Inspection·October 24, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record reviews, the facility failed to ensure 2 of 7 residents, (Resident #83 and Resident #107) reviewed for Preadmission Screening and Resident Review (PASRR) documented all diagnoses relevant to the screening. Residents Affected - Few Findings include: 1. Review of Resident #83's Level I PASRR screening, dated 7/17/2023, showed no entries documented on page 2 in Section I: PASRR Screen Decision-Making under Section A. MI [Mental Illness] or suspected MI. Review of Resident #83's face sheet, admission date 9/14/2024, revealed Resident #83 had diagnoses that included generalized anxiety disorder, brief psychotic disorder and other specified persistent mood disorders. 2. Review of Resident #107's Level I PASRR screening, dated 8/18/2024, showed schizophrenia documented on page 2 in Section I: PASRR Screen Decision-Making under Section A. MI [Mental Illness] or suspected MI. Review of Resident #107's face sheet, admission date 6/30/2024, revealed diagnoses that included other specified anxiety disorders. During an interview on 10/24/2024 at 7:48 AM, the Director of Nursing confirmed Resident #83's diagnoses of generalized anxiety disorder, brief psychotic disorder and other specified persistent mood disorders had not been included on his Level I PASRR screening dated 7/17/2023. She confirmed Resident #107's diagnoses of other specified anxiety disorders had been included on her Level I PASRR screening dated 8/18/2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 2 of 10 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 10/24/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #10) of 3 residents reviewed for skin conditions. Residents Affected - Few Findings include: During an observation on 10/21/2024 at 9:59 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. (photographic evidence obtained) During an interview on 10/21/2024 at 9:59 AM, Resident #10 stated I got a skin tear when we went for the storm. During an observation on 10/22/2024 at 7:50 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. Review of Resident #10's physician order, dated 10/14/2024, read, Skin tear site___Change dressing___Cleanse W(with)/___Apply___Cover W/___ Observe Area Daily. Frequency: Once a day. Special Instructions: Remove old dressing, cleanse wound with NS (normal saline) and cover with medipore dressing. During an interview on 10/22/2024 at 1:30 PM, Staff C, License Practical Nurse, (LPN), stated I changed [Resident #10's Name] dressing today. The old dressing was dated 10/19. I believe [Resident #10's Name] has wound care orders for daily dressing changes. During an interview on 10/22/2024 at 1:11 PM, Staff D, Wound Care Nurse, stated, As soon as my day starts, I let the nurses know what I will be doing as to wound care. I usually do the big wounds, and they [nurses] will do the rest. Some days I help and do them all. During an interview on 10/23/2024 at 10:26 AM, the Director of Nursing, (DON), stated, My expectation is for the nurse assigned to the resident with daily wound care orders would be completing that [wound care] daily and signing off on it. Review of the policy and procedure titled Dressing-Clean, last review date of 1/9/2024, read Purpose: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. Each wound site should be treated individually. Standard: Physician's orders should specify type of wound, frequency of change, type of dressing or products to be used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 3 of 10 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 10/24/2024 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 - 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 observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals were stored in a secured manner for 2 of 3 halls. Findings include: 1. During an observation on 10/21/2024 at 09:30 AM of Resident #243's room, one bottle of nasal spray (Oxymetazoline HCI 0.05% nasal decongestant), and 1 bottle of 4% lidocaine was sitting on bedside table not secured. (Photographic Evidence Obtained) During an interview on 10/21/2024 at 11:30 AM, Resident #243 stated, I usually have my nasal spray and my [Name Brand of 4% lidocaine] all the time because I need it so often. During an observation on 10/22/2024 at 1:20 PM of Resident #243's room, one bottle of nasal spray (Oxymetazoline HCI 0.05% nasal decongestant), and 1 bottle of 4% lidocaine was sitting on bedside table not secured. During an observation on 10/23/2024 at 7:57 AM with Staff F, License Practical Nurse (LPN) acknowledged the one bottle of nasal spray (Oxymetazoline HCI 0.05% nasal decongestant), and 1 bottle of 4% lidocaine was sitting on Resident #243's bedside table not secured. During an interview on 10/23/2024 at 7:57 AM, Staff F, LPN, stated Medications are not supposed to be at the bedside unless the resident has been accessed for self-administration and the medication still needs to be secured. During an interview on 10/24/2024 at 8:12 AM, the Director of Nursing stated, Per our policy, patients are not to have medication in their room unless they have been assessed for self-administration and the physician writes an order for self-administration. 