Inspection·March 31, 2022

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents receive respiratory care services for oxygen consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care, Resident #67, in a total sample of 42 residents. Residents Affected - Few Findings: During an observation on 3/28/2022 at 10:24 AM Resident #67 was observed resting in bed with oxygen being administered at 4.5 liters via nasal cannula. During an observation on 3/30/22 at 7:38 AM Resident #67 was observed with oxygen being administered at 4.5 liters via nasal cannula. Review of the medical record for Resident #67 documented diagnosis to include chronic obstructive pulmonary disease, emphysema, heart failure, hypertension, dysphagia (difficulty swallowing), and coronary artery disease. Review of the physician orders dated 9/27/2021 read, Administer O2 [oxygen] at 2.5 liters via nasal cannula or mask. Patient may remove as desired. During an interview on 3/30/2022 at 7:35 AM Resident #67 stated, I can't move to change that machine. I am always on oxygen. During an interview on 3/30/22 at 7:40 AM Staff A, LPN (Licensed Practical Nurse) stated, It [the oxygen] should be at 2.5 liters maximum. We should verify that oxygen is at the correct setting when we do rounds. Review of the Policy and Procedure titled Oxygen Administration with a last approval date of 3/16/2022 read: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 2 of 7 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 105297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brooksville Healthcare Center 1114 Chatman Blvd Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy and procedure review, the facility failed to ensure foods in the refrigerator/freezer are covered, dated, labeled, and shelved to allow circulation, to ensure equipment is in good condition, to ensure facility has and follows a cleaning schedule for the kitchen and food service equipment, and has the appropriate supplies to evaluate the safe operation of equipment. Findings: During a tour of the kitchen on 3/28/21 beginning at 9:15 AM an observation of the refrigerator, freezer and stock-room was conducted with the Certified Dietary Manager (CDM). The walk-in cooler has multiple pans of food that were without a use-by date or label if they are new or left-overs, and the name of the food. There are two pull out drawers located under the cook top that are encrusted with a black buildup of particles and spills that covered the entire surface of the catch pan area. A stack of food trays with multiple areas of cracks, chips, and wiring showing on the edges located at the beginning of the tray line; staff were observed pulling trays from the stack and using them to serve the residents' meals. Dust and grease build up is observed under the stove hood vent and on the light covers. Test strips being used for testing the sanitation of dish machine were expired as of 9/2021. The freezer is overfilled with multiple boxes making it difficult to enter, the boxes have broken seals, are crushed by the weight of boxes stored on top, are falling to the sides, and have opened flaps exposing food items. The convection oven has a black/brown buildup of spills on the bottom, sides, and the door of the oven. The walk-in cooler showed a large bin with four 10# rolls of ground beef dated 3/25/22 that are not labeled with use by dates. There is a large container of food with no label or date with spills on the lid that partially covered the container. The dry storage area had boxes stacked close to the ceiling and sprinkler heads with less than an 18 inch separation. (Photographic evidence obtained). During an observation of the kitchen on 3/29/22 at approximately 9:00 AM an additional bin of eight 10# rolls of ground beef are observed in the walk-in cooler on the same shelf with no use by dates. Review of the current and upcoming week's menu did not note a ground beef entrée. During an interview on 3/28/22 at 9:37 AM the Certified Dietary Manager (CDM) stated there is no cleaning schedule available. The CDM confirmed that all foods in the freezer and/or cooler should be closed properly to ensure the safety and protection of the food items and a use by date should be on the items according to the policy. During a follow-up interview on 3/31/2022 at approximately 9:30 AM, the CDM confirmed that someone had used a roll of the new supply of fresh ground beef and did not use the ground beef that was dated 3/25/22 and that there is no menu item to use the fresh ground beef. Review of the policy and procedure provided by the Dietary Services titled Food Preparation and Service read Food served once may not be served again. Review of the Policy titled Food Receiving and Storage read: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 5. Food in designated dry storage areas (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 3 of 7 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 105297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brooksville Healthcare Center 1114 Chatman Blvd Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm shall be kept off the floor (at least 18 inches clear of sprinkler heads, sewage/waste disposal pipes and vents). 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use by date. 9. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerator/walk-ins will not be overcrowded. 10. