Inspection·February 12, 2021

F 0550 drainage bag is covered with a privacy bag unless resident requests otherwise. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 2 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 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 reviews, the facility failed to ensure self-administration of medications was clinically appropriate for one resident (#28) of four residents sampled for medication administration. Residents Affected - Few Findings included: A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 utilized oxygen therapy secondary to COPD. Interventions included medications, nebulizers, and puffers as ordered. A review of Resident #28's Physician Order Report from 1/11/21 to 2/11/21 revealed an order, dated 12/23/2020, for ipratropium-albuterol solution for nebulization, 0.5 milligrams (mg) - 3 mg per 3 milliliter (ml) solution; 1 dose inhalation three times a day for a diagnosis of COPD. An observation was made on 02/10/2021 at 11:03 a.m. of Resident #28 resting in bed in her room. Resident #28 had a nebulizer mask on her face, which was attached to the running nebulizer machine on her nightstand. No staff were observed in the resident's room at the time of the observation. An interview was conducted on 02/10/2021 at 11:06 a.m. with Staff Q, Registered Nurse (RN), who was at the nurse's station. Staff Q, RN stated that Resident #28 had not been assessed for self-administration of medications and that the resident was totally dependent on staff for her care. An interview was conducted on 02/11/2021 at 03:57 p.m. with the facility's Director of Nursing (DON). The DON stated that residents may administer their own nebulizer treatments if a self-administration assessment is conducted, and if it is within the resident's plan of care. The DON also stated that it would not be acceptable to leave a nebulizer treatment and walk out of the room if the resident is not able to self-administer the medication. An observation of medication administration was conducted on 02/12/2021 at 09:32 a.m. with Staff E, Licensed Practical Nurse (LPN) for Resident #28. Staff E, LPN was observed preparing ipratropium-albuterol 0.5 mg - 3 mg per 3 ml solution for administration via nebulizer mask for Resident #28. Staff E, LPN was observed pouring the medication into the chamber of the nebulizer mask, applying the mask to Resident #28's face, and turning on the nebulizer. Staff E, LPN then explained to Resident #28 that she would be back in about 15 minutes to take the mask off and exited the room. An interview was conducted with Staff E, LPN following the observation at 10:12 a.m. Staff E, LPN stated that Resident #28 had not been assessed for self-administration of medications, but that she would normally stay near the resident's room and monitor the administration until it was completed. A telephone interview was conducted on 02/19/2021 at 02:24 p.m. with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that staff at the facility were educated on proper administration of nebulizer treatments to residents and that nurses should be in the room and available to the resident during the administration unless the resident is able to self-administer the medication. If a resident is able to put on and take off the nebulizer mask themselves, then an order would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 3 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 obtained, and an assessment would be conducted for self-administration of medications. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled, Medication Administration - Nebulizers, dated 09/2010, revealed under the section titled Procedures, that staff were to remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 4 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide a clean and homelike environment by leaving resident personal belongings in bags and boxes for five residents (#8, #10, #28, #35, and #41) of 26 sampled residents for four of four days. Findings included: 1. A review of Resident #8's medical record revealed that Resident #8 was admitted to the facility on [DATE] with diagnoses of dementia, COVID-19, cognitive communication deficit, and need for assistance with personal care. An observation was made on 02/10/2021 at 11:45 a.m. of Resident #8 eating lunch in his room. A large box was observed in the corner of Resident #8's room containing several belongings. An interview was conducted with Staff H, Certified Nursing Assistant (CNA) following the observation. Staff H, CNA stated that the large box in Resident #8's room contained his personal belongings from his previous room and they had not yet been put away. Staff H, CNA also stated that Resident #8's belongings were not unpacked and put away because he was not staying in the room for very long and he would be returning to his previous room. Staff H, CNA stated that Resident #8 also had a television out in the storage shed and that it was not brought to his room because he would be moving out of the room soon. An interview was conducted on 02/10/2021 at 11:50 a.m. with Staff I, Licensed Practical Nurse (LPN). Staff I, LPN stated that Resident #8 was staying on the unit temporarily and that all of his belongings were not brought over to his current room. Staff I, LPN was not able to state why Resident #8's belongings were not put away when he moved into the room and was not able to state how long Resident #8 would remain on the unit for. Staff H, CNA stated during the interview that Resident #8 refused to have his belongings put away, which is why they were still in a box in his room. Staff H, CNA was not able to state where Resident #8's refusal was documented. 