Inspection·June 23, 2023

F 0578 resident's medical records. F. DNR orders should be reviewed by the physician at least once every thirty days during a resident's first 90 days of admission, and at least once every sixty days thereafter. 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: 105317 If continuation sheet Page 2 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician was notified of a resident change of condition for 1 of 3 residents, Resident #320, reviewed for insulin administration and monitoring. Findings include: Review of Resident #320's admission record documented the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia, long term use of insulin, unspecified mood disorder, and exocrine pancreatic insufficiency. Review of Resident #320's physician order, dated 12/15/2022, read, documented, CBG [capillary blood glucose] AM & HS [morning and hour of sleep]; Notify MD [Medical Doctor] immediately if greater than 400 give 12 units and call MD. Review of Resident #320's Medication Administration Record (MAR) documentation on 02/1/2023 at 9:00 PM blood glucose level as 436 and on 02/24/2023 at 4:00 PM blood glucose level as 435. Review of Resident #320's medical record contained no documentation of the physician being notified of the resident's blood sugar being greater than 400 as ordered by the physician. During an interview on 6/22/2023 at 2:23 PM, the Director of Nursing (DON) stated, I was unable to find documentation for the notification to the MD of the blood sugar levels. I would have expected to find documentation for the 02/19/2023 and the 2/24/2023 levels. During an interview on 6/23/2023 at 10:14 AM the DON stated, Staff should contact the physician as stated in the order. Review of policy and procedures titled Change in Medical Condition of Resident/Guest(s) last reviewed on 1/10/2023 read, Purpose: To keep the physician, who is in charge of medical care, and family members/legal representatives, responsible for health care decisions and other resident/guest representative informed of the resident/guest(s) medical condition so they may direct the plan of care as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 3 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 accurately document the discharge status of 1 of 3 residents, Resident #118, sampled for discharge status review. Residents Affected - Few Findings include: Record review of the medical record for Resident #118 documented the resident was admitted on [DATE] and was discharged from the facility on 04/26/23. Review of Resident #118's Minimum Data Set (MDS) Discharge Return Not Anticipated Assessment, dated 04/27/23, under Section A read the resident was discharged to an acute hospital on [DATE]. Review of Resident #118's nursing note dated 04/26/23 at 9:38 AM read, Patient discharge from [NAME] River Health and Rehabilitation Center in stable condition with no respiration distress noted. Dated 04/26/23 at 9:40 AM read, Resident discharged to private home with home health services. During an interview on 06/21/23 at 12:37 PM, the Minimum Data Set (MDS) Coordinator reviewed the record and verified Resident #118 was discharged home and the MDS dated [DATE] documenting discharge to an acute hospital was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 4 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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. 2) Record review of Resident #57's care plan, start date 6/7/2021 documented Resident #57 has a potential for weight loss. Resident #57's care plan documented nutritional interventions to include chopped meats. On 6/20/23 at 12:57 PM, an observation of Resident #57's midday meal was completed. The observation revealed Resident #57 had been served a whole fish filet patty. The fish filet patty was not served in a chopped consistency. The fish filet patty was missing one bite from the corner. During an interview on 6/20/2023 beginning at 12:57 PM, Resident #57 stated she only had upper dentures because her lower dentures were out for adjustment and she could not eat the rest of her food. She stated the fish filet patty was too hard for her to eat. On 6/21/23 at 7:54 AM, an observation of Resident #57's morning meal was completed. The observation revealed Resident #57 had been served a whole sausage patty. The sausage patty was not served in a chopped consistency. None of the sausage patty had been eaten. On 6/21/23 at 8:35 AM, Resident #57 was dressed, seated on the side of her bed beginning to eat her meal. The sausage patty remained in the whole form as it was served to Resident #57. During an interview on 6/22/2023 at 12:05 PM, the Speech Therapist stated that she had recommended chopped meats for Resident #57 because Resident #57 takes huge bites and does not chew well. She stated that the facility encouraged Resident #57 to be safer with foods and that Resident #57 will wear her top dentures but will not wear her bottom dentures. During an interview on 6/23/2023 at 8:19 AM, the Certified Dietary Manager agreed Resident #57 was supposed to receive meat that was chopped into bite sized pieces to prevent