not being aware of the suicidal thoughts made by Resident #60 on 10/16 and was in the facility on Monday (10/16) and yesterday (10/18). Staff K stated another NP visited the facility also and wondered if Perhaps [Resident #60] would benefit speaking with a therapist that was going to visit the facility on Saturday (10/21). Review of Resident #60's admission Record revealed the resident was admitted on [DATE] with the payer source of Hospice Medicaid Pending. The admission Record included diagnoses not limited to unspecified heart failure, unspecified anxiety disorder, unspecified dyspnea, and restlessness and agitation. Review of Resident #60's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of Resident #60's Assessments, conducted on 10/19/23 at 4:12 p.m. did not reveal a psychosocial assessment had been conducted on 10/16, 10/17, 10/18, or 10/19/23 by the facility's Social Service Department. Review of Resident #60's progress notes revealed Staff J, LPN had not noted the resident made suicidal comments to several people, had not contacted the resident's emergency contact, had not notified the facility's Psychiatric provider, and had not notified the Attending Physician. The review of Resident #60's progress notes did not reveal Staff J had completed a Daily Skilled Note on 10/16/23, which would include whether behaviors were present or not. Review of Resident #60's Medication Administration Record (MAR) for October 2023 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 16 of 29 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 10/19/2023 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 0740 following: Level of Harm - Minimal harm or potential for actual harm -A physician order, started on 9/19/23, instructing staff to complete a Daily Skilled Note every shift. Residents Affected - Few -On 9/21/23 the resident had previously been ordered Lorazepam 1 mg as needed, which ended on 10/5/23. -Staff J had completed a Daily Skilled Note on 10/16/23. -On 10/18/23 the resident was ordered Celexa 20 milligram (mg) daily for depression. -On 10/19/23 the resident was ordered Lorazepam 1 mg every 2 hours as needed for anxiety. -The monitoring of Resident #60's behaviors started on 10/19/23. Review of the progress notes, on 10/19/23 at 2:49 p.m., did not show the SSD spoke with Resident #60 on 10/16/23 after voicing suicidal thoughts or a psychosocial assessment had been completed. During an interview on 10/19/23 at 3:18 p.m. the SSD reported being the Hospice Liaison for the facility. The SSD stated Hospice had been notified on 10/16/23 following the comments Resident #60 had voiced, the (Hospice) nurse Showed up right away and the Social Worker showed up About an hour later. The SSD reported speaking with the resident on 10/16/23 A little while after the Hospice SW spoke with the resident. The SSD confirmed not putting a note in the resident's record Must've been busy that day, I can put a late one in. The SSD stated the expectation would be to have written a note even when the Hospice nurse said it was one of (Resident #60's) jokes and didn't mean it. The SSD stated the Hospice nurse informed the resident not to say things like that. The SSD reported not knowing if Staff K, Psychiatry NP, had been notified. A late entry note, created on 10/19/23 at 3:46 p.m. and effective 10/16/23 at 11:35 a.m., from the facility's Social Service Director, revealed they were notified of a statement made by Resident #60 in Regards to if there were 3 white pills being on [Resident 60's] floor and [Resident 60] would take them all to see which one takes effect first. [Hospice] was notified and both hospice nurse and social worker were at facility to speak with resident and to educate [Resident 60]. Resident agreed with hospice to not make inappropriate jokes. An interview was conducted on 10/19/23 at 3:52 p.m. with the Hospice Registered Nurse (RN) assigned to Resident #60. The Hospice RN reported visiting the resident on 10/16/23 and the Hospice Social Worker had completed their assessment on that day. The RN stated Resident #60 had not voiced anything like that (suicidal ideation) before. During an interview on 10/19/23 at 6:03 p.m., the Director of Nursing (DON) stated the Hospice nurse alerted her to Resident #60's comments on 10/16/23 and he had a Dark sense of humor. The DON stated the expectation was the facility staff (nursing and Social Services) would write a note, the facility should have notified psychiatry and the (Attending) physician. The DON said the Hospice nurse informed her that she was going to notify psychiatry. A review of the facility policy titled, Behavioral Health Services - Treatment/Services for Mental/Psychosocial Concerns, undated, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 17 of 29 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 10/19/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few It is the policy of the facility to provide Behavioral Health Services in accordance with State and Federal regulations. The procedure revealed the following: - The facility will ensure that, a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; - If from a rehabilitative service such as but not limited to physical therapy, speech-language pathology, occupational therapy, and rehabilitative services for mental disorders and intellectual disability, are required in the resident's comprehensive plan of care