Inspection·March 16, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure medication self-administration orders were in place for one (Resident #27) of 30 sampled residents. Residents Affected - Few Findings included: During a facility tour on 03/13/22 at 9:55 a.m. to 10:48 a.m., medications were observed unattended on Resident #27's bedside table. The observed two tablets were in two separate plastic medicine dispensing cups. One of the tablets was a small round white pill. The second one was a large pink pill. (Photographic evidence was obtained) Resident #27 and her roommate were not in the room during the observation. The door was wide open. Review of the electronic medical record (EMR) for Resident #27 showed she was admitted to the facility on [DATE] with diagnoses to include unspecified dementia with behavioral disturbance, non-[NAME] Lymphoma, unspecified, and Gastro-esophageal Reflux disease. A review of the Minimum Data Set (MDS) for Resident #27 dated 01/07/22 showed a brief interview for mental status (BIMS) of 14 which indicated intact mental cognition. A care plan for Resident #27 dated 01/13/22 showed she was not care planned for self-administration of medication. An interview was conducted with Resident #27 on 03/13/22 at 12:00 p.m. She confirmed that some nurses leave her medications on her bedside table. She stated the nurse had brought her the medications per her request due to pain and stomach acid. She stated she did not take the medications and said, I forgot they were there. On 03/13/22 at 11:02 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). Staff F said Resident #27 could take medications independently. Staff F stated the medications were Tylenol and Tums. Staff F stated sometimes the resident demanded her medications, right then and there. Staff F said, [Resident #27] liked her meds left on her table to take them when she wants. Staff F stated the expectation was that residents were to be supervised when taking medications. Staff F said, Yes, it should be eyes on supervision for all medication administration. I should not have left the medications there. It was my mistake. Review of the EMR for Resident #27 on 03/13/22 at 11:20 a.m., physician orders showed that Resident #27 did not have current orders for Tylenol nor Tums. On 03/13/22 at 11:34 a.m., an interview was conducted with Staff F, LPN. Staff F stated he disposed of the medications in the drug Buster. Staff F confirmed there were no physician orders to administer the two medications. Staff F stated he had just called the doctor and that was why the phone orders were not documented. Staff F said, I had a lot to do. I did not have the orders at the time. I have called the doctor. On 03/13/22 at 11:40 a.m., an interview was conducted with the Assistant Director of Nursing (ADON.) The ADON stated that all medications should have a physician's order. The ADON stated Resident #27 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 2 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was planning to move to an ALF (assisted living facility) and they were waiting for an order to self-administer her medications. Further review of the EMR showed that Resident #27 did not have an order in place to self-administer medications. An interview was conducted on 03/13/22 at 11:45 a.m. with the Director of Nursing (DON). The DON confirmed medications should never be left unattended. The DON said, We have a lot of residents who wander. It is not safe. If a resident was on the self-administration program, they would have a lock to secure the meds. The DON stated she had started an in-service and coaching with Staff F, LPN. On 03/14/22 at 2:38 p.m., a review of physician orders showed that Resident #27 had received new orders to self-administer medications at bedside, in locked box, every shift, entered into the system on 03/13/22 at 11:46 a.m. by the DON and orders were signed by Dr. [name] on 03/14/22 at 10:16 a.m. 03/15/22 3:34 p.m., an interview was conducted with the DON. She stated Resident #27 had self-administration orders for Tylenol [Acetaminophen 325 mg] and Tums [Calcium carbonate tablet] and was given a lock and key. The resident still required the nurses to administer all other medication. The medications should be administered per professional standards, We follow physician orders. Review of a facility policy titled, self-administration of medications, revised February 2021, showed residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. The policy interpretation (2.) The IDT considers . (f.) The resident is able to safely and securely store the medication. (3.) If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medication administration record and care plan. The decision that a resident can safely self-administer medications is re-assessed periodically. (8.) Self-administered medications are stored and secured in a safe and secure place, which is no accessible by other residents. (9.) Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in-charge for return to the family or responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 3 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure care plan interventions and physician orders were followed for one (Resident #52) of five sampled residents related to catheter care. Findings included: During a facility tour on 03/13/22 at 9:24 a.m., Resident #52 was observed in her room. Resident #52's catheter was covered, urine discoloration was noted in the tubing. The urine was observed with a dark, tea color. On 03/15/22 at 9:35 a.m., Resident #52 was observed in bed. Her catheter was noted with dark brown and hues of red color. She stated that she did not feel very well. Photographic evidence of the catheter was obtained. An interview was conducted on 03/15/22 at 9:37 a.m. with Staff B, Licensed Practical Nurse (LPN). He stated he did not know there were concerns with the output and was not aware the resident was not feeling well. Staff B stated sometimes the resident preferred to lay in bed. He said, I gave her meds this morning. I did not notice anything unusual. Staff B observed the resident's catheter and said, Yes, that color is a bit dark. I did not know. I will take care of it. I will order a UA (urinalysis). He stated the Certified Nursing Assistance's (CNAs) were responsible for emptying catheters and were supposed to to report any concerns with resident's output during catheter care. On 03/15/22 at 9:48 p.m., Resident #52 was heard from the hallway crying, please help me. It hurts Upon entering the room, Resident #52 was observed lying on her bed, awake and alert. Resident #52 stated she had some breakfast and stated that her catheter was hurting, itchy and irritating. An interview was conducted on 03/15/22 at 9:45 a.m. with Staff E, CNA. Staff E was assigned to Resident #52. Staff E stated she had not emptied the catheter today as Resident #52 had not had any output. Staff E stated that the catheter was last emptied on the 11:00 p.m. - 7:00 a.m. shift. Staff E stated when CNAs empty catheters, they do not document output results. She said, we only document if the urine was not normal. Staff E observed Resident #52's urine and said, No, it should not look like that. On 03/15/22 at 10:19 a.m., an interview was conducted with the Assistant Director of Nursing (ADON.) The ADON stated that Resident #52 has had her catheter long term. The ADON stated that catheter monitoring entails to observe and document. The ADON stated that this included to trend patterns of output to see if it was out of the normal range. The ADON stated the CNAs should notify us [nurses] of irregularities and then we would initiate a change in condition. Review of Resident #52's electronic medical record (EMR) showed she was admitted to the facility on [DATE] with diagnoses to include, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side, neuromuscular dysfunction of bladder unspecified, presence of urogenital implants, personal history of urinary tract infections (UTI), urge incontinence. A quarterly minimum data set (MDS) for Resident #52 dated 02/04/22, Section C showed a Brief Interview for Mental Status (BIMS) of 05 which indicated severe cognitive impairment. Section G showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 4 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #52 required extensive assistance with activities of daily living (ADLs), with two persons assistance. A care plan for Resident #52 with a revision date of 09/23/20 showed a supra pubic catheter focus with a goal to remain free of catheter related trauma. Interventions included catheter care every shift and as needed, document, and notify physician of pain and discomfort due to catheter, document and notify physician for signs and symptoms of discomfort. Document and notify physician of signs and symptoms of UTI (pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, change in