choking. Record review of the policy titled Food Preparation Guidelines, last reviewed 1/10/23, read e. Food should be cut, chopped, pureed or ground to meet the individual needs of the resident/guest(s). Based on observation, interview, and record review, the facility failed to ensure the implementation of the comprehensive person-centered care plan for 2 of 7 residents, Residents #319 and #57, sampled for care plans. Finding include: 1) During an observation on 06/20/23 at 10:00 AM, Resident #319 was lying in bed. There was no floor mat on the right side of the bed. During an observation on 6/21/2023 at 8:00 AM, Resident #319 was lying bed with eyes closed. There was no floor mat observed to the right side of the bed. During an observation on 6/22/2023 at 7:40 AM, Resident #319 was lying in bed. There was no floor mat observed to the right side of the bed. During an observation on 6/22/2023 at 12:09 PM, Resident #319 was sitting on the floor next to the right side of the bed very agitated and confused. His bed was placed in the lowest position. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 5 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 I, Unit Manager, entered the room with Staff H, Certified Nursing Assistant (CNA), and assessed Resident #319. There was no floor mat placed on the right side of the bed. During an interview on 6/22/2023 at 12:16 PM, Staff I, LPN/Unit Manager, stated, [Resident #319's name] has no floor mat in the right side of [his] bed, he is care planned for floor mats to [be] placed on both sides of the bed. Review of Resident #319's care plan, start date 10/10/2022, documented, I don't want to fall x [times] 90 days. Interventions: 8. 10/21/2022 Mats to be placed along side bed when resident is occupying bed. During an interview on 6/23/2023 at 10:12 AM, the Director of Nursing stated, I expect staff to follow the care plan interventions or resolve the intervention if the approach is not working. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 6 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide a therapeutic diet intervention as recommended by the Occupational Therapist and ordered by the physician for 1 resident, Resident #57, of 5 residents reviewed for nutrition. Residents Affected - Few Finding include: Record review of Resident #57's physician's orders, dated June 2023, showed Resident #57 was ordered to receive a regular diet, no added salt, chopped [meats]. Record review of Resident #57's speech therapy discharge summary, dates of service 11/23/2022 12/7/2022, showed the occupational therapy discharge recommendations included soft and bite sized foods for the resident to swallow solids safely. On 6/20/23 at 12:57 PM, an observation of Resident #57's midday meal was completed. The observation revealed Resident #57 had been served a whole fish filet patty. The fish filet patty was not served in a chopped consistency. The fish filet patty was missing one bite from a corner. During an interview on 6/20/2023 beginning at 12:57 PM, Resident #57 stated she only had upper dentures because her lower dentures were out for adjustment and she could not eat the rest of her food. She stated the fish filet patty was too hard for her to eat. On 6/21/23 at 7:54 AM, an observation of Resident #57's morning meal was completed. The observation revealed Resident #57 had been served a whole sausage patty. The sausage patty was not served in a chopped consistency. None of the sausage patty had been eaten. On 6/21/23 at 8:35 AM, Resident #57 was dressed and seated on the side of her bed beginning to eat her meal. The sausage patty remained in the whole form as it was served to Resident #57. During an interview on 6/22/2023 at 12:05 PM, the Speech Therapist stated she had recommended chopped meats for Resident #57 because Resident #57 takes huge bites and does not chew well. She stated the facility encouraged Resident #57 to be safer with foods and that Resident #57 will wear her top dentures but will not wear her bottom dentures. During an interview on 6/23/2023 at 8:19 AM, the Certified Dietary Manager verified Resident #57 was supposed to receive meat that was chopped into bite sized pieces to prevent choking. Review of the policy titled Food Preparation Guidelines, last reviewed 1/10/2023, read, e. Food should be cut, chopped, pureed or ground to meet the individual needs of the resident/guest(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 7 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards for 2 of 3 residents, Residents #90 and #105. Residents Affected - Some Findings include: During an observation on 6/20/2023 at 9:31 AM, Resident #90 was lying in bed. Her nebulizer mask was observed sitting on the top of the nebulizer on her nightstand and was not bagged or dated. During an observation on 6/20/2023 at 9:56 AM, Resident #105 was lying in bed. Her nebulizer mask was observed sitting on top of the nebulizer on her nightstand and was not bagged. During an observation on 6/21/2023 at 8:04 AM, Resident #90 was lying in bed. Her nebulizer mask was observed to be on top of the nebulizer and was not bagged or