the facility will: a. Provide the required services included specialized rehabilitation services; or b. Obtain the required services from an outside resource or from a Medicare and or Medicaid provider of specialized rehabilitative services. - The facility will provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. A review of the facility policy titled, Administration - Social Services, undated, revealed, It is the policy of the facility to provide care and services related to social services, according state and federal regulations. The procedures revealed: - The facility will provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. - Medically related social services means services provided by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. These services might include: b. Maintaining contact with facility (with resident's permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning. c. Assisting staff to inform residents and those they designate about the resident's health status and health care choices and their ramifications; g. Providing or arranging provision of needed counseling services; h. Through the assessment and care planning process, identifying and seeking ways to support residents' individual needs; m. Meeting the needs of residents who are grieving. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 18 of 29 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 10/19/2023 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 0740 (Photographic Evidence Obtained) 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 19 of 29 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 (X3) DATE SURVEY COMPLETED A. Building 10/19/2023 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, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-four medication administration opportunities were observed and three errors were identified for three residents (#240, #33, #64) of seven residents observed. These errors constituted a 8.82% medication error rate. Residents Affected - Few Findings included: 1. On 10/16/23 at 5:06 p.m. an observation of medication administration with Staff L, Licensed Practical Nurse (LPN) was conducted with Resident #240. The staff member dispensed the following medications: - Symbicort 160/4.5 microgram (mcg) inhaler - Oxycodone/Acetaminophen 5/325 milligram (mg) tablet The staff member confirmed one tablet and one inhaler had been dispensed. A review of Resident #240's October 2023 Medication Administration Record (MAR) revealed the resident was scheduled to receive Oxycodone/Acetaminophen at 4:00 p.m. 2. On 10/17/23 at 8:54 a.m. an observation of medication administration with Staff M, Registered Nurse (RN) was conducted with Resident #64. The staff member dispensed the following medications: - Lexapro 10 milligram (mg) tablet - Hydrocodone/Acetaminophen 5/325 mg tablet - Incruse Ellipta 62.5 mcg inhaler - ORDER FOR 1 PUFF DAILY - Multivitamin over-the-counter (otc) tablet - Prostat Liquid Protein 30 milliliter (mL) - Senna S 8.6-50 mg - 2 tablets - Symbicort 160/4.5 mcg inhaler The staff member confirmed dispensing five tablets, one liquid, and two inhalers. Staff M administered oral medications, the liquid protein, administered 2 puffs of the Incruse inhaler, educated the resident to rinse and spit, and administered one puff of Symbicort. A review of Resident #64's October 2023 MAR identified the physician ordered: Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 mcg - 1 puff inhale orally one time a day for Chronic Obstructive Pulmonary Disease (COPD), Rinse mouth and spit after each use. 3. On 10/18/23 at 8:19 a.m. an observation of medication administration with Staff G, LPN was conducted with Resident #33. The staff member dispensed and administered the following medications: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 20 of 29 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 10/19/2023 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 - Multivitamin otc tablet Level of Harm - Minimal harm or potential for actual harm - Vitamin C 250 mg otc tablet - Zinc 50 mg otc tablet Residents Affected - Few A review of the October 2023 MAR identified the resident was to be administered one tablet of the Multivitamin with Minerals daily for wound healing. During an interview on 10/19/23 at 5:41 p.m. the Director of Nursing (DON) stated the expectation was for nurses to follow physician orders when administering medications and the medications were to be administered within the time frame of one hour before and one hour after of the scheduled time. A review of the policy titled, Administration of Drugs, dated April 2022, showed: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. The Interpretation and Implementation included the following: - Drugs must be administered in accordance with the written orders of the attending physician. - Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 21 of 29 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 10/19/2023 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 - Some 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 observations, interviews, and record review, the facility failed to ensure 1) medications on one medication cart (A-wing cart) were secured while unattended, 2) insulin pens and vials were dated in one medication cart (B-wing cart), 3) bottles of ophthalmic solutions were dated and internal/external