Inspection·December 19, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few date of 3/20/2024 showed it read, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines . Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. B. A family that wishes to be informed would designate a member to receive calls. Based on record review and interview, the facility failed to ensure the resident representative was notified of the accident requiring physician intervention for 1 of 6 residents reviewed for enteral medication administration, Resident #86, and for 1 of 4 residents reviewed for falls, Resident #17. Findings include: 1) Review of Resident #86's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses including but not limited to dysphagia, moderate protein calorie malnutrition, iron deficiency anemia, and gastro-esophageal reflux disease. Review of Resident #86's progress note dated 11/26/2024 showed it read, Orientee, [the Orientee's first name], training with this nurse 11/26/2024. During first med pass, around 5 pm, resident's roommate's medications were pulled by this nurse and given to orientee to be given to roommate. CNA [Certified Nursing Assistant] stepped out of the room a bit after meds [medications] were given to orientee and stated that the cup of fluids that were with meds were on this resident's bed side table. This nurse confronted orientee about who she gave the medicine to and she stated she gave to this resident. I informed orientee that before meds were given I confirmed with her who to give medications to by name. Orientee stated she had A and B beds mixed up from names on wall. MD [Medical Doctor] was notified of incident. Resident was given eliquis, senna, and hipprex. Resident currently on eliquis and senna. I informed MD that resident did not choke or cough. MD stated to keep an eye on resident. No other orders given. Review of Resident #86's physician order dated 6/5/2024 showed it read, NPO [nothing by mouth] diet NPO texture. During an interview on 12/17/2024 at 11:19 AM, Staff F, Registered Nurse (RN), stated, I was passing medication with [Staff E, RN's name], and she gave me medication to give to [Resident #86's name]. [Staff E's name] told me it was for him. They were PO [oral] medications. I tried to confirm with her [Staff E] again. [Staff E's name] said yes it is for A Bed. I gave the medication to B Bed. [Resident #86's name] had no signs of watery eyes, sneezing or coughing. [Resident #86's name] was NPO. He was not supposed to get oral medication. I mixed the residents up. When we realized the medication error, [Staff E's name] was going to notify the provider. I do not know if the family was notified or anyone else in the facility because [Staff E's name] said she would do the notifications. During an interview on 12/18/2024 at 11:23 AM, the Assistant Director of Nursing (ADON) stated, Staff are supposed to notify the Risk Manager, DON, notify the family of any change in condition. During an interview on 12/18/2024 at 11:25 AM, the Director of Nursing (DON) stated, The staff are supposed to notify the supervisor, the Risk Manager, myself, Administrator, medical director and family. During an interview on 12/18/2024 at 11:31 AM, Staff H, RN, Risk Manager, stated, No staff notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 2 of 11 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 12/19/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete me. The staff are expected to call me if there is a major incident. A major incident are medication error, falls, major skin tears. I do not care what time of the day; they need to call me. They also have to notify the provider and the family. During an interview on 12/19/2024 at 9:02 AM, the Administrator stated, Staff should immediately report medication errors to the DON, ADON or myself. They should notify MD and family. Event ID: Facility ID: 105297 If continuation sheet Page 3 of 11 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 12/19/2024 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 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** Based on record review and interview, the facility failed to ensure resident assessments were accurate for 1 of 3 residents reviewed, Resident #65. Residents Affected - Few Findings include: Review of Resident #65's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, type 2 diabetes mellitus, chronic obstructive pulmonary disease, dementia, heart failure, major depressive disorder, and generalized anxiety disorder. Review of Resident #65's physician order dated 12/9/2023 showed it read, May admit under [local hospice name and contact number] Hospice as of 12/9/2023 for services. Review of Resident #65's annual Minimum Data Set (MDS) dated [DATE] showed hospice care was not indicated under Section O- Special Treatments, Procedures and Programs. During an interview on 12/18/2024 at 12:45 PM, the MDS Coordinator stated, [Resident #65's name] is on hospice and it should have been marked yes. It has been coded wrong. Review of the facility policy and procedure titled Conducting an Accurate Resident Assessment with the last review date of 3/20/2024 showed it read, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Definition: Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 4 of 11 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 12/19/2024 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 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 record review and interview, the facility failed to develop a comprehensive care plan for 1 of 6 residents reviewed for medication administration, Resident #20. Findings include: Review of Resident #20's admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to chronic atrial fibrillation, essential hypertension, and cognitive communication deficit. Review of Resident #20's physician order dated 5/24/2024 showed it read, Pradaxa Oral Capsule 150 MG [milligram] (Dabigatran Etexilate Mesylate), Give 1 capsule by mouth two times a day for afib [Atrial Fibrillation]. Review of Resident #20's Medication Administration Record for December 2024 showed the resident received Pradaxa 150 mg twice a day at 9:00 AM and at 5:00 PM from 12/1/2024 through 12/17/2024. Review of Resident #20's care plan did not document a focus area or interventions for Atrial Fibrillation or anticoagulant medication. During an interview on 12/18/2024 on 11:40 AM, the MDS Coordinator stated, After reviewing [Resident #20's name] medications, she [Resident #20] should be care planned for atrial fibrillation and anticoagulants. Review of the facility policy and procedure titled Comprehensive Care Plan with the last review dated of 3/20/2024 showed it read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 5 of 11 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 12/19/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by physician for 1 of 6 residents reviewed for medication administration, Resident #13. Residents Affected - Few Findings include: Review of Resident #13's admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to heart failure, chronic kidney disease, and syncope and collapse. Review of Resident #13's physician order dated 2/28/2023 showed it read, Bisoprolol Fumarate Tablet 5 mg [milligram], Give 1 tablet by mouth one time a day for hypertension, Hold for HR<60 & notify MD [Heart Rate less than 60 and notify Medical Doctor]. Review of Resident #13's Medication Administration Record for December 2024 showed the resident received Bisoprolol Fumarate 5 mg on 12/3/2024 at 9:00 AM with a pulse of 59, 12/10/2024 at 9:00 AM with a pulse of 57, 12/11/2024 at 9:00 AM with a pulse of 59, and 12/16/2024 at 9:00 AM with a pulse of 56. During an interview on 12/18/2024 at 3:11 PM, the Advanced Practice Registered Nurse (APRN) #1 stated, We put parameters in place and hope that the staff will follow them. I would expect the nurse to hold the medication and not give it if it is out of parameters. Nurse can use vitals taken within the hour of when the medication is going to be given. During an interview on 12/18/2024 at 3:20 PM, the Director of Nursing stated, Staff is expected to follow physician orders and follow the parameters the provider has given. If a nurse is going to administer blood pressure medication, they should be taking the blood pressure and pulse right before administering the medication. If the pulse is close to the parameters, I would manually take the apical pulse to make sure the pulse is accurate. If it continues to be below the parameter, I would expect the nurse to hold the medication and notify the physician. 3) Review of Resident #13's physician order dated 2/28/2023 showed it read, Verapamil HCl ER [Extended Release] Oral Tablet Extended Release 180 MG (Verapamil HCl), Give 1 tablet by mouth one time a day for HTN [hypertension], Hold for BP [blood pressure] less than 105/60 or HR less than 55 & notify MD. During a medication pass observation on 12/17/2024 at 9:56 AM, Staff D, Licensed Practical Nurse (LPN), prepared medications for Resident #13 at the medication cart. The medications included one Bisoprolol 5 mg tablet and one Verapamil 180 mg tablet. The LPN prepared the medications in a medicine cup, entered Resident #13's room at 10:05 AM and administered the medications to the resident. During an interview on 12/17/2024 at 10:07 AM, Staff D, LPN, stated, I checked [Resident #13's name] vital signs [heart rate and blood pressure] shortly after 8 AM this morning. [Resident #13's name] blood pressure was 106 over 75 and the pulse was 65 at 8 AM. I don't know if I should have checked it closer to the time I gave her the medications. I figured it's not going to change that much over two hours. Review of the facility policy and procedure titled Medication Administration with the last review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 6 of 11 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 12/19/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few date of 3/20/2024 showed it read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 10. Ensure that the six rights of medication administration are followed: a. Right resident, b. right drug, c. Right dosage, d. right route. Review of the facility policy and procedure titled Medication Errors with the last review date of 3/20/2024 showed it read, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring resident receive care and services safely in an environment free of significant medication errors. Definitions: Medication error means the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order; manufacture's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services . Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders . c. In accordance with accepted standards and principles which apply to professionals providing services . 