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 4 of 7 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 105297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brooksville Healthcare Center 1114 Chatman Blvd Brooksville, FL 34601 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain the dumpster area in a sanitary condition to prevent the harborage and feeding of pests. Residents Affected - Few Findings: An observation of the dumpster area was conducted on 03/28/22 at 12:06 PM. The dumpster lid on 1 dumpster was open. An observation of the dumpster area was conducted on 3/29/22 at 7:15 AM. The dumpster lid on 2 dumpsters were left open. An observation of the dumpster area was conducted on 3/30/22 at 11:45 AM. The dumpster on 2 dumpsters were left open. An interview was conducted with the CDM on 3/31/22 at 9:20 AM. The CDM confirmed that they are supposed to keep dumpster lids closed at all times. Review of the policy and procedure titled Food-related Garbage and Rubbish Disposal was conducted on 3/31/22. The policy read, Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 5 of 7 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 105297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brooksville Healthcare Center 1114 Chatman Blvd Brooksville, FL 34601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection by not performing hand hygiene during medication administration for 6 of 8 observations. Residents Affected - Some Findings: During an observation on 3/28/2022 at 9:55 AM Staff A, Licensed Practical Nurse (LPN) was observed at the medication cart, pouring medications for Resident #128. Staff A did not perform hand hygiene prior to pouring the medications. Staff A entered the resident's room, did not perform hand hygiene, administered the medications, exited the room, did not perform hand hygiene, and returned to the medication cart. At 10:02 AM Staff A, LPN did not perform hand hygiene, poured medications for Resident #106, entered the resident's room, did not perform hand hygiene, administered the medications, exited the room, did not perform hand hygiene, and returned to the medication cart to pour medications for another resident. At 10:06 AM Staff A, LPN did not perform hand hygiene, began pouring medications for Resident #73. During this process a resident approached the medication cart, Staff A, LPN donned gloves without performing hand hygiene, repositioned the residents indwelling urinary catheter tubing that was dragging on the floor, removed the gloves, did not perform hand hygiene, resumed pouring the medications for Resident #73, entered the resident's room, did not perform hand hygiene, administered the medications, exited the resident's room, did not perform hand hygiene, returned to the medication cart, and began pouring medications for another resident. During interview conducted on 3/28/2022 at 10:27 AM Staff A, LPN stated, I should use hand sanitizer before I put on gloves to help with the catheter. I did not wash my hands or use hand sanitizer after I adjusted the catheter tubing. I should have used hand sanitizer before I pour meds and after I leave the resident's rooms. During an observation on 3/29/2022 at 8:27 AM Staff B, LPN poured medications for Resident #12, entered the resident's room, did not perform hand hygiene, assisted the resident to reposition in bed, administered the medications, left the resident's room, did not perform hand hygiene, and returned to the medication cart. At 8:35 AM Staff B did not perform hand hygiene, began pouring medications for Resident #17, entered the resident's room, did not perform hand hygiene, and administered oral medications to the resident. Staff B, LPN did not perform hand hygiene, did not don gloves, and removed a 2x2 dressing and tape from the resident's right forearm. The dressing was covered with dried blood, and Staff B discarded the dressing in the trash bin. Staff B did not perform hand hygiene, administered the resident's Proair inhaler two puffs, exited the resident's room, did not perform hand hygiene, and returned to the medication cart. At 8:45 AM Staff B did not perform hand hygiene and began pouring medications for Resident #63. Staff B entered the resident's room, did not perform hand hygiene, administered the medications, exited the resident's room, did not perform hand hygiene, and returned to the medication cart to prepare additional medications for administration. During an interview on 3/29/2022 at 9:15 AM Staff B, LPN stated, I should not have entered residents' rooms without using hand sanitizer. I should have put gloves on before removing the dressing, it did have old blood on it, and I should have washed my hands before I administered her inhaler. Review of the policy and procedure titled, Handwashing/Hand Hygiene, revision date August 2019, last approval date of 3/16/2022 read: Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation: 2. All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 6 of 7 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 105297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brooksville Healthcare Center 1114 Chatman Blvd Brooksville, FL 34601 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 personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-anti-microbial) and water for the following situations: c. Before preparing and handling medications; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites) g. before handling clean or soiled dressings, gauze pads, etc., after handling used dressings, contaminated equipment; m. after removing gloves. Review of the policy and procedure titled, Administering Oral Medications revision date October 2010, last approval date of 3/16/2022 read: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the procedure: 1. Wash your hands. 23. Perform hand antisepsis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 7 of 7