Inspection·May 12, 2022

F 0657 4/22/22 8:47 a.m. Patient refuses all medications this AM when asked why she was refusing meds she stated very loudly its none of your business, but if you need to know they are making me sick. Level of Harm - Minimal harm or potential for actual harm 4/7/22 11:33 p.m. Resident refused skin check X 2. Stated that her skin is fine. Residents Affected - Few A review of the Comprehensive Care Plan for Resident #21 revealed the following: Problem: Behavioral: Resident has unrealistic goals (edited 5/10/2022) Goal: Adjustment to new baseline with her ADLs (Activities of Daily Living) Approach: Psych (Psychiatric) consult The care plan did not indicate a behavioral concern related to refusal of medications, treatments, or nursing care for the resident. On 5/12/22 at 12:32 p.m., Staff H, Certified Nurse Aide (CNA) stated Resident #21 refuses care and medications often. She stated the resident was having a good day and had been cooperative, but some days the resident is very uncooperative and will not let the nurse aides do anything. Staff H stated she has to be patient with Resident #21 and give her time to adjust to what needs to be done. Staff H stated when the resident becomes combative, she lets the nurse know so they can assess the resident. On 5/12/22 at 12:44 p.m., Staff C, Licensed Practical Nurse (LPN) stated Resident #21 refuses her medications a lot and this has been going on for the last month or so. She stated Resident #21 is touch and go, and today she is pretty good. She stated when a resident refuses medications they document it on the MAR and notify the provider. She stated the NP was very familiar with the resident and was at the facility at least 3 to 4 days a week. She stated the MDS department was responsible for updates to the care plan. She confirmed there was no problem listed for the refusal of medications and treatments for Resident #21 on the current care plan. On 5/12/22 at 12:52 p.m., the MDS Coordinator, RN (Registered Nurse) stated if a resident has behaviors like refusal of medications and treatments this should be on the plan of care for the resident. She stated behavior care plans were driven by social services. After reviewing the most recent assessment for Resident #21, she confirmed the nursing notes are reflective of refusal of care and medications and stated it did not trigger in the assessment, but it should have. She confirmed the care plan should have a behavior problem area addressing the refusal of medications and treatment. A review of the policy titled Care Plans, Comprehensive Person-Centered with a revised date of December 2016 indicated the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 2 of 17 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 05/12/2022 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 0657 8. The comprehensive, person-centered care plan will: Level of Harm - Minimal harm or potential for actual harm a. Include measurable objectives and timeframes. g. Incorporate identified problem areas. Residents Affected - Few h. Incorporate risk factors associated with identified problems. m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 3 of 17 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 05/12/2022 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to provide dressing changes to an intravenous (IV) catheter site in accordance with physician orders for one (#5) of four residents in the facility receiving IV therapy. Residents Affected - Few Findings included: During a facility tour conducted on 05/09/22 at 10:01 AM, Resident #5 was observed laying on bed. Resident #5 was noted with a peripherally inserted central catheter (PICC) line with a gauze dressing dated 04/01/22 14:00 hours (2:00 PM) on the left arm. An attempt to interview Resident #5 was unsuccessful. (Photographic evidence was obtained.) A minimum data set (MDS) assessment for Resident #5 dated 03/30/22, section C cognitive patterns showed Resident #5 was not able to complete the brief interview for mental status interview, indicating severe cognitive impairment. Section G functional status showed Resident #5 required extensive assistance and dependency on staff for activities of daily living (ADLs). Additional observations on 05/10/22 at 09:03 AM and 05/11/22 at 8:44 AM, revealed the dressing dated 04/01/22 was still in place. Review of physician orders for Resident #5 dated 04/01/22 to 05/11/22 showed orders as follows: • Meropenem reconstitute solution; 1 gram; amount: 1 gram; intravenous [Diagnosis: Klebsiella pneumoniae as the cause of diseases classified elsewhere- Urine; wounds] Every 8 hours: 06:00, 14:00 (2:00 PM), 22:00 (10:00 PM) • Midline extension, connector and dressing change weekly. (Special instructions; date and time dressing for change and readjust standing Midline change before meals every Wednesday; 07:00-01:00.) • Midline extension, connector and dressing change as needed (PRN) due to soiling or dislodgement. • Check Midline site for signs and symptoms of infection every shift. An interview was conducted on 05/11/22 at 09:06 AM with Staff E, licensed practical nurse (LPN). Staff E observed the PICC line dressing with the date 04/01/22. Staff E stated she thought the PICC line dressing should be changed every 30 days. Staff E stated she would review the physician orders to see when it should have been changed. Staff E stated, either way it was past 30 days. Staff E stated she was assigned to care for Resident #5 and had not reviewed the orders yet. Staff E stated she would talk to the Director of Nursing (DON) and will get back with the surveyor. Staff E did not return. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 4 of 17 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 05/12/2022 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/11/22 at 03:35 PM, an interview was conducted with Staff F, LPN. Staff F stated the expectation for PICC line dressing was to change them weekly. Staff F said, That is the protocol. On 05/11/22 at 03:38 PM, an interview was conducted with Staff G, LPN. Staff G stated she does not change PICC line dressings. Staff G stated if she would have to change one, she would follow physician orders. Staff G stated she thought orders were in place to change the dressing weekly. A follow- up interview was conducted on 05/11/22 at 3:45 PM with the Director of Nursing (DON). The DON stated the expectation was standard practice, change the PICC line dressing every week. The DON stated physician orders were in place, and she did not know why Resident #5's PICC line dressing had not been changed. The DON said, I expect the nurses to complete dressing changes weekly or as ordered. Review of a facility policy titled, Midline dressing changes', revised April 2016, showed the purpose is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter site dressings. Under general guidelines (1) Change Midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Review of a job description titled, Licensed practical nurse, dated 09/04/20, showed an expectation to provide quality care to patients and perform technical skilled care in compliance with nursing standards, federal, state, local government regulations and company policies. Under essential functions provide direct and individualized nursing care to assigned patients. Ensures quality and safe delivery of nursing services to patients / clients. Change bandages, dressings and change catheters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 5 of 17 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 05/12/2022 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 Based on observation, record review, and interview, the facility failed to ensure proper storage of respiratory equipment for five (Resident #3, #28, #45 #48, #49) of 17 facility residents receiving respiratory therapy during three (5/9/2022, 5/10/2022, and 5/11/2022) of four days observed. Residents Affected - Some Findings included: 1. On 05/09/2022 at 10:07 a.m. and 12:13 p.m., Resident #49's nebulizer mask was observed on top of the nebulizer machine. Additionally, the oxygen nasal cannula and tubing were observed hanging over the oxygen concentrator. On 05/10/2022 at 08:50 a.m., observation revealed Resident #49's nebulizer facemask was not stored in the plastic storage bag, and the oxygen nasal cannula and tubing were hanging over the oxygen concentrator. On 05/11/2022 at 08:49 a.m., Resident #49's oxygen tubing was observed hanging over the oxygen concentrator, and the unbagged nebulizer facemask was on top of the bedside table. An observation was conducted with the Director of Nursing (DON) on 05/11/2022 at 10:15 a.m. During the observation, the DON confirmed Resident #49's nebulizer facemask was not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. Clinical Record review of Resident #49's Physician Order dated 12/13/2021 revealed the resident was to receive oxygen therapy via nasal cannula (NC) at 2 liters per minute continuous, and Ipratropium-albuterol solution for nebulization 0.5mg-3mg (2.5 mg base)/3ml inhalation every 4 hours (06:00, 10:00, 14:00, 1800, 2200, 0200). 2. On 05/09/2022 at 10:20 a.m., Resident #45's nebulizer facemask was observed in the top drawer of the bedside table, and the oxygen tubing was on the floor of the resident's room. The oxygen plastic storage bag dated 2/14/2022 was located on top of the oxygen concentrator. Interview with Resident #45 at the time of the observation revealed she did not know how her respiratory equipment should be stored. On 5/11/2022 at 08:38 a.m., an observation was made of Resident #45's unbagged oxygen cannula on the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:35 a.m. During the observation, the DON confirmed Resident #45's nebulizer facemask and oxygen nasal cannula were not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. A review of Resident #45's Physician Order dated 02/11/2021 revealed the resident was to receive Oxygen Therapy via Nasal cannula (NC) at 2 liters per minute as needed, and an order dated 12/09/2021 for Ipratropium-albuterol solution for nebulization 0.5mg-3mg (2.5 mg base)/3ml inhalation three times a day as needed. 