2. A review of Resident #10's medical record revealed that Resident #10 was admitted to the facility on [DATE] with diagnoses of dementia and COVID-19. An observation was made on 02/11/2021 at 09:54 a.m. in Resident #10's room. A large, clear bag was observed in the corner of Resident #10's room on the floor. The bag appeared to contain several blankets and other resident belongings. An interview was conducted following the observation with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN was not able to explain why the bag was on the floor of Resident #10's room and was not able to state who the bag belonged to. 3. A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with a diagnosis of hemiplegia. An observation was made on 02/11/2021 at 09:37 a.m. of Resident #28's room. A large, clear bag of belongings was observed on the floor of Resident #28's room underneath the sink. An interview was conducted following the observation with Staff F, LPN. Staff F, LPN stated that the bag of belongings should not be stored underneath of the resident's sink and was not able to state why the belongings were put there. Staff F, LPN also stated that she had concerns with resident belongings being kept in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 5 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bags and boxes and placed on the floor and that the concerns were mentioned to administrative staff, but nothing was done about it. An interview was conducted on 02/11/2021 at 12:57 p.m. with Staff G, CNA. Staff G, CNA stated that Resident #28's bag of belongings were placed in the MDS (Minimum Data Set) office. Staff G, CNA was not able to state why the belongings were not put away but stated that someone told her to put them there. An observation was made following the interview of the MDS office. The clear bag of Resident #28's belongings were observed on the floor of the office next to Staff J, MDS Nurse. An interview was conducted with Staff J, MDS Nurse, who was not able to state why the belongings were placed in the MDS office. A tour was conducted at 02/11/2021 at 01:01 p.m. with the facility's Director of Nursing (DON). The DON observed Resident #28's belongings in the MDS office and was not able to state why the belongings were brought to the office and not put away in Resident #28's room. The DON also observed the bag of belongings on the floor of Resident #10's room and stated that the belongings should not be kept in bags and boxes or placed on the floor. The DON stated that the items should have been put away. An interview was conducted on 02/11/2021 at 01:08 p.m. with the facility's Assistance Director of Nursing (ADON). The ADON stated that when a resident was diagnosed with COVID-19, belongings were boxed up and stored in the storage shed with the exception of five outfits for the resident. Once the resident is off of the COVID-19, the belongings should be returned to the resident. The ADON stated that CNAs bring the resident's belongings back to the resident's room and should put them away. Resident belongings should not be left laying on the floor and should be stored in the resident's dresser or closet. An interview was conducted on 02/11/2021 at 01:16 p.m. with Staff B, MDS Nurse. Staff B, MDS Nurse stated that Resident #28's belongings were placed in the MDS office because they had not had a chance to go through the bag to determine what Resident #28 needed. Staff B, MDS Nurse addressed that resident belongings should be put away when a resident returned to their room and should not be placed on the floor of the room. An interview was conducted on 02/11/2021 at 01:20 p.m. with Staff D, Supply in the facility's storage shed. Staff D, Supply stated that when a resident is transferred to the COVID-19 unit, all belongings get packed up and stored in the storage shed except for five outfits. Belongings are returned to residents once they are able to leave the COVID-19 unit. Several boxes with labels and signs that read Who's Stuff? was observed on the top shelf of the storage shed. Staff D, Supply stated that sometimes belongings were not labeled correctly by staff before storing them, so they had several unclaimed belongings in those boxes. (Photographic evidence obtained) 4. A review of the medical record for Resident #35 revealed that Resident #35 was readmitted to the facility on [DATE] with an original admission date of 