2. During an observation on 10/23/2024 at 8:20 AM, Resident #61 was eating breakfast in his room. On his meal tray there was a medication cup with a thick brown liquid inside another plastic cup. (photographic evidence obtained) During an interview on 10/23/2024 at 8:20 AM, Resident #61 stated, That is medication. The nurse will bring it to me, and I drink it after breakfast. I will not drink that [brown liquid in medication cup] today. During an interview on 10/24/2024 at 8:12 AM with the Director of Nursing stated, Medication should not be left at bedside. Nurse should take the medication with her and bring it back when resident is able to take it, and she is able to watch the resident take the medication. During an interview on 10/23/2024 at 8:25 AM with Staff C, LPN stated, There is medication in his room. If I wait for him [Resident #61] to take his medication he will start cursing me out. I try not to push. He likes to take his medication after breakfast. I will go back and check on him after breakfast. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 4 of 10 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 10/24/2024 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 Review of the facility policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, last review date of 1/9/2024 read, 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a physician/prescriber order and approval by the Interdisciplinary Care Team and Facility Administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 5 of 10 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 10/24/2024 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen's walk-in cooler, walk- in freezer, and in 2 of 3 nutrition rooms and appliances for preparing food were kept in a clean, sanitary manner in 1 of 3 nutrition rooms. Findings include: On 10/21/2024 at 9:15 AM, a tour of the main kitchen was conducted with the Certified Dietary Manager (CDM). During an observation of the walk-in cooler, there was 1 opened, undated, container of potato salad, 1 opened, undated container of ricotta cheese, and 1 opened container of sour cream with an expiration date of 10/18/24. There was three 1-inch-deep trays of unlabeled, undated vegetables sitting on the 3rd shelf. In the walk-in freezer there were 3 frozen pizzas with no opened, use by, or expiration date sitting on top of a box located on the top shelf. (Photographic evidence obtained) During an interview on 10/21/2024 at 9:30 AM, the CDM confirmed the unlabeled, undated foods, and stated, Those should be labeled and dated. On 10/21/2024 at 9:40 AM, a tour of the nutrition rooms was conducted with the CDM. In nutrition room [ROOM NUMBER], located on the south wing, there were three (3) opened, unlabeled, bottles of purple sport hydration drink sitting in the side shelf of the refrigerator door. There were two (2) unlabeled, undated, take-out sandwich bags with a 1/2 eaten sandwich wrapped in a paper towel in the bottom left drawer of the refrigerator. There was an unlabeled, undated, grocery store bag with a 1/2 lb. container of chicken salad, a plastic bag of pistachio nuts, and a plastic bag with homemade cookies. The microwave had a brown sticky-like substance on the door and the top of the microwave and there was also red splattered particles on the back wall of the microwave. In nutrition room [ROOM NUMBER], located on the west wing, there was one (1) opened, unlabeled, undated pint of cookie dough ice-cream, an opened, unlabeled, undated bag of frozen vegetables, and one (1) unlabeled frozen dinner meal sitting in the freezer's door shelf. During an interview on 10/21/2024 beginning at 10:00 AM, the CDM confirmed the unlabeled, undated items in the refrigerators in both nutrition rooms. The CDM stated, All foods should have the resident's name, room number, and the date it was brought in. The kitchen staff along with the nurses are responsible for keeping the nutrition rooms cleaned. Review of the policy titled, Food Preparation Guideline, last reviewed 1/9/2024, read, Process: d. Frozen foods should be properly thawed .Frozen fruits and vegetables should NOT be thawed before cooking. Allow extra time for preparation of these frozen products. Review of the policy titled, Food from Families and Friends, last reviewed 1/9/2024, read Purpose: To preserve the resident/guest(s) right to receive gifts of food from family and friends, while reducing the potential for food borne illnesses. Process: b. If food is to be stored, it should be labeled with resident/guest(s) name, dated and stored in airtight container. c. If refrigeration is necessary, food items should be stored in the nursing unit refrigerator or resident/guest(s) room refrigerator, and leftover cooked items discarded after 3 days, open items discarded after 7 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 6 of 10 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 10/24/2024 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 A policy and procedure was requested for food storage in the kitchen related to unlabeled and undated foods. None was provided. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 7 of 10 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 10/24/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, interviews, and record reviews, the facility failed to accurately document wound care dressing changes for 1 (Resident #10) of 3 residents reviewed for skin conditions. Residents Affected - Few Findings include: During an observation on 10/21/2024 at 9:59 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. (photographic evidence obtained) During an interview on 10/21/2024 at 9:59 AM, Resident #10 stated, I got a skin tear when we went for the storm. During an observation on 10/22/2024 at 7:50 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. Review of Resident #10's physician order, dated 10/14/2024, read, Skin tear site___Change dressing___Cleanse W(with)/___Apply___Cover W/___ Observe Area Daily. Frequency: Once a day. Special Instructions: Remove old dressing, cleanse wound with NS (normal saline) and cover with medipore dressing. Review of Resident #10's treatment administration history for the month of October 2024 for Skin tear site___Change dressing___Cleanse W(with)/___Apply___Cover W/___ Observe Area Daily. Frequency: Once a day. Special Instructions: Remove old dressing, cleanse wound with NS (normal saline) and cover with medipore dressing documented staff initials as treatment being done on 10/20/2024 and 10/21/2024. During an interview on 10/22/2024 at 1:30 PM, Staff C, License Practical Nurse, (LPN) stated I changed Resident #10's dressing today. The old dressing was dated 10/19. I believe Resident #10 has wound care orders for daily dressing changes. During an interview on 10/23/2024 at 10:26 AM, the Director of Nursing (DON) stated, My expectation is for the nurse assigned to the resident with daily wound care orders would be completing that [wound care] daily and signing off on it. Staff should document when they are completing the task and if they are not able to complete the dressing change, document and readdress. The documentation should be accurate. During an interview on 10/24/2024 at 7:45 AM, the DON stated, The nurses did not document accurately the dressing changes [for 10/20/2024 and 10/21/2024]. Review of the policy and procedure titled, Charting and Documentation Guidelines, last reviewed 1/9/2024, read, Purpose: Documentation in medical records of residents, by the interdisciplinary team, should provide: A source to support charges to the resident for services rendered. Process: I. Rules for Charting and Documentation: b) Be concise, accurate and complete and use objective terms. c) Document only the facts . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 8 of 10 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 10/24/2024 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 observations, interviews and record reviews, the facility failed to perform hand hygiene during wound care for 1 (Resident #10) of 3 residents reviewed for skin conditions and during meal delivery. Residents Affected - Few Findings include: 1. During an observation on 10/21/2024 at 1:24 PM, Staff A, Certified Nursing Assistant (CNA), entered Resident #22's room and placed a meal tray on the bedside table. Staff B, CNA, was in the room and assisted Staff A to readjust Resident #22 in his bed to set him up for lunch. Staff A, CNA, exited Resident #22's room and without performing hand hygiene removed another tray from the meal cart and entered Resident #72's room without performing hand hygiene. Staff A, CNA, started to feed Resident #72. During an interview on 10/22/2024 at 1:32 PM, Staff A, CNA, stated I should have used hand sanitizer in between residents when passing out meal trays. 2. During an observation on 10/22/2024 at 1:20 PM, Staff C, License Practical Nurse (LPN), came to Resident #10's doorway and Staff D, Wound Care Nurse, asked Staff C to come in and explain to Resident #10 she needed to change her dressing. Staff C stated to Staff D she was texting a provider and would come in. Staff C finished texting with a cellular phone and put it away in her pocket. Staff C, without performing hand hygiene, donned a pair of gloves and removed the dressing on Resident #10's right lower leg. Staff C, without performing hand hygiene, proceeded to place a new dressing on Resident #10's lower leg. During an interview on 10/22/2024 at 1:30 PM, Staff C, LPN, stated I should have washed my hands before putting on the gloves. During an interview on 10/23/2024 at 9:20 AM, the Infection Control Preventionist stated Staff should perform hand hygiene upon entering a resident's room and of course in between clean and dirty bandages. Gloves don't substitute hand hygiene. Staff should perform hand hygiene always before entering and upon exiting a room during meal delivery. During an interview on 10/23/2024 at 10:29 AM, the Director of Nursing (DON) stated Staff are expected to wash hands in between each resident encounter. The staff should wash their hands before donning gloves. Putting on gloves does not substitute hand hygiene. Review of the policy and procedure titled Hand Hygiene, with a last review date of 1/9/2024, read, Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. Process: 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 and after direct resident/guest contact. Before and after assisting a resident/guest with meals. Before and after changing a dressing. Review of the policy and procedure titled Dressing-Clean, with a last review date of 1/9/2024 read, Purpose: To provide guidelines for the care of wounds and soiled dressings, to decrease the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 9 of 10 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 10/24/2024 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 potential for nosocomial infection. Each wound site should be treated individually. Standard: Physician's orders should specify type of wound, frequency of change, type of dressing or products to be used. Process: 5. Wash hands and put on clean gloves. 6. Loosen the tape and remove the existing dressing, moisten with prescribed cleansing solution if needed to remove dressing. 7. Pull your glove off the hand and over the dressing; discard into appropriate receptacle. 8. Wash hands and put on clean gloves. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105317 If continuation sheet Page 10 of 10