3. On 05/09/2022 at 10:30 a.m., Resident #48 was observed to be lying in bed sleeping. The resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 6 of 17 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 05/12/2022 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 was not wearing respiratory/using respiratory equipment at the time of the observation. The resident's oxygen nasal cannula was observed unbagged on the bedside table. On 05/10/2022 at 08:30 a.m., Resident #48 was observed in his room. His unbagged oxygen nasal cannula was observed hanging over the left side bedrail. Residents Affected - Some On 5/11/2022 at 08:09 a.m., Resident #48's nebulizer facemask was observed to be unbagged on the bedside table. Interview with Resident #48 at the time of observation revealed the facemask was always stored in this manner on top of the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:00 a.m. of Resident #48's room. During the observation, the nebulizer facemask was on top of the bedside table, and the oxygen nasal cannula was hanging over the bedrail. The DON confirmed both respiratory devices were not stored appropriately. The DON immediately removed both respiratory devices and placed them in the garbage receptacle. Clinical Record review of Resident #48's Physician Order dated 12/13/2021 revealed the resident was to received oxygen therapy via nasal cannula (NC) at 2 liters per minute as needed, and Budesonide suspension for nebulization 0.5mg-2ml inhalation twice a day. 4. On 05/09/2022 at 11:00 a.m., Resident #28's room was observed with an unbagged nebulizer facemask on top of the bedside table. On 05/10/22 at 9:21 a.m. and 05/11/22 at 08:45 a.m., Resident #28's oxygen nasal cannula was observed on the floor of the room in front of the oxygen concentrator, and the unbagged nebulizer facemask was located on top of the bedside table. An observation was conducted with the DON on 05/11/2022 at 10:20 a.m. During the observation, the DON confirmed Resident #28's nebulizer facemask, and oxygen nasal cannula were not stored appropriately. The DON removed the facemask from the bedside table, and indicated the resident was not receiving nebulizer treatments. She then removed the oxygen cannula and placed both items into the garbage receptacle near the resident's bed. Clinical record review of Resident #28's Physician Order dated 04/22/2021 revealed Oxygen Therapy via Nasal cannula (NC) at 3 liters per minute as needed. 5. On 05/10/2022 at 08:45 a.m., an observation was made of Resident #3's room. During the observation, a nebulizer facemask was observed next to the plastic storage bag. On 05/11/2022 at 08:41 a.m., Resident #3's nebulizer facemask was stored on top of the bedside table near the plastic storage bag. An observation was conducted with the DON on 05/11/2022 at 10:24 a.m. During the observation, the DON confirmed Resident #3's nebulizer facemask was not stored appropriately. The DON removed the facemask from the bedside table and threw it into a garbage receptacle near the resident's bed. On 5/11/2022 at 10:30 a.m., the DON confirmed all respiratory devices for Residents #3, #28, #45, #48, and #49 were not stored appropriately. The DON stated, This needs to be addressed promptly. There will be staff education and monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 7 of 17 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 05/12/2022 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 - Some A follow-up interview with the DON on 5/11/2022 at 11:40 a.m., revealed all respiratory equipment for residents observed was removed and replaced with new respiratory devices to include nebulizer facemasks and oxygen nasal cannulas. A review of the facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer, with revision date of October 2010, revealed: Purpose: The purpose of this procedure is to administer aerosolized particles of medication safely and aseptically into the resident's airway. 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 8 of 17 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 05/12/2022 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure medications were stored and secured appropriately in one (A Wing) of two treatment carts and three (B-North, A-North, A-South) of four medication carts. Findings included: 1. On [DATE] at 3:29 PM, observation with Staff O, Registered Nurse (RN) of the A wing Treatment Cart revealed: • Nyst Ointment 100,000 USP opened, no date, no resident identifier, no pharmacy label • SSD Silver Sulfadiazine Cream opened, resident label not identifiable, no open date • Latanoprost Opthalmic Solution 125 mcg located in treatment cart • Muprocin Ointment 2% with no resident identifier or Pharmacy label, open date not observed • Calamine Lotion manufacturer expiration date on bottle 