Inspection·September 3, 2024

F 0759 for coronary artery disease. Level of Harm - Minimal harm or potential for actual harm - An order dated 6/26/2024 for amlodipine besylate 10 mg one tablet PO one time a day at 8:30 AM for hypertension. Residents Affected - Few - An order dated 6/26/2024 for clopidogrel 75 mg one tablet PO one time a day at 8:30 AM for atrial fibrillation. - An order dated 6/26/2024 for indapamide 1.25 mg one tablet PO one time a day at 8:30 AM for fluid retention. - An order dated 6/26/2024 for paroxetine hydrochloride (HCl) 30 mg one tablet PO one time a day at 8:30 AM for depression. - An order dated 6/26/2024 for levetiracetam 500 mg one tablet PO two times a day at 8:30 AM and 9:00 PM for seizures. - An order dated 6/26/2024 for magnesium oxide 400 mg one tablet PO two times a day at 8:30 AM and 9:00 PM for supplementation. - An order dated 8/31/2024 for depakote sprinkles 125 mg 3 capsules PO three times a day at 8:30 AM, 4:30 PM, and 9:00 PM for mood disorder. An observation of medication administration was conducted on 9/3/2024 at 9:18 AM with Staff A, LPN. Staff A, LPN prepared the following medications for administration to Resident #5: - Aspirin 81 mg chewable 1 tablet. - Amlodipine besylate 10 mg one tablet. - Clopidogrel 75 mg one tablet. - Indapamide 1.25 mg one tablet . - Levetiracetam 500 mg one tablet. - Depakote sprinkles 125 mg 3 capsules. After removing the medications from the medication cart Staff A, LPN crushed each medication individually and placed the medication in a small amount of pudding per Resident #5's preference. After preparing the medications Staff A administered the six medications to Resident #5 and returned to the medication cart. Staff A, LPN accessed Resident #5's electronic medication administration record (eMAR) and signed off the six medications as administered. Staff A, LPN also signed off paroxetine HCl 30 mg one tablet as administered but did not pull the medication from the medication cart to administer to Resident #5. After saving the data, the order for magnesium oxide 400 mg one tablet appeared as not being administered. Staff A, LPN removed magnesium oxide 400 mg one tablet, crushed the tablet, added the crushed tablet to a small amount of pudding, and administered the medication to Resident #5. After administering the medication Staff A, LPN accessed Resident #5's eMAR and marked the magnesium oxide 400 mg one tablet as administered. Staff A, LPN did not administer paroxetine HCl 30 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 2 of 4 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 09/03/2024 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 0759 one tablet to Resident #5. Level of Harm - Minimal harm or potential for actual harm Following the observation of medication administration, an interview was conducted with Staff A, LPN at 9:38 AM. Staff A, LPN accessed Resident #5's eMAR and reviewed the physician order for aspirin delayed release 81 mg. Staff A, LPN removed the bottle of aspirin 81 mg chewable tablets and stated she administered the chewable form of the medication to Resident #5 because he's a crush, I had to give the chewable. Staff A, LPN addressed Resident #5's physician order for aspirin 81 mg delayed release did not match what she removed from the medication cart and stated I'm not sure what to do after the fact. Staff A, LPN reviewed Resident #5's eMAR and observed the physician order for paroxetine HCl 30 mg. Staff A, LPN was not aware she did not remove the medication to administer to Resident #5 before signing the medication off as administered in the eMAR. During the interview with Staff A, LPN, Staff B, Registered Nurse (RN) and Unit Manager (UM) approached the medication cart and was interviewed. Staff B, RN UM stated Resident #5's physician order for aspirin 81 mg should be for the chewable form of the medication and not the extended release form. Staff B, RN UM also stated if a different form of a medication was administered and did not match the physician order, it would be considered a medication error. Staff B, RN UM stated medications should be administered between an hour before and an hour after the scheduled time and if a medication is going to be administered late, the nurse should notify the resident's physician before administering the medication. Staff A, LPN stated she was aware the resident's physician needed to be notified when a medication is administered late, but was not sure if the physician needed to be notified prior to administering the medication or after administering the medication. Staff A, LPN also stated, maybe I wouldn't have made the error if you weren't watching me. Residents Affected - Few An interview was conducted on 9/3/2024 at 1:57 PM with the facility's Director of Nursing (DON). The DON stated facility nursing staff were educated at orientation and at skills fairs on the rights of medication administration, which included the right medication, right dose, right resident, right time, and right route. The DON also stated nursing staff should notify the resident's physician if a medication was going to be administered late and the notification should occur prior to the late administration. The DON stated medications should be administered between an hour before and an hour after the scheduled time. A review of the facility policy titled Medication Administration, last revised on 9/1/2023, revealed under the section titled Policy, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy also revealed the following steps under the section titled Policy Explanation and Compliance Guidelines: - Review MAR to identify medication to be administered. - Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. - Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. - Administer medications as ordered in accordance with manufacturer specifications. - If any medication is not available, or the possibility of late administration, the Nurse will contact the Attending Physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105352 If continuation sheet Page 3 of 4 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 09/03/2024 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 0759 - Sign MAR after administered. 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 4 of 4