behavior, change in eating patterns.) Review of physician's orders for Resident #52 printed on 03/15/22 showed orders as follows: May change / replace supra catheter 16fr/10cc as needed for neurogenic bladder, order date 11/10/20, start date 11/10/20. Supra pubic urinary catheter care every shift and PRN (as needed), order date 5/26/20, start date 5/26/20. Supra pubic urinary catheter - may irrigate with 60 ml of NS (normal saline) every 8 hours PRN for blockage, leakage, increased sediment, or decreased output as needed, order date 5/26/20, start date 5/26/20. Supra pubic urinary catheter monitor output every shift if output is less than 300 ml, notify physician, order date 5/26/20, start date 5/26/20. The order also showed to monitor dark urine, as a side effect for antipsychotic medication, Risperdal: monitor dark urine, ordered 3/6/22, start date 3/6/22 Review of the Treatment Administration Record (TAR) for Resident #52 dated 3/1/22 -3/31/22 showed antipsychotic medication monitoring for dark urine without documentation indicating the findings. The review also showed Supra pubic catheter care and output documentation without indication of concerns with output or the color of Resident #52's urine color. The PRN orders for changing or replacing catheter did not show any documentation indicating any replacement. Orders to irrigate the Supra pubic catheter every 8 hours for blockage, increased sediment and output showed no documentation to indicate that Resident #52's catheter had been irrigated. On 03/15/22 at 12:38 p.m., an interview was conducted with the ADON. She stated Resident #52's tea color urine was normal. The ADON said, That's odd, the resident saw the Advanced Registered Nurse Practitioner (ARNP) last week. There were no complaints of concerns with urine color or output. The ADON presented a copy of the ARNP note dated 03/09/22. Review of the note showed that an assessment was documented as, patient's suprapubic catheter is in place and urine is clear and amber This finding was inconsistent with the ADON's response. An interview was conducted with the Director of Nursing (DON) on 03/15/22 at 12:43 p.m. The DON stated that they would document if anything out of the normal was noted in the resident's catheter output. She stated the Risperdal monitoring is generic, and the dark color urine monitoring was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 5 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm specific to this resident. The DON stated that Resident #52's output was documented if it was less than 300 ml. She stated if there were concerns with urine staff would report it. The DON did not produce documentation to show that the tea color output was baseline for Resident #52. Review of the ARNP's notes showed that Resident #52's urine was observed as follows: Residents Affected - Few On 03/09/22 Resident #52 was seen and the suprapubic catheter is in place and urine is clear amber. On 03/02/22 Resident #52 was seen and the suprapubic catheter is in place and urine is clear amber. An interview was conducted on 03/16/22 at 9:44 a.m. with Staff E, CNA. Staff E stated she took care of Resident #52 all day yesterday and the resident did not have hardly any output. Staff E said, she had just about 20 cc's all day and the urine was very dark. It is not her baseline. Staff E stated that she had notified the nurse. Staff E confirmed that resident #52's urine output was normally clear. Staff E stated that Resident #52's catheter was changed this morning because it was clogged. 03/16/22 9:43 a.m., Resident #52 was observed in her room. The resident reported that she was not feeling well, her catheter hurt. She said her catheter was changed this morning because it was blocked. Resident #52 stated that the nurse spoke to her about drinking more fluids. Resident #52 stated that she had a glass of juice. The resident's output was noted clear. An interview was conducted on 03/16/22 at 9:47 a.m. with Staff B, LPN. Staff B confirmed he had just changed Resident #52's catheter because it was clogged and there was no return. Staff B stated on third shift (11:00 p.m. - 7:00 a.m.), the resident's output was 50 ml. He stated there was an order to contact the physician if the output was less that 300 ml. Staff B stated he could not confirm if the night shift nurse called the doctor. Staff B stated the night nurse had reported Resident #52 had a scant amount of output. He stated he attempted to flush the catheter and could not get through. He stated during the flushing attempt, he noted the catheter was clogged and decided to change it. An interview was conducted with the DON on 03/15/22 at 2:21 p.m. She said, My expectation is that the nurses should be monitoring the resident's [catheter]. The CNA's can empty it, but if there are concerns with reports of pain, color or change in condition, the nurses should assess and report to the doctor. Review of a facility policy titled, suprapubic catheter care, revised October 2010, showed that the purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Under steps and procedures (12.) Check the urine for color and clarity. Under documentation record (7.) Character of urine such as color (straw colored, dark, or red), clarity (cloudy, solid particles, or blood) and odor. (8.) Any problems or complaints made by the resident during the procedure. Under Reporting (2.) Notify the physician of any abnormalities in the skin assessment or the character of the urine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 6 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (Resident #49) of thirty sampled residents , was set up and assisted with Eating Activities of Daily Living (ADL) during three meals. Residents Affected - Few Findings included: On 3/13/2022 at 12:15 p.m., a staff member was observed to deliver a lunch tray to Resident #49. The staff member left after setting up the meal. Resident #49 was observed in her room alone and with no Eating supervision or Eating assistance. An interview with Staff H, Personal Care Assistant (PCA) revealed she was not sure if Resident #49 required Eating supervision or Eating assistance. At 12:24 p.m. the Director of Nursing entered Resident #49's room to assist her with eating. The Director of Nursing did not stay in the room the entire meal service, and left the room at 12:45 p.m. There were periods of time, at least fifteen minutes, when Resident #49 was left in her room with her lunch tray in front of her and with no staff present. When the meal tray was removed, it was observed that between 25% - 50% of the meal had been consumed. On 3/14/2022 at 8:00 a.m., Staff J, CNA, brought Resident #49 her breakfast tray. After setting up the tray, she left the room. From 8:00 a.m. through to 8:32 a.m., the resident was in her room with her breakfast tray placed in front of her and with no staff assistance for eating. At 8:27 a.m., an attempt to interview the resident was unsuccessful as the resident had cognitive deficits. An observation of the resident revealed her breakfast plate consisted of pancakes with butter and syrup, hot cereal, a cup of yogurt, a carton of whole milk, one glass of juice and a glass of water. At one point the resident was observed to just move her food around with her fork. She did not bring food up to her mouth. At 8:40 a.m. when Staff J went into the room to remove the tray, the resident had only consumed less than 25% of her meal. An interview with Staff J revealed she was new and did not know the resident or what the resident's Activities of Daily Living (ADL) Eating activities were. She believed she was just set up only. She confirmed she did not return to the room between 8:00 a.m. and 8:40 a.m. to either cue or assist the resident with eating. On 3/14/2022 at 12:10 p.m., Resident #49 was provided with her lunch tray. At 12:30 p.m., Resident #49's daughter was observed in the room. She was standing up next to the resident and assisting with bringing the spoonful of food up to her mouth. When the resident tried to feed herself, she just moved the food around with her spoon. She held the spoon with the backside of the spoon up and unsuccessfully tried to scoop the food onto to spoon. The resident's daughter revealed staff had come in the room, dropped off the meal tray, lifted the lid, and left. The daughter confirmed the resident was not able to feed herself and needed assistance. The daughter said when she arrived the meal was already in the room. She began to assist the resident because Resident #49 was having difficulties picking up food items with her spoon. There were no staff in the room to either supervise or assist with eating from 12:10 p.m. through 12:40 p.m., when staff came to the room and picked up the tray. Observation of the meal tray after the resident was finished, revealed she only consumed approximately 25% - 50% of her meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 7 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing (X3) DATE SURVEY COMPLETED A. Building 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #49's admission record revealed she was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include but not limited to traumatic brain compression, protein calorie malnutrition, dysphagia, cognitive communication deficit, and dementia. Review of the MDS assessment,dated 2/7/2022, revealed: Cognition/BIMS score - not scored but indicated Short Term/Long Term memory problems with Severely Impaired decision making skills; Mood - Poor appetite 2-6 days assessed; ADL - Eating is Total dependence with one person physical assist). Review of the current physician's order sheet for the month of 3/2022 revealed a diet order to include: Regular Diet, minced and moist, regular consistency. Review of the following nurse progress notes, dated, revealed: 1. 