dated. (Photographic evidence obtained) During an observation on 6/21/2023 at 8:16 AM, Resident #105 was lying in bed. Her nebulizer mask was observed to be on her nightstand and was not bagged or dated. Review of the physician's order for Resident #90 dated 6/19/2023 read, Albuterol SUL [sulfate] 2.5 mg/ml soln [milligrams per milliliter solution] one UD [unit dose] inhaled via neb tx [nebulizer treatment] every 6 hours as asa [sic] needed dfro [sic] sob [shortness of breath]/ wheezing. Review of the physician's order for Resident #105 dated 3/6/2023 read, Albuterol SUL 0.63 mg/3 ml soln inhale one UD via nebulizer tx every 4 hours as needed for sob/ wheezing. Review of the care plan for Resident #90, dated 5/21/2023, read Administer nebulizer treatment as directed. Change tubing as ordered. Review of the care plan for Resident #105, dated 3/7/2023, read Administer nebulizer treatments as ordered. Change nebulizer tubing as directed. During an interview on 6/22/2023 at 9:49 AM, Staff A, Registered Nurse (RN), stated, The nebulizer masks are to be bagged and dated. [Resident #90's name] nebulizer mask is not bagged or dated. During an interview on 6/22/2023 at 9:56 AM, Staff A, LPN stated, Nebulizer masks are to be bagged and dated. [Resident #105's name] nebulizer mask is not bagged or dated. During an interview on 6/22/2023 at 10:17 AM, the Director of Nursing stated, My expectation is that all nebulizer masks are to be bagged and dated. Review of the facility policy tilted Nebulizer, last reviewed 1/102023 read, V. After completion of therapy: a) Remove nebulizer container. b) Rinse container with fresh tap water. c) Dry with clen paper towel or gauze sponge. d) Wipe mouth piece or mask with damp paper towel or gauze sponge. e) Store in plastic bag. VI. Documentation should include length of therapy. VII. Discard administration setup every seven (7) days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 8 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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. 2) During an observation on 6/20/2023 at 10:19 AM, Resident #31 was lying in bed. Several medications were observed in a small cup sitting on resident #31's over the bed table. (Photographic evidence obtained). During an interview with Resident #31 on 6/20/2023 at 10:19 AM stated, My Parkinson's medicine is in that cup and the nurse left it this morning. During an interview with Staff A, Registered Nurse (RN) on 6/22/2023 at 9:52 AM, That is [Resident # 31's name] medications and she should not have that at her bedside. During an interview with the Director of Nursing (DON) on 6/22/2023 at 10:17 AM stated, My expectation is that no medications are to be left at a resident's bedside. Review of policy and procedure titled Storage and Expiration of Medications, Biologicals, Syringes and Needles last reviewed on 1/10/2023 reads, Procedure: 3. General Storage Procedures: 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 4. facility should ensure that medications and biologicals: 4.2 Have not been retained longer than recommended by manufacturer or supplier. 5. Once any medication or biologicals package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure medications and biologicals are stored at their appropriate temperature according to the United States Pharmacopeia guidelines for temperature ranges. 16. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication). 18. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assist Facility in complying with its obligations pursuant to Applicable Law relating to the proper storage labeling, security and accountability of medications and biologicals. Based on observation, interview, and record review, the facility failed to ensure all drugs were stored and labeled in accordance with currently accepted professional principles and manufacturers' recommendations and under proper temperature in 4 of 6 medication carts and failed to ensure medications were stored in locked compartments to permit only authorized personnel to have access. Findings include: 1) During an observation of the North Wing Back Hall medication cart on 6/20/2023 at 8:58 AM, with Staff D, Registered Nurse (RN) there was one Levemir vial with no open or expiration date and a Novolog vial with an expiration date of 6/5/2023. During an interview on 6/20/2023 at 9:01 AM, Staff D, RN stated, Medication should be labeled with an open and expiration date when the medication is first opened. Expired medications should be disposed and not kept in the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 9 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 Review of the manufacturer's recommendations for Detemir injection (Levemir) read, Pen or vial, vial throw away after 42 days. During an observation of the South Wing Back Hall medication cart on 6/20/2023 at 9:05 AM, with Staff E, License Practical Nurse (LPN) there was an unopened vial of Novolog and one bottle of Timolol eye drops with an expiration date of 5/12/2023. During an interview on 6/20/2023 at 9:09 AM, Staff E, LPN stated, Unopened insulin vials should be kept refrigerated