03/2022 An interview with Staff O at the time of the observation confirmed the Nyst ointment, SSD Silver Sulfadiazine Cream, and Mupirocin ointment was not labeled for pharmacy, resident or identified with a date opened. Staff O stated, The Latanoprost Opthalmic Solution 125 mcg should be secured in the medication cart, not treatment cart. Staff O confirmed the Calamine Lotion was expired, needed to be discarded, and reordered if needed for resident care. A phone interview conducted on [DATE] at 12:05 PM with the facility Pharmacist confirmed the Nyst 100,000 ointment required a prescription for a resident and needs to be coordinated through the pharmacy with a label, and the date should be 1 year from the date dispensed. The SSD Silver Sulfadiazine Cream also required a prescription for an individual resident. The Pharmacist stated if there is not a resident specifically on the label, it should be pulled off the cart, and the pharmacist notified. The Latanoprost Opthalmic Solution 125 mcg should be stored in the top drawer of the medication cart with medication stock not the treatment cart. The pharmacy expectation for the Muprocin ointment 2% is that it is utilized for a single resident with a prescription required and should go through pharmacy services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 9 of 17 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 05/12/2022 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 Review of the facility policy titled, Storage of Medications revised [DATE] revealed: Level of Harm - Minimal harm or potential for actual harm - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Residents Affected - Few 2. On [DATE] at 11:25 AM, the Medication Cart B North was observed unlocked, open in hallway, drawers able to open with medication access for residents, staff and visitors. On [DATE] at 11:35, Staff K, Licensed Practice Nurse (LPN) confirmed the medication cart was unlocked. Staff K reported that he was assigned to this medication cart and it was a mistake to leave it unlocked. An interview with the Pharmacist on [DATE] at 12:50 PM revealed he has brought unlocked medication carts to the facility's attention during his audits and confirmed that this was a security concern. A review of the facility policy titled, Storage of Medications, revised [DATE] revealed: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 3. On [DATE] at 8:59 AM, Medication Cart A-North was observed with 4 medication cards on top of the cart with no staff in attendance. Residents were observed passing the cart in the hallway as medications remained on top of the cart observable and with no staff present. On [DATE] at 9:01 AM, the Director of Nursing (DON) approached the cart. The DON called over Staff J, LPN to review the medication cards and inquire as to why they were placed on the top of the medication cart. The prescription Venlafaxine Tab 75 mg was identified as the medication card which was filled on top of the medication cart. An interview was conducted on [DATE] at 9:05 AM with the DON. The DON stated, The only medication card that has medication in it is the first medication card on the bottom, which is not appropriate. The other medication cards are empty and might be in the process of being discarded. The DON stated to Staff J, LPN that this needs to be corrected, and it is a priority. An interview with Staff J, LPN on [DATE] at 9:10 AM confirmed she had left the medication cards on top of the medication cart and the medication card with Venlafaxine 75 mg tab should be with another resident in another medication cart. A phone interview conducted on [DATE] at 12:50 PM with the facility Pharmacist confirmed medications should not be stored on top of an unattended medication cart at any time, and this was a security issue. 4. On [DATE] at 10:34 AM, observation with Staff E, LPN of Medication Cart A-South revealed: 3 Insulin pens contained in a plastic bag for 1 Resident. The expiration dates of [DATE] were written in marker and the pharmacy label noted refrigerate until opened for 1 pen. A second insulin pen had a handwritten note on it open on [DATE] and a third insulin pen had a handwritten note on it Date Opened [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 10 of 17 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 05/12/2022 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 Interview with Staff E, LPN at the time of the observation revealed, Insulin pens should have label on it that says day opened, not date expired from Pharmacy. There are 3 insulin pens with expiration date on it rather than date opened, and the expiration dates are not supposed to be on the pen. On [DATE] at 12:15 PM a phone interview with the facility Pharmacist's revealed Insulin pens should be in the refrigerator until use. The manufacturer guidelines need to be followed. If observing 3 pens for 1 resident in the medication cart in a bag, the date opened should be the date removed from the refrigerator. The expiration tag dated [DATE] needs to be clarified with the nurse. The date the insulin pen is removed from the refrigerator is the date it is opened, not the date expired. The Pharmacist reported that he would not expect to see all 3 pens for this resident in the medication cart. A review of the facility Medication Cart Reference Sheet titled, Expiration Dating of Common Pharmaceuticals dated [DATE] revealed: Insulin Pen Injector Cartridges see Manufacturer recommendations, refrigerate and remove only one pen at a time. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 11 of 17 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 05/12/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and policy review, the facility did not ensure the kitchen was maintained in a sanitary manner during 3 of 4 days of survey. Residents Affected - Some Findings included: An initial tour of the facility's kitchen was conducted on 05/09/22 at 09:48 AM. The tour was facilitated by the assistant certified dietary manager/CDM2 The kitchen tour revealed concerns with dirty vents located above food prep areas and clean dish storage areas. The vents were noted with dust, debris, and bio-growth. The CDM2 stated maintenance is supposed to clean the vents once a month. Concerns with Bio growth on the edge of the sink in dishwashing area were identified. The CDM2 stated they would clean it up. The CDM2 said, that is not sanitary. The CDM2 stated they have had that problem before. Photographic evidence was obtained. On 05/11/22 at 11:15 AM, a kitchen tour was conducted with the Registered Dietician (RD). An observation was made of ceiling vents in dish storage area and food service areas with dirt, debris, and bio growth. An interview was conducted on 05/11/22 at 11:35 AM with the RD. The RD stated she thought maintenance had cleaned all the vents. RD stated it will be done right after food service. An interview was conducted on 05/11/22 at 01:14 PM with the CDM2. The CDM2 stated they had scrubbed the sink area and removed the bio growth. The CDM2 stated they had scrapped off the old caulking in the sink area and applied new caulking. The CDM2 stated maintenance staff cleaned some vents, but they forgot the other two. A second interview was conducted with the RD on 05/11/22 at 1:11 PM. The RD stated the vents had now been cleaned and the CDM and maintenance will ensure surfaces are maintained in clean manner. When asked what the expectation was, the RD said, The vents will be cleaned weekly and then monthly after that. The RD stated dirty vents with debris over clean dishes and food service areas were of concern due to cross contamination. The RD said, We will make sure cleaning is done. On 05/11/22 at 1:39 PM, a telephonic interview was conducted with the CDM1. The CDM1 stated she had conducted an inspection a few weeks earlier and had identified the vents in the kitchen needed to be cleaned. The CDM1 stated the list was given to maintenance director. The CDM1 said, I forgot to follow-up. It was on my list 3 weeks ago. The CDM1 stated the expectation is to clean vents once a month. The CDM1 stated she would conduct inspections on an on-going basis. The CDM1 stated they did not have the vents on the checklist. The CDM1 said, I can understand the concern with dust flowing on food or food serving dishes. It is not sanitary. An interview was conducted with the Director of Maintenance (DOM) on 05/11/22 at 4:20 PM. The DOM stated he did not know the cleanliness and maintenance was on his list. The DOM said, I will make sure it is done going forward. It is on my list to make sure we dust them every week. The DOM stated the black stuff looked like bio growth. The DOM stated cleaning should be done more often. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 12 of 17 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 05/12/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 05/11/22 at 5:11 PM, the nursing home administrator (NHA) reviewed photographic evidence and stated the staff are always cleaning. It should not look like that. The NHA said, No, bio growth in the kitchen and near food surfaces is not good. I will follow-up and make sure they take care of it. Review of a facility policy titled sanitation revised October 2008, showed food service areas shall be maintained in a clean and sanitary manner. Review of a facility policy titled, cleaning and disinfection of environmental surfaces revised August 2019 showed environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standards. Review of a facility policy titled, maintenance service revised December 2009, showed maintenance service will be provided to all areas of the building, grounds, and equipment. (2) Functions of maintenance personnel include maintaining the building in compliance with current federal. State, and local laws, regulations, and guidelines. Buildings will be maintained in good repair and free from hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 13 of 17 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 05/12/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 and other infections on two (101-110 and 119-128) of six hallways and one of one laundry area. Residents Affected - Some Findings included: 1. On 5/9/22 beginning at 11:30 AM, Staff I, Certified Nursing Assistant (CNA) was observed delivering and setting up lunch trays for residents in rooms 101 through 108. No hand hygiene by Staff I was observed between each tray delivered. 