2/7/2022 Nutrition/Dietary 15:55 (3:55 p.m.) - RD (Registered Dietician) readmit review. Regressed 0 75% with full assist with meals. 2. 2/28/2022 18:07 (6:07 p.m.) nutrition/dietary - Regressed to 0-50% with mostly full assist with meals. 3. 3/8/2022 11:02 a.m. nutrition/dietary - Improved to mostly 26 - 50% with mostly full assist with meals. Review of the current care plans with a next review date 4/28/2022 revealed: Has ADL self care performance deficit related to cognition. Current participating in therapy to improve her ability, with interventions in place to include but not limited to: Eating - The resident is able to eat with assistance by staff. On 3/16/2022 at 11:00 a.m., an interview with the Director of Nursing confirmed Resident #49 was currently assessed and care planned as Total Dependence, with one person physical assist with Eating. She said the floor nurse was supposed to monitor which residents were to be supervised and provided with Eating assistance and assign a staff member to that resident. She was not aware there were times when staff just dropped off the tray in Resident #49's room. She said they had a lot of new Agency staff and they needed to be inserviced better related to Eating assistance. On 3/16/2022 at 1:00 p.m., the Director of Nursing provided the Assistance with Meals policy and procedure, dated and revised July of 2017, for review. The policy revealed: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Dining Room Residents: 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 8 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 b. Keeping interactions with other staff to maintain while assisting residents with meals. Level of Harm - Minimal harm or potential for actual harm Residents Confined to Bed: 2. The nursing staff will prepare residents for eating. Residents Affected - Few Residents Requiring Full Assistance: 1. Nursing staff will remove trays from the food cart and deliver the trays to each resident's room; 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: b. Keeping interactions with other staff to a minimum while assisting residents with meals. All residents: 3. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 9 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to apply splints and braces to one (Resident #57) of seven residents requiring the use of supportive devices. Findings included: Resident #57 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified Alzheimer's disease, left knee contracture, swan-neck deformity of right fingers, unspecified polyosteoarthritis, and other specified joint contracture. The Quarterly Minimum Data Set, dated [DATE], identified that the resident had bilateral upper and lower extremity functional limitation in range of motion. An observation of Resident #57, on 3/14/22 at 10:24 a.m., revealed the resident was lying in bed. The residents' bilateral hands appeared to be contracted and a soft blue cylindrical device with an elastic band was observed lying on the blanket in front of the resident's left hand, no other upper extremity orthotic device was observed. On 3/15/22 at 11:14 a.m., Resident #57 was observed lying in bed with the head of the bed raised, dressed in a hospital gown, and with the soft blue cylindrical palm protecting device lying on the blanket, no other orthotic device was visible. An observation on 3/15/22 at 4:37 p.m., was conducted with Staff U, Registered Nurse (RN), of Resident #57 lying in bed. The resident had the soft blue palm protecting device with the elastic band around her left forearm. The observation revealed no other upper extremity orthotic device in use by the resident. Staff U retrieved a wrist splint and an elbow brace and stated that the resident had a couple of splints that staff applied after dinner. Staff U identified that the brace was for the residents' right elbow and the splint was for her left hand. When the Staff U observed the blue cylindrical device around the left forearm, she stated it doesn't go there, and moved it to the left antecubital area of the left arm with the soft portion on the inside and the white band on the outside of the elbow. The staff member stated that the resident did get out of bed, not often, during the day shift. An observation, on 3/16/22 at 8:03 a.m., identified that Staff P, agency CNA, served Resident #57 a meal tray that held multiple chopped food items. Staff P stated the resident did not require assistance. Staff R, CNA, informed Staff P the resident did require assistance and the meal consistency was not correct. The observation revealed that the resident was lying in bed, nonverbal and was not wearing any type of orthotic device. A physician order, dated 5/14/20, instructed staff to Apply bilateral hand and elbow splints while out of bed (OOB) as tolerated. Check skin integrity every (q) shift. (Every shift). This order was discontinued at 12:13 p.m. on 3/16/22. The March 2022 Treatment Administration Record indicated that staff had documented administered on the day, evening, and night shift. The documentation did not differentiate if the splints had been applied or that the residents skin integrity was checked. The TAR did not indicate how long Resident #57 had tolerated the splints. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 10 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An encounter note, signed by an Advanced Registered Nurse Practitioner (ARNP) on 3/9/22 at 1:14 p.m., identified that the provider visited Resident #57 as the resident was lying in bed and that the residents' fingers are contracted. A review of the progress notes revealed an Activity Participation note, 2/15/22, that identified Resident #57 was in a wheelchair at times. A Restorative program note, dated 2/4/22 at 3:08 p.m., identified that Passive Range of Motion (PROM) was completed to bilateral upper extremities and digits then arm braces were applied to both upper extremities and the right hand splint was applied. A Restorative note, dated 1/19/22, indicated the resident received Passive Range of Motion (PROM) to bilateral upper extremities, 15 repetitions in all planes and that upper body braces and right hand splint were applied for 4-6 hours or as tolerated. Therapy was notified of the resident's left hand becoming tight and the writer would often roll a wash cloth in left hand to help. The progress notes, from 1/19 to 3/16/22 did not include any further Restorative progress notes. The progress notes did not indicate that nursing staff had documented that splints had been applied or how long the resident tolerated wearing the devices. A review of the CNA Plan of Care (POC) Response History for Resident #57, identified staff had provided splinting assistance six times (3/4, 3/7, 3/8, 3/11, 3/12, 3/14, and 3/15/22) from 3/1 - 3/16/22. The POC history for staff providing range of motion (ROM) to the upper extremity was on 2/18/22 for 10 minutes. A review of Resident #57's care plan identified the resident had an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) impaired mobility and generalized weakness. (Resident) has swan-neck deformity of the right (R) fingers and muscle wasting and atrophy of left (L) hand. Restorative program: PROM bilateral (BIL) shoulder elbow and hand elbow orthotics and R resting hand splint. The interventions included but were not limited to Apply bilateral hand and elbow splints while OOB as tolerated, up to 6 hours - RESTORATIVE PROGRAM. The splint intervention was initiated on 5/14/20, revised on 11/19/21, and indicated the Licensed Practical Nurse (LPN) and/or Registered Nurse (RN) was responsible for the application of the splints. Staff V, RN stated on 3/16/22 at 9:30 a.m., Resident #57 had not been out of bed this week. Staff W, Physical Therapy Assistant (PTA), stated, on 3/16/22 at 10:27 a.m., she knew Resident #57 but did not know for sure who put the braces on the resident. Staff X, PTA, stated she thought restorative was putting them on the resident and did not think the resident was on (therapy) caseload anymore. On 3/16/22 at 10:45 a.m., Staff R, Certified Nursing Assistant (CNA), stated she did not think the facility had a restorative aide on staff today. The Assistant Director of Nursing (ADON) stated on 3/16/22 at 10:52 a.m., she did not think the facility had a restorative aide, all staff participated in the restorative program, and the nurses and CNA's put Resident #57's braces on. The ADON stated she would have to research the physician order regarding whose responsibility it was to put the braces on. A review of the physician order for the resident's braces indicated the braces were as needed and staff document by exception. Staff W, reported, during the ADON interview, the responsibility for applying Resident #57's braces and splints were nursing staff. The Director of Nursing (DON) entered the conversation and stated she had a turn over in the restorative department and had identified that CNA's could put braces/splints on. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 11 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the physician order would need to clarified as to what should occur when the resident did not get out of bed. The DON stated during a mock survey completed 2-3 weeks ago she had identified that there was an issue regarding braces/splints. The DON stated on 3/16/22 at 11:33 a.m., she had identified an issue with splints and braces and the facility had only one resident (Resident #57) with a truecontracture She stated she had identified an aide that was going to be trained to provide restorative services. The DON stated she had not educated any aides on the application of braces. The policy, Resident Mobility and Range of Motion, dated 2001 and revised July 2017, identified that Residents will not experience an avoidable reduction in range of motion (ROM), Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM, and Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The policy indicated that Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 12 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to ensure two (#28 and #64) of three sampled residents for unnecessary medications received insulin within the accepted parameter of before meals as ordered by the physician. Residents Affected - Few Findings include: 1. According to the admission Record, Resident #28 was admitted on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with diabetic cataract, and aphasia following cerebral infarction. A review of Physician Orders for Resident #28 on 5/11/22 revealed: - Novolin R Solution 100 unit/milliliter (mL) (Insulin Regular Human): Inject 5 unit subcutaneously with meals for Diabetes Mellitus (DM). - Novolin R Solution 100 unit/mL (Insulin Regular Human): Inject as per sliding scale: if 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 315-400 = 10 units. If greater than 400 give 10 units and call MD [medical doctor], subcutaneously before meals and at bedtime for DM. A review of Resident #28's May 2022 Medication Administration Record (MAR) on 5/11/22 at 10:37 a.m. identified Staff Member A, Licensed Practical Nurse (LPN) administered 4 units of Novolin R. The MAR indicated the insulin per sliding scale was scheduled at 11:00 a.m. and the order for 5 units with meals was scheduled for 12:00 noon. A review of the meal delivery times indicated the meal cart was to be delivered to Resident #28's hallway at 12:00 noon. During an interview on 5/11/22 at 10:52 a.m., the Director of Nursing (DON) stated insulin administration before meals was per physician orders, insulin should be given a half hour or forty-five minutes before the meal. During a Medication Administration observation, on 5/11/22 at 11:58 a.m., Staff Member A stated insulin orders would be available an hour before they are due and there was no standard time for insulin administration. Staff A stated short-acting insulin should be given a half hour or forty-five minutes before a meal, and confirmed he administered it when it pops up at the scheduled time of 44:00 a.m. The staff member confirmed at that time residents on the unit (Resident #28 and #64's) had not received the lunch meal. An observation at the time of the interview indicated a meal cart had not been delivered to the hallway. On 5/11/22 at 12:00 p.m., Resident #28 was observed in bed with eyes closed. On 5/11/22 at 12:16 p.m. a meal cart was observed on Resident #28's hallway and two residents, not including Resident #28, were observed with a lunch meal. A second meal cart was delivered on 5/11/22 at 12:18 p.m. to the hallway. Staff Member A was observed at 12:29 p.m. on 5/11/22 delivering and setting up a meal tray for Resident #28. The observation revealed Resident #28 received a meal one hour and fifty-two minutes after the MAR indicated the resident had been administered 4 units of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 13 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 short-acting recombinant human insulin, ordered to be administered before meals. Level of Harm - Minimal harm or potential for actual harm The Food and Drug Administration identified (https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/019938s066lbl.pdf) that Novolin R was a short-acting insulin used to improve glycemic control in adults with diabetes mellitus and should generally be injected approximately 30 minutes prior to the start of the meal. The website, Medscape, instructed that Novolin R be inject subcutaneously (sc) approximately 30 minutes before meals into the thigh, upper arm, abdomen, or buttocks. This information was located at https://reference.medscape.com/drug/humulin-r-novolin-r-insulin-regular-human-999007#11. Both sources were accessed on 05/11/22. Residents Affected - Few 2. According to the admission Record Resident #64 was admitted on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with diabetic neuropathy, and long term (current) use of insulin. A review of the Physician's Order Summary Report for Resident #64 revealed: - Novolog FlexPen Solution 100 unit/mL (Insulin Aspart): Inject as per sliding scale: if 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10, subcutaneously before meals and at bedtime for DM. If blood sugar (BS) less than 60 or greater than 401 call MD. A review, on 5/11/22 at 11:12 a.m., of Resident #64's May 2022 MAR identified the resident had been administered 2 units of the rapid-acting insulin, Novolog for a blood glucose level of 176 by Staff Member A, Licensed Practical Nurse (LPN). The MAR identified the residents' Novolog was scheduled to be administered at 11:30 a.m. The resident was observed lying in bed, on 5/11/22 at 12:16 p.m., and a meal cart was observed on the resident's hall at 12:18 p.m. On 5/11/22 at 12:40 p.m., observations indicated Resident #64 did not have a meal tray delivered or set up for her. The observation revealed that one hour and twenty-eight minutes after the MAR indicated the resident had received the rapid-acting insulin, the resident had not received a meal. During an interview on 5/11/22 at 1:45 p.m. the DON stated the time frame for insulin administration was what the physician ordered. She stated 30-45 minutes prior to a meal was appropriate unless the resident was snacking on peanut butter crackers. She reported she had entered Resident #64's room and the said the resident had refused lunch. A telephone interview was conducted, on 5/11/22 at 3:47 p.m. with the Consultant Pharmacist. The Pharmacist said it was up to the Physician to schedule medications and hopefully the orders would say one hour before and one hour after meals. Mynovoinsulin.com (https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html) identified that the rapid-acting insulin, Novolog, helps lower mealtime blood sugar spikes and starts acting fast. Eat a meal within 5 to 10 minutes after taking it. The manufacturer information (https://www.novo-pi.com/novolog.pdf) instructed users to inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks, or upper arm. The manufacturer identified that: Hypoglycemia is the most common adverse effect of all insulins, including NOVOLOG®. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (e.g., driving or operating other machinery). Hypoglycemia can happen suddenly, and symptoms may differ in each individual and change over time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 14 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the same individual, and the risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal. Sources were accessed on 05/11/22. Review of a facility-provided policy, Insulin Administration, revised September 2014, indicated the three key characteristics of insulin were: - a. Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose; - b. Peak effects - the time when the insulin is at its maximum effectiveness; and - c. Duration of effects - the length of time during which the insulin is effective. The guidelines of the policy identified the onset of a rapid-acting insulin (Novolog) was 10-15 minutes and peaked between 0.5 - 3 hours and the onset of a short-acting (Novolin R) insulin was 0.5 - 1 hour and peaked between 2.5 - 5 hours. An attempt was made, on 5/11/22 at 4:25 p.m., to contact the primary physician for Resident #28 and #64. The Physician's office stated they would have the Nurse Practitioner who visited the facility return the call; however, no return call was received by completion of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 15 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure psychotropic medications were monitored for patient-specific behaviors and staff documented observed behaviors for two (Residents #28 and #64) of five residents sampled for unnecessary medications. Findings included: 1. Resident #28 was admitted on [DATE]. The admission Record included diagnoses not limited to narcolepsy without cataplexy, unspecified convulsions, vascular dementia without behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, moderate recurrent major depressive disorder, and generalized anxiety disorder. The Order Summary Report, active as of 3/15/22, identified the following orders: - Antidepressant Medication - Bupropion. Monitor for weight gain, agitation, anxiety, insomnia, dry mouth, restlessness, fatigue, constipation, diarrhea, and headaches. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code Other/See Nurse's Notes' and progress note findings. Every shift related to unspecified single episode Major Depressive Disorder. - Behaviors - Monitor for the following: (specify) Picking at skin, restless movement, inappropriate sexual behavior, insomnia, repetitive verbalizations, excessive drying, destroying property, hitting, biting, kicking, spitting, throwing items, cursing, screaming, complaining, racial slurs, pacing, wandering, stealing, delusions, hallucinations, psychosis, refusing care, refusing treatment. Document Y if monitored and none of the above observed. N if monitored, and any, every shift. Observe behavior each shift; document exhibited behavior and intervention. The order was started on 3/7/22. - Bupropion Hydrochloride (HCl) tablet 75 milligram (mg) - Give 1 tablet by mouth two times a day for Major depressive disorder. The order started on 1/27/22. An observation on 3/13/22 at 11:02 a.m., identified Resident #28 was lying in bed wearing a hospital gown with a flat affect. On 3/14/22 at 10:15 a.m., the resident was dressed in a hospital gown and reported feeling terrible and began crying. Staff V, Registered Nurse (RN) was notified of the residents' crying at 10:16 a.m. on 3/14/22. Staff V stated she would look in on the resident and that Resident #28's son had recently passed away. A review of the March 2022 Medication Administration Record (MAR) identified Resident #28 had received Bupropion twice daily. The MAR indicated that the behaviors were administered according to the chart codes/follow up codes listed on the MAR and did not reveal a Y or N was used to designate whether behaviors had been exhibited. A review of the progress notes, on 3/16/22 at 1:35 p.m. did not reveal any progress notes made later than 3/11/22 and did not reveal that the resident had exhibited the behavior of crying. The Annual Minimum Data Set (MDS) dated 1/722, indicated Resident #28 did not exhibit any behaviors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 16 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 and had a mood score of 1, related to staff identifying that the resident appeared to be feeling down, depressed or hopeless 2-6 days of the comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm The care plan for Resident #28 indicated the following: Residents Affected - Few - resident has /potential for insomnia and had difficulty falling asleep and staying asleep. - A focus identified that Resident #28 had the potential for decline in MOOD related to (r/t) Generalized anxiety disorder (d/o) and adjustment d/o with mixed disturbance of emotion and conduct as evidence by (AEB) history (hx) of verbal aggression toward staff. An intervention instructed staff to Medication as ordered, observe for side effects and monitor for symptoms of anxiety and mood stability. - A focus indicated the resident had a tendency to cry at times. Resident has adjustment disorder with mixed disturbance of emotions and conduct. She often appears sad. She speaks few words. The interventions instructed staff to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. - Uses antidepressant medication r/t the diagnosis of Major Depressive d/o and is at risk for adverse effects. The interventions instructed staff to administer antidepressant medications and to observe/document/report as needed (prn) adverse reactions to antidepressant. 2. Resident #64 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified schizoaffective disorder and unspecified anxiety disorder. The Order Summary Report, active as of 3/16/22 at 12:37 p.m., indicated the following orders: - Antidepressant Medication - Bupropion. Monitor for weight gain, agitation, anxiety, insomnia, dry mouth, restlessness, fatigue, constipation, diarrhea, and headaches. Document: Y if monitored and none of the above observed. N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift. - Antipsychotic Medication - Risperdal. Monitor for dry mouth, constipation, blurred vision, difficulty urinating, hypotension, dark urine, yellow skin, Nausea/Vomit (N/V), lethargy, drooling Extrapyramidal Symptoms (EPS) (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift. - Behaviors - Monitor for the following: (specify) Picking at skin, restless movement, inappropriate sexual behavior, insomnia, repetitive verbalizations, excessive crying, destroying property, hitting, biting, kicking, spitting, throwing items, cursing, screaming, complaining, racial slurs, pacing, wandering, stealing, delusions, hallucinations, psychosis, refusing care, (and) refusing treatment. Document 'Y' if monitored and none of the above observed. 'N' if monitored, and any, every 8 hours. Observe behavior each shift; document exhibited behavior and intervention. - Bupropion HCl tablet 75 mg - Give 5 mg by mouth one time a day related to unspecified single episode Major Depressive Disorder, started on 11/18/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 17 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Risperdal 3 mg tablet - Give 1 tablet by mouth two times a day related to unspecified schizoaffective disorder. The care plan for Resident #64 included the following focuses with corresponding interventions: - Cognition: Resident has impaired cognitive function/dementia or impaired thought processes r/t difficulty making decisions, impaired decision making, psychotropic drug use, (and) short term memory loss. The interventions included instructions to Administer medications as ordered. Observe for side effects and effectiveness. - Mood: (Resident) used antidepressant medication r/t dx of Major Depressive d/o. The interventions instructed staff to administer antidepressant medications as ordered, monitor/document side effects and effectiveness, and to observe/document/report PRN adverse reactions to antidepressant therapy, change in behavior/mood/cognition. - Mood: (Resident) used antipsychotic medications r/t dx of schizoaffective disorder. The interventions included administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness, and to monitor/document/report PRN any adverse reactions of psychotropic medications. A review of Resident #64's Treatment Administration Record (TAR) indicated that staff had documented a checkmark for side effects of antidepressant and antipsychotic medications, which per chart codes indicated that the monitoring was administered. The instructions indicated that staff were to document Y or N for monitoring. The behavior monitoring included on the TAR did not indicate whether staff were monitoring for the behaviors related to antidepressant use or antipsychotic use. The monitoring for behaviors indicated NA at 6:00 a.m. on 3/7, 3/12, 3/12, and 3/14/22. On 3/15/22 at 11:35 a.m., Staff V stated behaviors were documented on the Treatment Administration Record (TAR) and reported behaviors were not patient-specific but random selected behaviors, and that staff could not document what behavior was exhibited just a yes or no. During an interview with the Director of Nursing (DON) on 3/15/22 at 3:50 p.m., she stated resident behaviors to be monitored should be patient specific and that the Resident #64 had schizoaffective disorder and did not have any behaviors. She reviewed the MAR and TAR for Resident #64 and identified that the behaviors to be monitored were not patient-specific. She stated she wished that they would know what behaviors patients did not exhibit all the time. The DON stated that she had been working on getting