until it is opened. Expired medication should be thrown away and new medication ordered. Review of the manufacturer's recommendations Novolog read, Unused vials of Novolog should be stored under refrigeration between 36 and 46 degree Fahrenheit. During an observation of the South Wing Front Hall medication cart with Staff F, LPN there was one unopened Lantus Solostar insulin pen labeled, Refrigerate till open then room temperature. During an interview on 6/20/2023 at 9:21 AM with Staff F, LPN stated Insulin should be refrigerated until it is opened. Review of the manufacturer's recommendations for Lantus Solostar pen read, Always store UNOPENED Lantus Solostar pens in the refrigerator. During an observation on 6/20/2023 at 9:25 AM of the [NAME] Wing Back Hall medication cart with Staff C, LPN, there was one expired Lispro insulin pen with an opened date of 5/9/2023, one expired Basaglar insulin pen with opened date of 5/13/2023, one expired Novolog insulin pen with an opened date of 5/15/2023, one expired opened bottle of Latanoprost eye drops with an expiration date of 6/4/2023, two opened bottles of Timolol with no opened date and expiration date, and one opened bottle of Brinzolamide eye drops with no opened or expiration date. During an interview on 6/20/2023 at 9:30 AM Staff C, LPN stated Medication should be labeled when first opened with the opened date and expiration date. Medication that is expired should be returned to the pharmacy or disposed of. Review of the manufacturer's recommendations for Lispro insulin pen read, Insulin Lispro: Throw away pen/vials after 28 days of use, even if there is still insulin left. Review of the manufacturer's recommendations for Basaglar read, Store your opened Pen at room temperature up to 86 degrees Fahrenheit and throw it away after 28 days. Review of the manufacturer's recommendations for Novolog insulin pen read, Insulin Name: Novolog. Expiration upon opening or removing from refrigerator: 28 days. Review of the manufacturer's recommendations for Timolol read, Use the timolol eye drops within the expiry date shown on the bottle and within 4 weeks of opening. This will help to lower the risk of eye infections and make sure the eye drops work properly. Review of the manufacturer's recommendations for Brinzolamide read, Use the timolol eye drops within the expiry date shown on the bottle and within 4 weeks of opening. This will help to lower the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 10 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 risk of eye infections and make sure the eye drops work properly. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/22/2023 at 12:50 PM, the Director of Nursing stated, Staff should be labeling medications as per protocol. If the medication is expired, it should be removed from the medication cart. I do not think insulin needs to be refrigerated until it is opened. I think we refrigerate insulin for longer shelf life. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 11 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to ensure cleaning of equipment per policy guidelines to maintain sanitary standards of equipment. Residents Affected - Some Findings include: A walk-through tour of the kitchen was conducted on 6/21/23 at 07:16 AM with the Certified Dietary Manager (CDM). There was a built-up black substance on the interior door of the ice machine. The microwave was observed to have numerous dried food particles inside on the sides, top and base. The robot coupe (chopper/grinder) was observed to have water nesting in the bottom of the base. The mixer was observed to have food particles on the base and bowl of the mixer. The can opener was observed to have a buildup of dried food particles on and around the blade and base of the can opener. (Photographic evidence obtained). An interview was conducted with the CDM on 6/21/23 at 9:20 AM. The CDM verified the presence of a black built-up substance on the interior door of the ice machine, the microwave had numerous food particles on the sides, top and base of the equipment, the mixer was covered, was to be clean and there were food particles on the base and the bowl, the can opener had dried food particles on the blade and base, the robot coupe bowl (chopper/grinder) was clean and should have been inverted to prevent wet-nesting; the robot coupe bowl had water standing in the bottom from being washed and placed back on the base. The CDM stated the dietary department has a cleaning schedule for assigned daily, weekly, monthly, and as needed duties. The CDM confirmed the cleaning schedule was not being followed. Review of the policy and procedure titled Cleaning Schedules with an effective date of 2/1/2022 read, To prevent the spread of bacteria that may cause food borne illnesses. Process: e. The Dietary Manager should supervise adherence to the cleaning schedule, and inspect the kitchen weekly for cleanliness. Review of the policy and procedure titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of 04/17/214 read, 24. Ice Machine, Dispensers, Chests: (at least monthly) Wash machine, inside and outside, including legs and handle. 