8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible . d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 7 of 11 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 12/19/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to appropriately label a medical nutrition supplement prior to administration according to professional standards of practice for 1 of 6 residents reviewed for tube feeding, Resident #3 (photographic evidence obtained). Findings include: During an observation on 12/17/2024 at 8:50 AM, Resident #3 was resting in bed quietly with her eyes open. There was a feeding pump on a pole to the left side of her bed. The feeding pump was turned off. There was a 1000 ml (milliliter) bag of liquid hanging on the pole that read, Peptamen 1.5 kcal [kilocalorie; a unit of energy that is equal to 1000 calories]/ml nutritionally complete formula. There was no information written under Patient Name, Patient ID, Date/Time Started, or Tube Feeding Order label of the bag or no additional label or writing on the front or back of the bag. Review of Resident #3's physician order dated 1/23/2023 read, Peptamen 1.5 Cal Liquid (Nutritional Supplements), Give 45 ml/hr [hour] via G-Tube [gastrostomy tube] every shift for up at 10 am and down at 6 am. During a follow up observation on 12/17/2024 at 12:34 PM, Resident #3's feeding tube port was connected to the feeding tubing, receiving Peptamen 1.5 nutritional formula at 45 ml/hr through the feeding tube pump. There was no information written under Patient Name, Patient ID, Date/Time Started, or Tube Feeding Order label of the bag or no additional label or writing on the front or back of the bag. During an interview on 12/18/2024 at 1:38 PM, Staff A, Licensed Practical Nurse (LPN), stated, I noticed the bag of nutrition wasn't labeled and dated. I should have done it before I started the feeding pump. During an interview on 12/18/2024 at 2:53 PM, the Assistant Director of Nursing stated, The tube feeding product needs to be labeled with the date, time, and the initials of the person that hung it. It is only good for so long, so the date and time are important. During an interview on 12/19/2024 at 8:33 AM, the Director of Nutritional Services stated, We don't have a specific policy on labeling the nutritional feeding product for feeding tubes, but it falls under labeling for medication administration. The nurse needs to fill out the information on the nutritional feeding product being hung for the resident with the resident's name, room, date, start time and rate, as shown on the label, before they hang the new bag of nutrition for tube feeding. Review of the facility policy and procedure titled Labeling of Medications and Biologicals with the last review date of 3/20/2024 showed it read, Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 8 of 11 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 12/19/2024 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 ensure staff performed hand hygiene during meal service in 1 of 3 units (300 Unit) and during medication administration in 2 of 8 medication pass observations, and failed to ensure staff used proper personal protective equipment in 1 of 3 units (300 Unit) while providing high contact care to the residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: 1) During an afternoon meal service observation on 12/17/2024 at 12:58 PM, Staff C, Certified Nursing Assistant (CNA), carried a used plastic cup out of Resident #113's room and set it on the drink cart in the hallway. Without performing hand hygiene, Staff C grabbed a clean glass from the cart, filled it with sweet tea beverage and returned to Resident #113's room. At 1:00 PM, Staff C exited Resident #113's room and without performing hand hygiene, grabbed a tray for Resident #77 from the food cart, and without performing hand hygiene, entered Resident #77's room, assisted the resident with meal setup at the bedside table, and without performing hand hygiene, exited the room. At 1:02 PM, Staff C exited Resident #77's room, and without performing hand hygiene, entered Resident #115's room and assisted the resident with reaching his personal items on his bedside stand. At 1:04 PM, Staff C exited Resident #77's room, and without performing hand hygiene, went to the meal cart and grabbed the tray for Resident #64. Without performing hand hygiene, Staff C entered Resident #64's room, assisted the resident with tray setup on her bedside table, and cut up the resident's food for her. Without performing hand hygiene, Staff C exited Resident #64's room at 1:05 PM, and returned to the meal cart. Without performing hand hygiene, Staff C grabbed the meal tray and a cup for Resident #53 and entered Resident #53's room. At 1:06 PM, without performing hand hygiene, Staff C set the tray on the bedside table, raised the head of Resident #53's bed up, placed the bedside table over Resident #53's bed, and without performing hand hygiene, assisted Resident #53 with meal set up and opening the resident's drinks. Without performing hand hygiene, Staff C exited Resident #53's room at 1:08 PM and approached Resident #16 in the hallway. Without performing hand hygiene, Staff C wheeled Resident #16 in her Geri-chair to the resident's room. During an interview on 12/17/2024 at 1:11 PM, Staff C, CNA, stated, I didn't know about sanitizing my hands between tray delivery. During an interview on 12/18/2024 at 2:53 PM, the Assistant Director of Nursing stated, Staff need to be performing hand hygiene after delivering meal trays to each resident. 