the monitoring patient-specific. A review of Resident #28's and Resident #64's MAR and TAR indicated that staff were documenting with a checkmark and not a Y or N. She stated that the documentation of Y or N were backwards and a N should be documented if no behaviors were exhibited. The observation of Resident #28's crying and notification to Staff V was discussed with the DON. The DON confirmed that the residents documentation (MAR, TAR, and progress notes) did not include documentation of the observed behavior. An interview was conducted on 3/16/22 at 8:41 a.m. with the psychology Advanced Registered Nurse Practitioner (ARNP). She stated that she knew the staff used checkmarks for behaviors and since every facility did things differently she adapted to the facility and did not make them adapt to her. She stated she gathers information with record reviews, observations, and interviews with staff and the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 18 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 A request was made multiple times for a policy related to psychotropic medication use. Level of Harm - Minimal harm or potential for actual harm The facility provided a policy for Antipsychotic Medication Use, dated 2001 and revised December 2016. The policy identified that: Residents Affected - Few - The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 19 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and two errors were identified for two (Resident s #44 and #16) of seven residents observed. These errors constituted a 7.69% medication error rate. Residents Affected - Few Findings included: 1. On 3/14/22 at 4:26 p.m., an observation of medication administration with Staff S, Licensed Practical Nurse (LPN), was conducted with Resident #44. Staff S was observed obtaining a blood glucose level of 307 from the resident. Staff S placed an Insulin pen needle onto a Novolin R insulin pen, dialed the dosage selector to 2 units, held the pen with the needle pointing downwards, and expressed the 2 units. Staff S dialed the dosage selector to 8 units, re-entered the resident room, washed hands, and without gloves the staff member injected the insulin into the residents right arm. Staff S stated, on 3/14/21 at 5:49 p.m., she primed the Insulin pens to ensure it came out and made sure the air did too. A review was conducted with Staff S member of the observation of holding the pen with the needle pointing downwards. The staff member confirmed holding the pen with the needle down and that the air bubble would not have been expressed. 2. On 3/14/22 at 5:32 p.m., an observation of medication administration with Staff T, Licensed Practical Nurse (LPN), was conducted with Resident #16. Staff T reported previously obtaining a blood sugar of 528 from the resident. After contacting the Advanced Registered Nurse Practitioner (ARNP) she removed a Lispro Insulin pen from the medication cart. Staff T placed a needle on the pen and dispensed the following medications: - Glipizide 5 milligram (mg) tablet - Metformin 1000 mg tablet - Lispro 15 units The staff member administered the oral medications to Resident #16 as the resident began eating dinner and administered 15 units of Insulin into the left upper arm. Immediately following the observation, Staff T reported priming with 2 units of Insulin after putting the needle on the Insulin pen then stated maybe she did not. On 3/15/22 at 3:46 p.m., the Director of Nursing (DON) stated that Insulin pens should be primed with 2 units and discarded. She stated that the air bubble in the Insulin pen would have been on top if the needle was held upside down. The DON reported that she was aware that Staff T had not primed the pen. The Consultant Pharmacist stated, on 3/16/22 at 12:19 p.m., an Insulin pen needed to be primed and confirmed the air bubble would not have been removed if the pen was held with the needle down. The policy, Insulin Administration, dated 2001 and revised September 2014, did not include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 20 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 information on the procedure for insulin administration via an Insulin pen. Level of Harm - Minimal harm or potential for actual harm According to the manufacturers' pharmaceutical insert, located at https://www.novo-pi.com/novolinr.pdf, instructed users to give an airshot before each injection: Residents Affected - Few -- Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin: -- Turn the dose selector to select 2 units. -- Hold your Novolin® R FlexPen® with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. -- Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. -- A drop of insulin should appear at the needle tip. If not, change the needle, and repeat the procedure no more than 6 times. -- If you do not see a drop of insulin after 6 times, do not use the Novolin® R FlexPen® and contact Novo Nordisk at [PHONE NUMBER]. -- A small air bubble may remain at the needle tip, but it will not be injected. The manufacturer for Lispro Kwikpen instructed users at https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, to prime the insulin pen before each use by selecting 2 units and while holding the pen with the needle pointing up, tap the cartridge holder to collect bubbles at the top then depress the dose knob until it reads 0. The instructions indicated users were to repeat the priming process no more than 4 times if insulin was not seen being extracted. The manufacturer indicated that: Prime before each injection: · Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. · If you do not prime before each injection, you may get too much or too little insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 21 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to (1) ensure medications were inaccessible to unauthorized personnel, residents, and visitors as evidence by leaving ten Insulin pens on top of one (200-hall) of four medication carts and (2) ensure medications were not left at bedside for one (Resident #27) of 30 sampled residents Findings included: 1. On 3/14/22 at 4:16 p.m., a random observation of the 200-hall revealed the floor nurse was in room [ROOM NUMBER] and the medication cart was parked further down the hallway. The observation identified the following Insulin pens on top of a locked unattended medication cart: - three Levemir pens - one Lantus Solostar pen - two Novolog pens - two Novolin R pens - one Lantus pen - one Humalog pen Staff U, Registered Nurse (RN), returned to the cart, approximately a minute later, and confirmed the findings. Staff U confirmed the pens should not have been left on top of the cart. On 3/16/22 at 12:19 p.m., the Consultant Pharmacist stated that finding the Insulin pens on top of an unattended medication cart was inappropriate. 2. During a facility tour on 03/13/22 at 9:55 a.m. to 10:48 a.m., medications were observed unattended on Resident #27's bedside table. The observed two tablets were in two separate plastic medicine dispensing cups. One of the tablets was a small round white pill. The second one was a large pink pill. (Photographic evidence was obtained) Resident #27 and her roommate were not in the room during the observation. The door was wide open. Other residents, staff and visitors were observed walking the hall outside Resident #27's room, with access to the unsecured medications. Review of the electronic medical record (EMR) for Resident #27 showed she was admitted to the facility on [DATE] with diagnoses to include unspecified dementia with behavioral disturbance, non-[NAME] Lymphoma, unspecified, and Gastro-esophageal Reflux disease. A review of the Minimum Data Set (MDS) for Resident #27 dated 01/07/22 showed a brief interview for mental status (BIMS) of 14 which indicated intact mental cognition. A care plan for Resident #27 dated 01/13/22 showed she was not care planned for self-administration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 22 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 of medication. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Resident #27 on 03/13/22 at 12:00 p.m. She confirmed that some nurses leave her medications on her bedside table. She stated the nurse had brought her the medications per her request due to pain and stomach acid. She stated she did not take the medications and said, I forgot they were there. Residents Affected - Few On 03/13/22 at 11:02 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). Staff F stated the expectation was that residents were to be supervised when taking medications. Staff F said, Yes, it should be eyes on supervision for all medication administration. I should not have left the medications there. It was my mistake. On 03/13/22 at 11:40 a.m., an interview was conducted with the Assistant Director of Nursing (ADON.) The ADON stated that all medications should have a physician's order. The ADON stated Resident #27 was planning to move to an ALF (assisted living facility) and they were waiting for an order to self-administer her medications. Further review of the EMR showed that Resident #27 did not have an order in place to self-administer medications. An interview was conducted on 03/13/22 at 11:45 a.m. with the Director of Nursing (DON). The DON confirmed medications should never be left unattended. The DON said, We have a lot of residents who wander. It is not safe. 03/15/22 3:34 p.m., an interview was conducted with the DON. She stated the medications should be administered per professional standards, We follow physician orders. The Storage of Medication policy, dated 2001 and revised November 2020, indicated that The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The Interpretation and Implementation of the policy identified that Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 23 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the Quality Assurance Committee was actively involved in the effective creation, implementation, and monitoring of the plan of correction (POC) for deficient practice identified during the annual recertification survey, conducted on 3/13/22 to 3/16/22. The facility developed a plan of correction with a completion date of 4/16/22. During a revisit survey conducted on 5/11/22 deficient practice was again identified at F758, F761, and F656 with an additional deficiency identified at F757. Findings include: The Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership policy, revised March 2020, identified that The quality assurance and performance improvement program was overseen and implemented by the QAPI committee, which reports its findings, actions, and results to the administrator and governing body. The interpretation and implementation of the policy indicated the following: - 1. The administrator, whether a member of the QAPI committee or not, it is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. - 2. The governing body is responsible for ensuring that the QAPI program: -- a. is implemented and maintained to address identified priorities; -- d. is based on data, resident and staff input, and other information that measures performance; and -- e. focuses on problems and opportunities that reflect processes, functions, and services provided to the residents. 4. The responsibilities of the QAPI committee are to: -- a. collect and analyze performance indicator data and other information; -- b. identify, evaluate, monitor, and improve facility systems and processes that support the delivery of care and services; -- c. identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process; -- g. coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; 1. The facility developed a plan of correction related to the monitoring of patient-specific behaviors for the use of psychotropic medications for two (#28 and #64) residents, which included the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 24 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some To ensure psychotropic medications are monitored for patient-specific behaviors, the following corrective action has been implemented. -Resident's #28 and #64 are monitored for patient-specific behaviors by nursing staff. Resident #28 was assessed by nursing staff for crying behaviors and documented findings. Resident #64 chart reviewed to ensure accurate behavior monitoring on 3/7, 3/12, and 3/14. All residents receiving psychotropic medications were audited by Director of Nursing (DON)/Designee to ensure proper monitoring and documentation is present. In an effort to clarify documentation, non-pharmacological interventions will be addressed in the nursing progress notes when utilized. Education was provided to all licensed staff by DON/Designee. regarding monitoring and documentation of patient-specific behaviors related to psychotropic medications. DON/Designee will perform audits for accuracy and completion of patient-specific behavior monitoring related to psychotropic medications weekly x [times] 4 then monthly until substantial compliance is achieved. Findings will be reported monthly to the Quality Assurance Committee until such time substantial compliance has been determined. The Director of Nursing (DON) reported on 5/11/22 at 1:45 p.m., the Treatment Administration Record (TAR) (where psychotropic medications were documented) did not include Y or N' and that a checkmark indicated that behaviors were monitored. During an interview on 5/11/22 at 4:30 p.m., the DON confirmed psychotropic medication monitoring should be individualized to the resident and she had added all the behaviors (to the physician order), so staff had references to possible behaviors. She confirmed two different residents receiving the same medication could exhibit different behaviors. Resident #28 was observed on 5/11/22 at 12:00 p.m., lying in bed with eyes closed. The admission Record for Resident #28 revealed diagnoses not limited to vascular dementia without behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, moderate recurrent major depressive disorder, generalized anxiety disorder, and primary insomnia. The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #28 had a Brief Interview of Mental Status (BIMS) score of 3 out of 14, indicative of a severe cognitive impairment. The MDS indicated that the resident received 7 days of an antidepressant medication during the assessment period. The Order Summary Report for Resident #28 included physician orders as follows: - Behaviors - Monitor for the following: (specify) Picking at skin, restless movement, inappropriate sexual behavior, insomnia, repetitive verbalizations, excessive crying, destroying property, hitting, biting, kicking, spitting, throwing items, cursing, screaming, complaining, racial slurs, pacing, wandering, stealing, delusions, hallucinations, psychosis, refusing care, (and) refusing treatment. Document Y if monitored and none of the above observed. N if monitored and any every 8 hours. Observe behavior each shift; document exhibited behavior and intervention. Dated 4/4/22. - Bupropion hydrochloride (HCl) 75 milligram (mg) tablet - Give 1 tablet by mouth two times a day for Major Depressive Disorder (MDD) related to Major Depressive Disorder recurrent moderate. Dated 1/27/22. A progress note, dated 5/2/22 at 5:18 a.m., indicated that Resident #28 had exhibited a behavior YES but did not identify the type of behavior exhibited. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 25 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #64 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified schizoaffective disorder, and unspecified anxiety disorder. The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #64 had a Brief Interview of Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview. The MDS indicated that the resident received 7 days of an antipsychotic and antidepressant during the assessment period. The Order Summary Report for Resident #64 included physician orders as follows: - Behaviors - Monitor for the following: (specify) Picking at skin, restless movement, inappropriate sexual behavior, insomnia, repetitive verbalizations, excessive crying, destroying property, hitting, biting, kicking, spitting, throwing items, cursing, screaming, complaining, racial slurs, pacing, wandering, stealing, delusions, hallucinations, psychosis, refusing care, (and) refusing treatment. Document Y if monitored and none of the above observed. N if monitored and any every 8 hours. Observe behavior each shift; document exhibited behavior and intervention. Dated 3/6/22. - Bupropion HCl 75 mg tablet - Give 75 mg by mouth one time a day related to unspecified single episode Major Depressive Disorder. - Risperdal 3 mg tablet - Give 1 tablet by moth two times a day related to unspecified schizoaffective disorder. During an interview on 5/11/22 at 12:37 p.m. Staff Member A, Licensed Practical Nurse (LPN), stated the only options to document (behaviors) were a Y, N, or n/a, if a behavior was observed the nurse had to document a note, which does not automatically generate. Review of both Resident #28 and Resident #64's physician orders indicated staff were to monitor for the same behaviors and did not indicate behaviors exhibited by the individual residents. The facility was 77 upon entry for the revisit survey on 5/11/22. The list of residents on psychotropic medications provided on 5/11/22 indicated 59 residents were receiving psychotropic medications. The random audit log provided by the facility indicated two residents were audited per four weeks all completed on 3/22/22 and one resident was audited one time monthly which was also completed on 3/22/22. The eight residents who were audited during the four week period did not include either Resident #28 or Resident #64, and the one resident audited for the monthly audit was neither resident. The Director of Nursing (DON) stated, on 5/11/22 at 3:06 p.m., after reviewing the audits completed for the monitoring of patient-specific behaviors, oh no thats wrong, let me fix it. The audit was returned identifying two residents, not including either Resident #28 or #64, were audited on 3/22, 3/29, 4/5, and 4/12/22, and the resident, who was not listed on the original audit, was completed on 4/19/22 for the one month audit. On 5/11/22 at 4:02 p.m., the DON stated random audits would consist of 40-50% of the affected residents, and 40-50% of the approximate number of residents on psychotropic medications would be 30. She confirmed two residents were audited weekly for a total eight residents in the four week period. 