27. Meat Grinder/Buffalo Chopper: (after each use) Air dry on clean surface or dry with clean paper towels or cloth to prevent rust. 28. Mixer: (after each use) Take out bowl and beater. Wash in pot and pan sink or dish machine. Thoroughly scrub machine (include motor housing), air dry. 35. Microwave Oven: (daily and as needed) Wash walls inside and out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 12 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 during medication administration and resident care for 1 of 2 residents, Resident #34 sampled for gastric tubes. Residents Affected - Few Findings include: During an observation on 6/22/2023 at 9:25 AM, Staff C, Licensed Practical Nurse (LPN) brought the medication cart to the back of the [NAME] Unit next to the nursing station. Staff C, without performing hand hygiene, donned gloves and began to pour medications for Resident #34. Staff C without performing hand hygiene entered Resident #34's room. Staff G, Certified Nursing Assistant (CNA) entered the room and without performing hand hygiene assisted Staff C with repositioning Resident #34. Staff C used a washcloth to cleanse Resident #34's face. Staff C removed the gloves and without performing hand hygiene prepared a cup of water for a gastric tube flush that included checking the water temperature with her outer left hand. Staff C entered Resident #34's room with wound care supplies and donned gloves without performing hand hygiene. Staff C's stethoscope fell to the floor. Staff C cleaned the gastronomy insertion area and removed the gloves. Staff C then donned gloves without performing hand hygiene and applied gauze to the gastrostomy insertion site. Staff C picked the stethoscope up from the floor and placed the stethoscope around her neck without sanitizing the stethoscope, then Staff C placed the stethoscope on Resident #34's pillow and donned gloves without performing hand hygiene. Staff C used the stethoscope to auscultate Resident #34's right upper quadrant. Staff C administered medication via the gastric tube and once finished put the syringe away in a plastic bag without rinsing the syringe after use. Staff C removed the gloves and exited Resident #34's room without performing hand hygiene. Staff C returned to the medication cart, without performing hand hygiene, and signed off medications on the computer for Resident #34. Staff C returned to Resident #34's room, did not perform hand hygiene upon entering. Staff C placed a nutritional supplement drink on the bed side table. Staff C performed hand hygiene, donned gloves, and used the stethoscope without sanitizing it, to auscultate Resident #34's right upper abdomen. Staff C, LPN administered Resident #34's feeding via gastric tube and after finishing placed the bolus syringe back into plastic bag without rinsing it. Staff C removed the gloves and exited the room without performing hand hygiene. During an interview on 6/22/2023 at 10:22 AM Staff C, LPN stated, I should have washed my hands or used hand sanitizer since I was providing direct patient care. When the stethoscope fell on the floor, I should have sanitized it before using it. During an interview on 6/22/2023 at 12:49 PM, Director of Nursing (DON) stated, Staff should wash hands before and after, definitely after. Use hand sanitizer or wash hands. When the stethoscope fell on the floor staff should have disinfected the stethoscope. Once the bolus syringe is used staff are expected to rinse the syringe in the resident's restroom. During an interview on 6/22/2023 at 8:27 AM, Staff G, Certified Nursing Assistant (CNA) stated I did forget to wash my hands, but I normally do. Staff C asked me to assist, and I forgot. Review of the policy and procedure titled Cleaning IC [Infection Control] for Equipment, last reviewed 1/10/2023 read 2. Implement infection control cleaning of equipment. C. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and at IC nurse's instructions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 13 of 14 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 105317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal River Health and Rehabilitation Center 136 Northeast 12th Avenue Crystal River, FL 34429 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the policy and procedure titled Hand Hygiene last reviewed 1/10/2023 read, Standard: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. II. Hand Sanitizer: If hands are not visibly soiled, use an alcohol-based hand sanitizer for routinely decontaminating hands in all clinical situations other than those listed under Handwashing above. III. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. When hands are visibly soiled (Hand washing with soap and water); before and after direct resident/guest contact (for which hand hygiene is indicated by acceptable professional practice). Before or after changing a dressing. Upon and after coming in contact with a resident/guest(s) intact skin (e.g. when taking a pulse or blood pressure, and lifting a resident/guest(s). Event ID: Facility ID: 105317 If continuation sheet Page 14 of 14