7/07/2014. Resident #35's diagnoses included COVID-19, and anxiety. In a quarterly MDS (minimum data set) assessment dated [DATE], the resident was assessed to have a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 02/09/21 at 11:50 a.m. Resident #35's belongings were observed in bags in the wheelchair that was next to her bed, and on top of her dresser near the door. On 02/10/21 at 10:37 a.m. the resident's belongings were observed in bags in the wheelchair and on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 6 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 0584 top of the dresser. Level of Harm - Minimal harm or potential for actual harm On 02/10/21 at 03:05 p.m. the resident's belongings were observed in bags in the wheelchair and on top of the dresser. Residents Affected - Some On 02/11/21 at 08:35 a.m. the resident's belongings were observed in bags in the wheelchair and on top of the dresser. 5. A review of Resident #41's medical record revealed that Resident #41 was admitted to the facility on [DATE] with the most recent readmission date being 1/21/2021 for diagnoses that included but not limited to chronic pain, fever, insomnia, cough, nausea with vomiting and depressive episodes. On 02/09/21 at 11:15 a.m., Resident #41 said that when she was moved to the COVID unit, they (the facility) packed up her personal items and that since moving back to her original room, she has yet to get it back. She said that she has asked, but whoever she asks, doesn't know where it is. She said it's getting old that no one knows where her stuff is. On 02/11/21 at 02:55 p.m. Resident #41 said that someone brought her personal items back to her last night (02/10/21). The staff member did not put it away, but instead left it sitting in multiple boxes on top of her bedside dresser, and she said that a box was sitting in her closet unpacked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 7 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to make prompt efforts to resolve a grievance for one resident (#9) of one resident sampled for grievances. Findings included: A review of Resident #9's medical record revealed that Resident #9 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit and need for assistance with personal care. An interview was conducted on 02/10/2021 at 11:03 a.m. with Resident #9. Resident #9 stated that her dentures were missing for two days. Resident #9 also stated that she wrapped her dentures in a brown paper napkin and placed them on her bedside table. When she woke up the next morning, they were gone from her bedside table. Resident #9 stated that she was not sure what the facility was doing regarding her missing dentures and she reported that they were missing to the nursing staff. A review of Resident #9's Progress Notes revealed a note, dated 02/03/2021 at 11:22 a.m., that a Certified Nursing Assistant (CNA) reported to the nurse that Resident #9's dentures were reported missing. Resident #9 told the CNA that she wrapped the dentures in a brown paper napkin on the night of 02/02/2021 and left them on her bedside table. The note revealed that the nurse reported the lost dentures to the Director of Nursing (DON) and administration. A review of the facility's Grievance Log revealed a grievance, dated 02/03/2021, that Resident #9 had a grievance related to missing dentures. No documentation was revealed under the sections titled Follow-Up Investigation or Resolution. An interview was conducted on 02/11/2021 at 11:58 a.m. with the facility's Nursing Home Administrator (NHA). The NHA stated that he was informed of Resident #9's missing dentures on 02/08/2021. The NHA was not able to state why the concern was not reported sooner than 02/08/2021. The NHA stated that his initial goal was to close out the investigation on 02/08/2021 but the grievance was not investigated by then. Typically, the goal would be to resolve a grievance within three days of the grievance being reported and to strive toward resolving grievances as quickly as possible. The NHA stated that staff were aware that Resident #9's dentures were missing and that efforts were being made to locate them. An interview was conducted on 02/11/2021 at 12:45 p.m. with Staff G, CNA. Staff G was assigned to Resident #9's care for the 7:00 a.m. to 3:00 p.m. shift. Staff G, CNA stated that she was not aware that Resident #9's dentures were missing. Staff G, CNA spoke with Resident #9 and confirmed with her that the dentures were missing. A review of the facility policy titled, Investigate Complaint/Grievance, revised on 07/19/2018, revealed that all grievance and complaint reports must be resolved and reviewed by the NHA within 3 working days of the receipt of the grievance or complaint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 8 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan that included minimum healthcare information necessary to properly care for two residents (#2 and #276) of nine residents with an indwelling urine catheter. Findings included: On 02/11/2021 at 10:10 a.m. an