medications were not stored in the same compartments on one medication cart (C-wing cart) of four medication carts observed. Findings included: An observation was made on 10/18/23 at 8:19 a.m. of medication administration with Staff G, Licensed Practical Nurse (LPN) for Resident #33. The nurse dispensed one Multivitamin over the counter (otc) tablet, one Vitamin C otc tablet, and one Zinc otc tablet from separate bottles. The staff member left the three otc medication bottles sitting on the unlocked and unattended medication cart (A-wing cart) as the medications were administered in the resident's room. The medication cart was parked in the hallway and to the side of the doorway to the resident's room. An observation was conducted with Staff N, Registered Nurse (RN) on 10/18/23 at 11:42 a.m. of the B-wing medication cart. The observation revealed the following: - Lantus insulin pen. Storage bag dated 10/13/23, pen was not dated. A label attached to the pen allowed for the medication to be dated with an open date. -An opened undated Levemir insulin vial, storage bag dated as opened on 10/13 and another date of 10/2/23 was written on another label. -An opened undated Insulin Aspart vial, storage bag dated as opened on 10/12/23. -An opened undated vial of Insulin Lispro. The storage bag was dated with both 10/1/23 and 10/13. -An opened undated bottle of Olopatadine 0.2% solution, storage bag dated 9/29/23. An observation was conducted with Staff O, LPN on 10/18/23 at 12:11 p.m. of the C-wing medication cart. The observation revealed the following: -An opened undated bottle of Latanoprost 0.005% ophthalmic drops. The storage bag was dated 9/20/23. -An opened undated bottle of Brimonidine 0.2% ophthalmic drops, neither the box nor the label attached to the bottle was dated. The storage bag was dated 10/16/23. -An opened undated bottle of Artificial Tears, the box was dated 7/23/23. -An opened undated bottle of Artificial Tears, the box was dated 3/19/23. -An opened undated bottle of Artificial Tears, the box was dated 4/26/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 22 of 29 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 10/19/2023 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 -A bottle of Saline Nasal spray, was stored with a box of rectal Bisacodyl suppositories, and multiple respiratory inhalers. -An opened, undated bottle of ProStat liquid protein. Staff O, LPN tipped the bottle over to identify the manufacturer's expiration date. The label of the bottle instructed to Discard 3 months after opening. Residents Affected - Some An interview on 10/18/23 at 1:48 p.m. was conducted with the Regional Director of [Pharmacy Name]. The Director stated dates of insulin could be on the package (storage bag) or the pen/vial as staff could not reuse the storage bag, and they should be using the (storage) bag that comes from the pharmacy. She stated the policy was the same for eye drops, dates did not need to be on the bottle itself, the Prostat needed to be discarded after three months, and the pharmacy recommended separating external and internal products. During an observation, on 10/19/23 at 5:45 p.m. the Director of Nursing (DON) stated open dates should be on the vials, bottles, and pens. The DON stated the expectation would be all medications were put away and carts locked before leaving them unattended, external, and internal medications should be stored separately. A review of the he facility policy titled, Storage of Medications, dated April 2022, revealed the following: Drugs and biologicals should be stored in a safe, secure, and orderly manner. The Interpretation and Implementation identified the following: -1. Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are returned to the pharmacy for proper labeling before storing. -3. No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this Center. All such drugs are destroyed. -6. Compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) -7. Drugs are stored in an orderly manner in cabinets, drawers, or carts. These compartments are sufficient size to prevent crowding. Each resident is assigned a cubicle or drawer to prevent the possibility of a drug from one resident being given to another resident. According to Cleveland Clinic, (located at https://my.clevelandclinic.org/health/drugs/18710-artificial-tears-eye-solution) Most experts recommend discarding the product (Artificial Tears eye solution) after 30 days. According to Mayo Clinic, (located at https://www.mayoclinic.org/drugs-supplements/latanoprost-ophthalmic-route/proper-use/drg-20064474) identified an opened bottle of Latanoprost (Xalatan) can be stored in the refrigerator or at room temperature for 6 weeks. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 23 of 29 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 10/19/2023 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. During an observation of medication administration on 10/18/23 at 8:21 a.m. with Staff G, LPN the following medications were dispensed for Resident #37: Residents Affected - Some -Buspirone 10 milligram (mg) tablet -Folic Acid 1 mg tablet -Diltiazem 120 mg tablet -Montelukast 10 mg tablet -Spirolactone 50 mg tablet -Xifaxan 550 mg tablet -Potassium 20 milliequivalents (meq) Extended Release (ER) tablet -Omeprazole 20 mg over the counter (otc) tablet -Iron 325 mg otc tablet -Magnesium oxide 400 mg tablet otc. Staff G, LPN placed the tablets in a medication cup while dispensing and when asked to confirm there were 10 tablets, Staff G poured the tablets out of the cup and onto an 8x11 piece of paper lying on the medication cup. Staff G put the tablets back into the cup with bare hands including a couple that had rolled off the paper and onto the top of the medication cart. Staff G confirmed 10 tablets and turned toward the doorway of Resident #37's room. Based on observation, interview, and record review, the facility failed to maintain and implement an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to prevent the development and transmission of communicable diseases and infections as evidenced by: 1. five staff members (P, Q, N, T, U) not donning and doffing personal protective equipment (PPE) when entering and exiting resident rooms on contact isolation; 2. one staff member (G) not following infection control guidelines during medication administration; 3. a mechanical lift used for multiple residents not being cleaned and disinfected after each use; and 4. one staff member (U) not effectively cleaning and disinfecting environmental surfaces and tools used for cleaning to mitigate the transmission of communicable diseases for a sample of four resident rooms (B-wing rooms 3, and 5 and A-wing rooms 2, and 5) out of five resident rooms designated as transmission-based precautions. Findings included: 1. On 10/16/23 at 1:22 p.m. Staff P, Physical Therapist (PT) and Staff Q, Certified Occupational Therapist Assistant (COTA) were observed entering room [ROOM NUMBER] on the B Wing. A Contact Precautions sign was observed hanging beside the door that read, STOP EVERYONE MUST: clean their hands, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 24 of 29 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 10/19/2023 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 Level of Harm - Minimal harm or potential for actual harm including before entering the room and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. (Photographic Evidence Obtained) Staff P, PT and Staff Q, COTA were observed walking into the room without donning a gown or gloves and then assisted a resident in this room out of bed and down the hall to the therapy department. Residents Affected - Some During an interview on 10/16/23 at 1:46 p.m. Staff P, PT confirmed room [ROOM NUMBER] B Wing was on contact precautions due to a foot infection. Staff P, PT confirmed she did not don a gown prior to entering room [ROOM NUMBER] B Wing and she assisted the resident to the therapy department. Staff P, PT stated the therapy department had permission from the nurse to assist this resident to the therapy department. Staff P, PT reviewed the Contact Precautions sign located on the wall next to room [ROOM NUMBER] B Wing and stated, in the other facility I work for we follow what all the signs say. During an interview on 10/16/23 at 1:54 p.m. Staff Q, COTA stated I was aware room [ROOM NUMBER] B Wing was on Contact Precautions. Staff Q, COTA stated a couple of weeks ago Staff S, Licensed Practical Nurse (LPN)/Unit Manager (UM) gave permission for therapy to enter room [ROOM NUMBER] B Wing and assist this resident down to the gym for therapy. Staff Q, COTA stated the resident's wound was covered so the therapy department only used gloves. Staff Q, COTA reviewed the Contact Precautions sign and stated, We use gloves depending on the patient. During an interview on 10/16/23 at 2:05 p.m. Staff S, LPN/UM stated when a room was under Contact Precautions all staff needed to don a gown and gloves before entering the room and doff prior to exiting the designated contact precaution room. On 10/18/23 at 1:04 p.m., Staff N, Registered Nurse (RN) was observed entering room [ROOM NUMBER] B Wing, that still had the Contact Precautions sign, with gloves only. Staff N, RN was touching and investigating the resident's Intravenous Therapy (IV) pump and tubing that was beeping. During an interview on 10/18/23 at 1:10 p.m. Staff N, RN stated, I did not put on a gown because I did not provide direct care. Staff N, RN stated he only checked on the IV that was beeping. Staff N stated when a room was under Enhanced Precautions You wear a gown and gloves no matter what. Staff N, RN stated when a room was under Contact Precautions; You wear gloves, but gown and gloves when doing patient care. Review of the facility policy titled, Contact Precautions sign, revealed the following: STOP CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Used dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Review of the facility policy titled, Enhanced Precautions sign, revealed the following: STOP ENHANCED PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 25 of 29 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 10/19/2023 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 Transferring Level of Harm - Minimal harm or potential for actual harm Changing Linens Providing Hygiene Residents Affected - Some Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheotomy. Wound Care: any skin opening requiring dressing. During an interview on 10/19/23 at 6:29 p.m. the Infection Preventionist (IP) stated she was just hired last week and was still learning the job from Staff S, LPN/Unit Manager and the previous IP. During an interview on 10/19/23 at 6:29 p.m. Staff S, LPN/UM and the previous IP stated the facility was currently