2. The facility developed a plan of correction related to the storage and labeling of medications that included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 26 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some To ensure medications are inaccessible to unauthorized personnel, residents, and visitors and ensure medications are not left at bedside, the following corrective actions has been implemented. Immediately removed medications that were observed unattended on Resident #27's bedside table. Residents #27 has current physician order and facility assessment in place for self-administration of medications. The insulin pens observed on top of the medication cart were immediately removed off the cart and placed inside the locked medication cart. DON/Designee completed full house audit to ensure resident's medications were secured in appropriate storage areas. Education provided by DON/Designee to all licensed nurses regarding 483.45(g) and Storage of Medication policy. DON/Designee will perform random audits weekly x 4 then monthly x 1 regarding storage of drugs and biologicals. Findings will be reported monthly to the Quality Assurance Committee until such time substantial compliance has been determined. An observation of the 200-wing medication cart was conducted on 5/11/22 at 9:22 a.m., with Staff Member A, Licensed Practical Nurse (LPN). The observation of the cart revealed one opened bottle of Levemir insulin that was delivered on 4/29/22 and was undated as to when it was opened. The staff member confirmed the insulin vial should have been dated when it was opened. According to rxlist.com (https://www.rxlist.com/levemir-drug.htm), Unrefrigerated Levemir vials should be discarded 42 days after they are first kept out of the refrigerator. Source accessed on 5/11/22. An observation was conducted on 5/11/22 at 9:29 a.m., of the 400-wing medication cart with Staff Member B, Registered Nurse (RN). An unopened vial of Novolin R was observed in the medication cart along with an opened bottle of Novolin R prescribed to the same resident. The pharmacy label of the unopened bottle of the insulin indicated it was delivered on 5/10/22. The staff member confirmed the unopened bottle of Novolin R should be stored in the refrigerator. The vial did not identify when it was removed from the refrigerator or when it was placed in the medication cart. The manufacturer information, located at https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/019938s066lbl.pdf, identified that an unopened bottle of Novolin R should be stored in the refrigerator or if carried as a spare or if refrigeration is not possible could be kept at room temperature if kept as cool as possible (not above 77 degrees Fahrenheit (F). Vials of opened or unopened vials of Novolin R can be stored for 42 days at room temperature up to 77 degrees Fahrenheit. Source accessed on 5/11/22. The facility-provided policy titled, Storage of Medications, revised November 2020, indicated medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. 3. Observations of Resident #64 on 5/11/22 at 10:30 AM revealed the resident lying in bed, eyes closed, and no discomfort noted. A catheter bag was observed hanging on the side of the bed with clear urine noted. Review of the resident's record revealed she was admitted to the facility on [DATE] and diagnosis that included End Stage COPD (Chronic Obstructive Airway Disease), and Morbid Obesity. Review of the resident's current Physician's Orders included Indwelling Urinary Catheter -size 16fr [French]/10ml [milliliters] for diagnosis Obstructive Uropathy with a start date of 11/2/21; Indwelling Urinary Catheter care Q [every] shift and PRN [as needed] with a start date of 11/2/21. Further review of the record revealed no care plan was present related to the presence or care of an indwelling catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 27 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/12/21 at 2:55 PM with the Nursing Home Administrator (NHA), and the Director of Nursing (DON), the DON reviewed Resident #64's record and was unable to locate a care plan related to the resident's use of a urine catheter. A request to speak to the Minimum Data Set (MDS) Coordinator at this time revealed there currently was no MDS staff person in the building. The DON reported it was her expectation that residents who had urine catheters was to obtain a physician order, follow the orders, and notify the Physician of any changes. Both the NHA, and the DON reviewed the chart and confirmed there was no care plan related to the presence of a catheter. The DON reported while doing the facility's plan of correction (POC), she did not check for the presence of a care plan. Observations of Resident #6 on 5/11/22 at 9:40 AM revealed the resident was lying in bed appropriately dressed and groomed with catheter bag hanging on the side of the bed. An interview conducted with the resident on 5/11/22 at 3:30 PM revealed the resident was not in pain, and some of the staff deal with his catheter, but some don't know what they are doing. Review of the resident's record revealed Physician Orders that included Indwelling catheter monitor output Q shift, if <300ml notify physician with a start date of 4/22/22; Indwelling catheter 16fr/10ml for diagnosis [blank]. Further review of the record revealed no diagnosis present for the use of the urinary catheter. Additional record review revealed no care plan was present in the record related to the presence or care of an indwelling catheter. During an interview with the DON on 5/12/22 at 3:40 PM, she confirmed there was no care plan present in the resident record related to the use of a catheter. The DON confirmed during POC audits, she did not check for the presence of a care plan, and as this resident was recently re-admitted , the resident was not audited. A review of the POC urine catheter audits indicated Random Audits Daily x [times] 7 then Weekly. Resident #64 was part of the audit on two occasions, and Resident #6 did not appear on the audit sheet. Review of the audit sheet with the DON revealed she completed the audit of all residents with catheters daily for seven days, and then one resident was audited one time weekly for four weeks. The DON reported nurses were not involved in doing the audits as she completed them herself. The DON was unable to provide documentation to support this information. Review of the facility policy titled Catheter Care, Urinary with a revised date of September 2014 revealed under the sub-title Preparation: 1. Review the residents care plan to assess for any special needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 28 of 29 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure all essential members of the Quality Assurance Committee attended the meeting and were involved with the discussion and implementation of the plan of correction regarding the deficiencies identified during the annual recertification survey conducted on 3/13/22 to 3/16/22. Residents Affected - Few Findings include: The roster of attendance for the Risk Management/Quality Assurance Committee meeting, dated 3/23/22, did not identify the Medical Director attended or was involved via other means. Also, the Medical Director did not attend or was involved in the Licensed Independent Practitioners (LIP) Credentialing Committee also held on 3/23/22. During an interview, on 5/11/22 at 4:02 p.m., the Nursing Home Administrator (NHA) reviewed the roster of attendees of the QAPI meeting on 3/23/22. She confirmed the roster did not identify the Medical Director had attended. She stated she had a hard time believing he was not there, and he must have forgotten to sign in. She stated after the exit conference for the annual survey on 3/16/22 she had a telephone conversation with him regarding the findings and they discussed the deficiencies, auditing, and problems with education. The policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, revised March 2020, indicated the Medical Director served on the committee along with other members of the facility management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105343 If continuation sheet Page 29 of 29