2) During an observation on 12/17/2024 at 8:46 AM, Staff A, Licensed Practical Nurse (LPN), was wearing a black thumb and wrist brace [a brace covering the thumb and fingers with an open end at the tips of the fingers and thumb that provides support to limit movement of the thumb and is used for injuries] on her left hand. Without performing hand hygiene, Staff A prepared the medications for Resident #3 at the medication cart. At 8:53 AM, without performing hand hygiene, Staff A gathered the prepared medications and entered Resident #3's room. Staff A set the medications down on the bedside table at 8:54 AM. Without performing hand hygiene, Staff A donned a gown and left the neck and the waist areas of the gown untied. Without performing hand hygiene, Staff A donned a glove over her thumb and wrist brace on her left hand, and a glove on her right hand. During medication administration through the G-tube (Gastrostomy tube) from 8:55 AM to 8:59 AM, Staff A's gown around the neck area fell forward with the inside of the gown folding down over the outside of the gown. Staff A used her gloved hands to administer the medications and pulled the gown back up around her neck area four (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 9 of 11 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 12/19/2024 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 - Few times while administering the medications. At 9:00 AM, Staff A doffed her gown and gloves and entered the resident's bathroom to wash her hands at the sink. While wearing the left-hand thumb and wrist brace covering her left hand, Staff A was scrubbing the tips of her left fingers with the soap. Staff A then exited the bathroom and returned to the medication cart to prepare medication for another resident. During an interview on 12/18/2024 at 1:38 PM, Staff A, LPN, stated, I should have performed hand hygiene before I prepared the meds and before I donned my gloves for [Resident #3's name] medication administration. I should have tied my gown at the neck. I always tie the gown and then put it around my neck. It kept falling down during administering the medications through [Resident #3's name] G-tube. It can cause contamination. 3) During an observation on 12/18/2024 at 10:53 AM, Staff B, Licensed Practical Nurse (LPN), gathered the blood glucose monitor and supplies to check Resident #124's blood glucose without performing hand hygiene. At 10:54 AM, Staff B entered Resident #124's room with the blood glucose monitor and supplies without performing hand hygiene. Staff B exited Resident #124's room and without performing hand hygiene, returned to cart with the blood glucose monitoring supplies to obtain alcohol wipes. At 10:55 AM, Staff B returned to Resident #124's room and without performing hand hygiene, donned gloves and performed the blood glucose monitoring. At 10:57 AM, Staff B exited Resident #124's room while still wearing her used gloves, accessed the bottom drawer of the medication cart, obtained a cleaning wipe, and cleaned the glucometer. At 10:59 AM, Staff B doffed her gloves and started preparing medication administration for another resident, without performing hand hygiene. During an interview on 12/18/2024 at 11:02 AM, Staff B, LPN, stated, I didn't sanitize my hands before entering [Resident #124's name] room. I didn't sanitize my hands when I returned to the cart. I should have removed my gloves in the room and re-sanitized my hands in the room before I returned to the cart to clean the glucometer. During an interview on 12/18/2024 at 2:53 PM, the Assistant Director of Nursing stated, Staff need to be performing hand hygiene during medication administration. They should be performing hand hygiene before administering the medication and after they are done. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 30/20/2024 showed it read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand Hygiene Table: Condition . Between resident contacts . Before applying and after removing personal protective equipment (PPE), including gloves; Before preparing or handling medications; Before performing resident care procedures. Review of the facility policy and procedure titled Medication Administration with the last review date of 3/20/2024 showed it read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 4. Wash hands prior to administering medication per facility protocol and product . 16. Observe resident consumption of medication. 17. Wash hands using (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 10 of 11 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 12/19/2024 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 facility protocol and product. Level of Harm - Minimal harm or potential for actual harm 4) During an observation on 12/18/2024 at 9:47 AM, Staff C, CNA, entered Resident #8's room with a clear plastic bag with linen and towels. There was an enhanced barrier precautions signage posted outside next to the door. Resident #8 was lying in bed and Staff C provided personal hygiene care to Resident #8. Staff C was leaning over Resident #8, wearing gloves but no gown. Residents Affected - Few During an interview on 12/18/2024 at 10:42 AM, Staff C, CNA, stated, I was changing [Resident #8's name] brief and socks. I gave her clothes to put on and then changed the linen to the bed. I forgot to put on a gown when providing care for [Resident #8's name]. You wear a gown for residents who are on enhanced barrier precautions for the protection of other residents. During an interview on 12/18/2024 at 1:50 PM, the Assistant Director of Nursing and Infection Preventionist stated, I tell my staff when a resident has any opening that should not be there, the resident needs enhanced barrier precautions. Staff are expected to use gloves and gowns any time they are doing direct contact care. Review of Resident #8's physician order dated 4/1/2024 showed it read, Enhanced Barrier Precautions due to (Tube Feeding). Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 3/20/2024 showed it read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO [Multidrug Resistant Organism] . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room . 4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105297 If continuation sheet Page 11 of 11