looking for Contact Precautions signs that fit the facility's policy. Staff S, LPN/UM stated the Contact Precautions signs the facility had now were from the Centers for Disease Control and Prevention (CDC) and stated, We are trying to find signs that match our policy. Staff S, LPN/UM stated for Contact Precaution rooms, You definitely need gloves if you're just going into the room and if you're not going to be in contact with anything else. Staff S, LPN/UM stated the nurse should wear gowns and gloves when the nurse was providing care and when providing care to residents with Intravenous Therapy (IV). Staff S, LPN/UM stated, Housekeeping needs to gown up as well. Staff S, LPN/UM stated residents under Contact Precautions should not come out of their rooms unless a surgical wound has been resolved. Staff S, LPN/UM stated, If it is something that is a wound that has a lot of excoriate and someone can come in contact with that they are encouraged to stay in their rooms. An interview was conducted with the Director of Nursing (DON) on 10/19/2023 at 6:34 p.m. The DON stated she has been in contact with the local Department of Health (DOH) infection specialist regarding Candida Auris (C-Auris). The DON stated the facility has implemented isolation precautions based on the DOH and Center for Disease Control (CDC) recommendations. The DON stated the residents who are currently on Enhanced Barrier Precautions do not have active infections. The residents are all colonized. If the resident has a change and has signs and symptoms of an active infection, their isolation would be increased to Contact Precautions. The DON reported she decided the placement of new resident admissions. She stated they try to cohort residents with colonized C-Auris together. She stated Enhanced Precautions require gown and gloves only when you are giving direct care. She stated Contact Isolation requires a gown and gloves when entering the room. 3. On 10/17/2023 at 10:40 a.m., Staff H, Certified Nursing Assistant (CNA) was observed in room [ROOM NUMBER] on B wing, with a resident care lift. Staff H, CNA was observed exiting the room with a resident care lift covered in a clear bag and in her other hand, a clear bag with soiled linen enclosed. Staff H, CNA placed the resident care lift against the handrail and proceeded to discard the linen bag in the appropriate location. An interview was conducted with Staff H, CNA on 10/17/2023 at 10:46 a.m. Staff H, CNA stated they are instructed to bag the resident care lift after each use. This indicates the lift is clean and ready for the next use. We don't wipe the lift down after each use, just bag it. We only wipe the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 26 of 29 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 10/19/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some patient lift down with alcohol wipes after utilizing the lift with a resident who is in isolation. Staff H, CNA stated when entering a contact isolation room, you only need to wear gloves. You only need to don a gown if you are going to be providing care. Enhanced isolation means you don gown and gloves when entering the room. During an interview on 10/17/2023 at 4:30 p.m. Staff H, CNA confirmed alcohol wipes are not kept in resident rooms and the patient lift was not wiped down upon exiting room [ROOM NUMBER] on B wing earlier in the day as this was not the process. On 10/18/2023 at 9:53 a.m. Staff T, Plant Ops (PO) was observed approaching the door of room [ROOM NUMBER] on B wing. An isolation cart was observed beside the door and a Contact Isolation sign was posted in the middle of the door instructing staff to don gown and gloves prior to entering the room. Staff T, PO knocked on the door and entered the room. No personal protective equipment (PPE) was donned. Staff T, PO proceeded to work on the closet door. At 9:56 a.m. Staff T, PO exited the room and completed hand hygiene with an alcohol-based hand sanitizer (ABHS). At 10:00 a.m. Staff T, PO entered room [ROOM NUMBER] on B wing, donned gloves, proceeded to the bathroom, completed a task, doffed gloves, exited the bathroom, and proceeded to exit to the hallway. Staff T, PO completed hand hygiene with ABHS after exiting the room. An interview was conducted with Staff T, PO on 10/18/2023 at 10:05 a.m. Staff T, PO stated when entering isolation rooms you only need PPE when going near the resident bed. On 10/18/2023 at 10:20 a.m., Staff U, Housekeeping Aide (HA) was observed in room [ROOM NUMBER] on A Wing, with gown and gloves. room [ROOM NUMBER] had 4 beds in the room. At the time of the survey, three residents resided in room [ROOM NUMBER] on A wing. All three residents were colonized for C-Auris. Staff U, HA was observed cleaning multiple residents' surfaces with the same rag. Staff U, HA changed the rag throughout the room, just not between residents' sections. On 10/18/2023 at 10:39 a.m., Staff U, (HA) was observed in room [ROOM NUMBER] on A wing and a Contact Isolation sign was observed in the middle of door, and an isolation cart sitting next to the door. Staff U, HA donned a gown and gloves. At 10:44 a.m. Staff U, HA was observed exiting room [ROOM NUMBER] on A Wing. Staff U, HA placed the used mop, with the microfiber cloth still attached directly on the cleaning cart between the center console and the clean microfiber mop head bucket. Staff U, HA exited the