2. On 5/9/2022 at 11:23 a.m. a lunch meal tray service was observed in the hallway of the facility serving rooms 119 to 128. Staff A, CNA was observed getting a tray from an open metal dining cart and taking the tray into room [ROOM NUMBER]. Staff A was observed proceeding to get another tray from the cart without conducting hand hygiene and taking the tray into room [ROOM NUMBER]. Staff A could be seen setting up the food tray for the resident in room [ROOM NUMBER] without performing hand hygiene. Staff A proceeded to exit the room and was not observed to perform hand hygiene. Staff A then put on a gown and gloves, took another tray from the dining cart, and entered room [ROOM NUMBER]. room [ROOM NUMBER] was marked with a sign indicating Droplet/Contact Isolation. Staff A came to the doorway and was handed another tray for room [ROOM NUMBER] by another staff member. Staff A could be seen setting up the tray for each resident in the room. Staff A exited the room, removed the gown and gloves in the hallway, and placed them in a small metal receptacle. Staff A was not observed conducting hand hygiene after removal of her gown and gloves. Staff A was observed putting on another gown and gloves and taking another tray from the dining cart and taking the tray into room [ROOM NUMBER]. room [ROOM NUMBER] was marked with a sign indicating Droplet/Contact Isolation. Staff A set the tray on an overbed table and reached out into the hallway, while still wearing the same gown and gloves, to take another tray from the cart for room [ROOM NUMBER]. Staff A did not perform hand hygiene, and did not change her gown and gloves prior to serving the second resident in the room. Staff A proceeded to exit room [ROOM NUMBER], take off her gown and gloves in the hallway, and place them into a small metal receptacle. Staff A, CNA was not observed to perform hand hygiene after removal of her gown and gloves. Staff A then removed another tray from the dining cart and took the tray into room [ROOM NUMBER]. Staff A could be seen setting up the tray for the resident. Staff A returned to the hallway and without performing hand hygiene, she left the hallway and brought back a box of gowns to restock the supply in the hallway. Staff A , without performing any hand hygiene, proceeded to put on another gown and gloves and get another tray from the dining cart. Staff A was observed taking the tray into the room for Resident #21. Resident #21's room was not marked as being in isolation of any kind. Staff A was observed setting up the tray for the resident. Staff A exited Resident #21's room, took off her gown and gloves in the hallway and placed the items in a small metal receptacle. Staff A was not observed performing hand hygiene after removal of the gown and gloves. Staff A then assisted another employee to put on a gown, and she left the hallway pushing the dining cart as she left. On 5/09/22 at 11:45 a.m., a visitor was observed approaching Resident #21's room with a mask and shield on. The visitor was observed putting on gloves and a gown to enter the room. The visitor stated Resident #21 was on isolation due to being exposed to COVID. No signage was observed on the door indicating the resident was on isolation or providing any direction to visitors for Personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 14 of 17 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 05/12/2022 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 0880 Protective Equipment (PPE) usage. Photographic evidence was obtained. Level of Harm - Minimal harm or potential for actual harm A review of facility policy entitled Handwashing/Hand Hygiene with a revision date of August 2019 revealed the following: Residents Affected - Some Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1 All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in prevention the transmission of healthcare-associated infections. 