observation of Resident #276 revealed the resident had an indwelling urine catheter. The indwelling catheter bag was observed in a vanity cover and laying flat on the floor under the bed. On 02/11/2021 at 10:23 a.m. an observation of Resident #2 revealed the resident had an indwelling urine catheter. The indwelling catheter bag was observed in a vanity cover and laying flat on the floor. Review of the clinical record for Resident #276 showed an admission date of 01/11/2021 and admitting diagnoses that included, but not limited to muscle weakness, COVID-19, pneumonia, hypertension and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed the resident had an indwelling urinary catheter. Further review of the clinical record on 02/10/2021 at 8:00 a.m. revealed no documentation of the indwelling urinary catheter on the care plan, as well as no interventions or goals for the catheter and care. A subsequent review of the clinical record on 02/11/2021 at 8:38 a.m. showed a problem of indwelling catheter added to the care plan, with a problem start date of 02/10/2021 and a revised date of 02/11/2021. Interventions included provide catheter care as ordered. Further review of the Physician Order Report 1/11/21 - 2/11/21 showed no physician's order for the indwelling urinary catheter or care modalities. A review of CMS Form 3008 dated 01/11/2021 showed the indwelling urinary catheter was inserted on 01/9/2021 at 13:00 (1:00 p.m.) in the hospital for urine retention. Review of the clinical record for Resident #2 revealed an admission date of 07/04/2019, a readmission date of 01/21/2021 and admitting diagnoses that included, but not limited to hydronephrosis with renal and ureteral calculi obstruction, pyelonephritis, and COVID-19. The Physician Order Report dated 1/11/21 2/11/21 showed physician orders for: Flush/irrigate catheter with 60ml [milliliters] NS [Normal Saline] for leakage/blockage, catheter to straight drainage for obstructive uropathy, change catheter PRN [as needed] for leakage/blockage/dislodgement; contact doctor if balloon size changed is required, record output every shift, and catheter care every shift. The record also indicated the resident was on Contact Precautions for colonized ESBL (Extended Spectrum beta-lactamases) in the urine. The 5-day MDS dated [DATE] revealed the resident had a urinary catheter. The active care plan was reviewed and did not indicate any listed problems, goals, or interventions related to the indwelling urinary catheter. On 02/11/2021 at 10:26 a.m. an interview was conducted with Resident #2. He stated he had been at the facility for several years and just recently came back after a trip to the hospital. He said he had a catheter as he had an infection in his urine, and it was put in at the hospital. On 02/11/2021 at 10:32 a.m., an interview with Staff A, Registered Nurse (RN) confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 9 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 0655 resident had an indwelling urine catheter and was on contact precautions for ESBL in his urine. Level of Harm - Minimal harm or potential for actual harm An interview with Staff B, MDS RN was conducted on 02/11/2021 at 2:51 p.m. Staff B, MDS RN stated care plans are updated by the resident's nurse as well as the multi-disciplinary team and discussed each morning at the team meetings. She stated the care plan for Resident #276 was updated yesterday; however, she confirmed the indwelling urine catheter should have been added to the care plan upon the resident's admission. Staff B, MDS RN also said she was unaware that the care plan for Resident #2 did not include his indwelling urinary catheter, and further stated it should have been added upon his re-admission. Residents Affected - Few During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 02/11/2021 at 2:59 p.m., the DON stated it was her expectation that indwelling urinary catheters would be included in the resident's care plan upon admission or readmission. A review of a facility-provided policy titled, Comprehensive Care Plans, and dated 07/19/2018 revealed: 2. The Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to, the Resident Assessment Instrument. 9. Care Plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident's goals. 13. Care Plans are ongoing and revised as information about the resident and the resident's condition change. 14. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. The policy did not address baseline care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 10 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility policy, the facility failed to store respiratory equipment in accordance with professional standards of practice for two residents (#28 and #35) of three residents sampled for respiratory care. Residents Affected - Few Findings included: 1. A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 utilized oxygen therapy secondary to COPD. Interventions included medications, nebulizers, and puffers as ordered. A review of Resident #28's Physician Order Report dated 1/11/21 - 2/11/21 revealed a physician's order, dated 12/23/2020, for ipratropium-albuterol solution for nebulization, 0.5 milligrams (mg) - 3 mg per 3 milliliter (ml) solution; 1 dose inhalation three times a day for a diagnosis of COPD. An observation was made on 02/10/2021 at 11:06 a.m. of Staff Q, Registered Nurse (RN) removing a nebulizer mask from Resident #28 following a nebulizer treatment. Staff Q, RN was observed removing the mask from Resident #28 and placing the mask on the nebulizer machine on Resident #28's nightstand. Staff Q, RN stated that she would normally wipe off the nebulizer mask and place the mask upright next to the machine. Staff Q, RN also stated that she did not store the nebulizer mask inside of a storage bag after nebulizer treatments. An observation was made on 02/11/2021 at 09:16 a.m. in Resident #28's room. Resident #28's nebulizer mask was observed laying on top of the nebulizer machine on Resident #28's night stand. An interview was conducted with Staff E, Licensed Practical Nurse (LPN) following the observation. Staff E, LPN stated that Resident #28's nebulizer mask should not be laying on the night stand and that the nebulizer mask should have been stored inside of a plastic bag with the resident's name and date. Staff E, LPN was not able to state why Resident #28's nebulizer mask was not stored properly. A interview was conducted on 02/11/2021 at 03:57 p.m. with the facility's Director of Nursing (DON). The DON stated that respiratory equipment was replaced on a weekly basis, including oxygen tubing and nebulizer equipment. All oxygen tubing and nebulizer equipment should be dated and have a bag included with the date on it for storage purposes. The DON stated that respiratory equipment should be stored in a plastic bag when it was not in use and that it would not be acceptable to store a nebulizer mask on the resident's night stand because it could get dirty. A review of a facility policy titled, Nebulizers, dated 09/2010, revealed that after treatment nursing staff rinse and disinfect the nebulizer equipment according to manufacturer's recommendations and facility policy. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Change equipment and tubing per nursing facility policy. A review of the facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, revealed under the section titled, Infection Control Considerations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 11 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Related to Oxygen Administration, to change the oxygen cannula and tubing every 7 days, or as needed and to keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use. The policy also revealed, under the section titled, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol, to remove the nebulizer container, rinse the container with fresh tap water, and dry on a clean paper towel or gauze sponge after use. Reconnect to the administration set-up when air dried and store the circuit in a plastic bag marked with the date and the resident's name between uses. (Photographic evidence obtained.) 2. A review of the medical record for Resident #35 revealed that Resident #35 was admitted to the facility on [DATE] for diagnoses that included COVID-19, viral pneumonia, and anxiety. A review of Resident #35's active physician orders included: Oxygen therapy: oxygen via NC (nasal cannula) @ (at) 2 liters per minute continuously dated 12/14/2020 with no end date, and oxygen therapy: verify that tubing is changed weekly once a day on Wednesday dated 12/14/2020. A review of the care plan initiated on 10/23/19 and edited on 12/21/20 revealed that Resident #35 had a problem documented as, [Resident #35] has a pulmonary condition/DX [diagnosis] and has the potential for difficulty breathing . Interventions included: Administer O2 (oxygen) as ordered. On 02/09/21 at 11:50 a.m., it was noticed that Resident #35 had an oxygen concentrator next to her bed. The concentrator was off, and the resident was not wearing a nasal cannula. The oxygen tubing was lying over the top of the concentrator undated and unbagged. On 02/10/21 at 10:37 a.m. Resident #35 was observed lying in bed with no oxygen on. The oxygen concentrator was against the wall next to her roommate's bed with the tubing lying over the top of it without being bagged or dated. (Photographic evidence obtained.) On 02/10/21 at 03:05 p.m. Resident #35 was lying in bed without oxygen on, the tubing was lying over the top of the concentrator, unbagged and undated. On 02/11/21 at 08:35 a.m. the resident was observed lying in bed with no oxygen on. The tubing was lying over the top of the concentrator, unbagged and undated. On 02/11/21 at 12:45 p.m. an interview was conducted with Staff M, Registered Nurse (RN) Consultant and the Interim Director of Nursing (DON). They both said that the tubing on all oxygen should be changed weekly, and there should be a bag for the nasal cannula for when the tubing is not in use. The tubing should be dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 