room, in full PPE (gown and gloves). Staff U, HA proceeded to walk around the cleaning cart. Doffed the gown, draped it on the side of the cleaning cart, the trash receptacle was on. Doffed the gloves, and disposed of them in the trash receptacle, on the cleaning cart. A resident approached Staff U, HA and they hugged. Staff U, HA proceeded to complete hand hygiene with ABHS. An interview was conducted with Staff U, HA on 10/18/2023 at 10:59 a.m. outside of the Speech Therapy (ST) room. The ST room was at the end of B hall. room [ROOM NUMBER] on A wing was on another wing. The soiled mop had not been moved. Staff U, HA stated they treat all isolation rooms the same. They don/doff gown and gloves upon entering/exiting the rooms. Staff U stated they plan for the items they will need in the isolation room to minimize the trips to the cart. She stated they utilize individual rags and microfiber mops to clean and complete hand hygiene by utilizing ABHS. She stated they don't need to utilize soap and water unless their hands get soiled. They need to go to the bathroom or at the end of the day. Staff U, HA confirmed she did not utilize soap and water prior to exiting room [ROOM NUMBER] on A Wing, and the microfiber mop was left to rest on the cleaning cart until getting ready to enter the next room. She stated once she exits the isolation room, she does not touch the mop until she arrives at the next room and puts gloves on. She stated she then removes the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 27 of 29 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 10/19/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dirty microfiber mob head, and places the dirty one in a plastic bag. She then places the mop in the microfiber mop head bucket for a new pad. Staff U, HA confirmed she utilized multiple rags to clean resident rooms but does not change rags in between resident beds (sections). An interview was conducted with Staff D, Environmental Supervisor (EVS) on 10/18/2023 at 11:25 a.m. Staff D, EVS confirmed responsibility of overseeing Housekeeping and Laundry Services. Staff D, EVS stated isolation rooms should have the microfiber mop head removed prior to doffing PPE and placing the used mop head in the bag for appropriate cleaning. He stated the staff should doff the PPE they have on and place the gown and gloves in the trash can inside the room door. He stated they have placed larger trash cans in all isolation rooms to ensure appropriate hygiene practice occurs. Staff D, EVS stated the resident rooms do not have sinks by the door, so the staff only utilize ABHS. Staff D, EVS confirmed Staff U, HA did not practice the correct process, listed above. Review of the facility policy titled, Isolation Precautions, Categories of, dated 2/23/23, revealed the following: Policy: Transmission-based isolation precautions will be used for residents who are documented or suspected to have infections or communicable diseases that can be transmitted by droplet transmission or by contact with dry skin or contaminated surfaces. Transmission-based isolation precautions are to be used in addition to standard precautions. Enhanced barrier precautions are to be used with multidrug-resistant organisms. Policy Interpretation and Implementation: 1. Transmission-based isolation precautions have been established in order to ensure the appropriate isolation techniques are implemented in this center when necessary. 2. Isolation should be the least restrictive possible for the resident under the circumstances. Contact Precautions: Gown/Gloves Enhanced Barrier Precautions: Gowns/Gloves-during high resident care activities Review of a policy titled, Candida Auris, dated September 2023, revealed the following: Policy: Fungal infections caused by candida auris (C-Auris) are resistant to commonly used antifungal medications and are difficult to treat. C-Auris is associated with a high mortality rate and has the potential to cause outbreaks in facilities. Facility will follow CDC guidelines to manage C-Auris: Currently CDC defines the following targeted organisms for use in Enhanced Barrier Precautions (EBP): C-Auris Facility will place the resident in either contact or enhanced barrier precautions for the duration of their stay . Residents with colonized infection will be placed on EBP . Having health care personnel change their PPE including gloves and performing hand hygiene before and after interaction with each patient. Alcohol based sanitizers are okay for use as C-Auris does not produce any spores . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 28 of 29 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 10/19/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some When patients are placed in shared rooms, facility must implement strategies to help minimize transmission between roommates. Clean and disinfect as if each bed area were a different room. For example: Clean and disinfect any shared or reusable equipment. Change mop heads, cleaning clothes, and other cleaning equipment between bed areas . Gowns and gloves must be worn when providing direct resident care/high contact care . Residents are permitted to leave their rooms for activities, dining, etc. EBP will remain in place for the duration of the admission for residents with colonization . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105275 If continuation sheet Page 29 of 29