2 All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. .7 Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .b before and after direct contact with residents .f before donning sterile gloves .l after contact with objects in the immediate vicinity of the resident m after removing gloves n before and after entering isolation precaution settings o before and after eating or handling food p before and after assisting a resident with meals .8 Hand hygiene is the final step after removing and disposing of personal protective equipment 9 The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10 Single-use disposable gloves should be used .c when in contact with a resident or the equipment or environment of a resident, who is on contact precautions. A review of the facility policy entitled Isolation-Categories of Transmission-Based Precautions with a revision date of October 2018 indicated the following: Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 15 of 17 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 05/12/2022 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 0880 laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation: Residents Affected - Some 1 Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 2 Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne. .5 When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a The signage informs the staff of the type of CDC (Centers for Disease Control) precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions 1 Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. .4 Staff and visitors will wear gloves when entering the room .b Gloves will be removed and hand hygiene performed before leaving the room 5 Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions 1 Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets , larger than 5 microns in size, that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). .4 Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. 3. On 5/12/2022 at 9:29 a.m., an interview was conducted with the Director of Nursing (DON) and Assistant Nursing Director (ADON)/Infection Preventionist (IP), related to infection control procedures for hand hygiene. The DON revealed that her expectation for all staff is that they perform hand hygiene before between and after resident care. She further indicated that all staff must use Personal Protective Equipment (PPE) appropriately based on the signage posted on each resident isolation precaution room. The ADON indicated the facility does in-service training and stated The education is working; we are finding that the staff is telling other staff to wash their hands and don PPE. We are following the Centers for Disease Control (CDC) guidance (as a main source), pulling up the website (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 16 of 17 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 05/12/2022 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 0880 continuously. Level of Harm - Minimal harm or potential for actual harm On 5/12/2022 at 11:00 a.m., an observation was conducted with the DON of the Laundry area. Personal items of a large cup and two bags were on top of the folding table. These items were right next to many clean and folded resident gowns, that were placed on top of each other in a pile. Staff P, Laundry Aide, confirmed that her personal items were on the table, and stated, the facility does not provide a locker, there is no place to put items. Immediately after the interview a bottle of (Cleanser and Disinfectant) was seen on the other side of the folding table with no kill time on the label. Staff P confirmed she uses the product to clean the folding table and did not know the product kill or dwell time when she uses the product on the table. She stated, I do not know, I put it on and let it dry and do it once when I come into work. Residents Affected - Some Further observations revealed that Staff P, Laundry Aide was wearing her own gown and surgical gloves while sorting dirty clothes on the dirty side of the laundry area. Staff P was observed wearing the same gown while transferring clean clothes into the dryers on the clean side of the laundry area. Staff was not using the facility provided PPE items of gown, goggles, and black gloves. Staff P was asked about her gown and stated, I refuse to use that [expletive]. She further indicated that she brings three gowns from home and changes them when necessary. On 05/12/2022 at 12:00 p.m. an interview with the DON and ADON (IP) was conducted. The ADON provided a copy of education and in-service training given to Staff P on 3/19/2022, held by the Housekeeping Director. Staff P signed and acknowledged she understood product kill and dwell time for the of (Cleanser and Disinfectant). The ADON also provided the product information, which showed that the product has a 10-minute kill time in order to be effective. She further revealed that all staff in the laundry room must wear the appropriate PPE which is hanging on hooks in the laundry room. The ADON stated Staff P cannot bring in her own personal gowns from home, and she cannot wear gloves that we use to take care of patients while sorting laundry. The DON reported that following the observation of the laundry area at 11:00 a.m. on 5/12/22 with the surveyor, all laundry on the folding table was being rewashed and the folding table was re-cleaned. The DON reported that maintenance was going to install a locker for staff to place all personal items in to avoid having personal items in the laundry area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 17 of 17