12 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards in one medication room (100 unit) of two medication storage rooms in the facility and two (100 unit and 200 unit) of six medication carts in the facility. Findings included: A medication cart inspection on the 100 unit was completed on 02/12/2021 at 11:42 a.m. with Staff E, Licensed Practical Nurse (LPN). A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. An observation of the label revealed text that read Use within 90 days (3 months) of first opening. Staff E, LPN stated that they were never told that they needed to date blood glucose test strips once they were opened and observed that label. Staff E, LPN addressed that the blood glucose test strips should be dated per the label instructions. A medication storage room inspection on the 100 unit was completed on 02/12/2021 at 12:01 p.m. with Staff E, LPN. An inspection of a medication storage refrigerator revealed a temperature log, last completed on 02/09/2021. No entries were observed for 02/10/2021 or 02/11/2021. An inspection of a narcotics storage refrigerator also revealed a temperature log, last completed on 02/09/2021. No entries were observed for 02/10/2021 or 02/11/2021. Staff E, LPN stated that the 11 PM to 7 AM staff were responsible for completing the temperature logs and that it should be completed daily. Two large boxes of various medications were observed on the counter in the medication storage room. Staff E, LPN stated that the 11 PM to 7 AM shift was also responsible for documenting and completing the return of medications to the pharmacy and was not sure why so many were being kept in the medication storage room. An interview was conducted on 02/12/2021 at 12:27 p.m. with the facility's Director of Nursing (DON). The DON stated that the temperature log for the medication refrigerators should have been completed daily by the 11 PM to 7 AM shift. The DON also stated that the 11 PM to 7 AM shift returned medications to the pharmacy by putting the medications in bags and conducting an inventory of the medications. The DON addressed that the medications were not inventoried, and stated that the medications should not accumulate in large quantities in the medication storage room. The DON also stated that blood glucose monitoring strips should be dated upon opening in accordance with the label instructions. A medication cart inspection on the 200 unit was completed on 02/12/2021 at 12:31 p.m. with Staff F, LPN. A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. An observation of the label revealed text that read Use within 90 days (3 months) of first opening. Staff F, LPN stated that they did not date blood glucose test strips upon opening and asked for what reason?. A vial of Levemir insulin was observed in the medication cart, with a label that read Discard after 42 days. The label had two sections, which read, Date Vial Opened and Date Vial Expires which were not dated. The manufacturer's box that the Levemir insulin was stored in also had a label that read Date Opened, which was not dated. A vial of Lantus insulin was observed in the medication cart, with a label that read Discard unused portion 28 days after opening, and a section that read, Date Opened, which was not dated. The manufacturer's box that the Lantus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 13 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870 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 insulin was stored in also had a label that read Date Opened, which was not dated. Staff F, LPN stated that the insulins should have been dated when they were opened and was not able to state why the insulins were not dated. A telephone interview was conducted on 02/19/2021 at 02:24 p.m. with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that she conducted monthly visits to the facility and conducted spot checks of the medication carts and the medication rooms. Expiration dates of medications, dating of medications, dating of glucose test strips, temperature logs, and medication storage and stock were all things that she checked during visits to the facility. The Consultant Pharmacist stated that the nursing staff dropping off medications to go back to the pharmacy had been a challenge because the nursing staff often forget to bring the boxes to the front of the facility for pickup, so there may be a few more than usual. The Consultant Pharmacist stated that blood glucose monitoring strips and insulins should be dated once they are opened. A review of the facility policy titled, Medications and Medication Labels, dated on 05/2016, revealed that multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications. Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label. A review of the facility policy titled, Storage of Medication, dated 09/2018, revealed that medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify temperature has remained within accepted limits. (Photographic evidence obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 14 of 14