Inspection·March 26, 2021

F 0582 Level of Harm - Minimal harm or potential for actual harm indicated that the resident's child was the Care Conference person and Power of Attorney, and that the resident was the responsible party. The facility provided the resident with a Notice of Medicare Non-Coverage (NOMNC) on 11/4/20. The NOMNC did not identify the date that the resident's Medicare A services would end. The facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) which would identify the option chosen by the resident. Residents Affected - Few On 3/26/21 at 7:53 a.m., the Minimum Data Set (MDS) Coordinator identified that she had been responsible for completing the NOMNC forms since February 2021. She stated the previous Director Of Communications (DOC) had been doing them but was no longer with the company. She reviewed the NOMNC for Resident #13 and stated that the service end date should have been added and that a SNFABN should have been completed. The MDS Coordinator confirmed that the SNFABN was not included with the NOMNC and that she did not have a copy of it in the resident record. Follow-up interview on 3/26/21 at 8:15 a.m. with the MDS Coordinator confirmed that the SNFABN should have been completed for the resident and signed by the resident. She stated that if residents remain in the facility after receiving a Beneficiary Notice that the resident would receive both an Advance Beneficiary Notice of Non-coverage and a Notice of Medicare Non-Coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to provide an activity program based on the assessment and care planned preferences for three (#40, #7, and #42) of three residents reviewed for activities out of a total sample of 29 residents. Residents Affected - Some Findings included: 1. Review of Resident #40's admission record revealed an original admission date in 2016. Review of the annual Minimum Data Set (MDS) assessment, dated 2/4/21, revealed that the resident was rarely/never understood therefore the Brief Interview for Mental Status (BIMS) was not conducted. Continued review of the MDS revealed the resident had short and long term memory impairment and was unable to participate in the activity preference interview. The staff assessment of activity preferences was completed and listed that the resident had no activity preferences check marked. A review of the prior MDS annual assessment conducted 3/12/20 revealed the resident interview for activity preferences was conducted. This indicated that it was somewhat important for the resident to listen to music, be around animals, keep up with the news, do her favorite activities, go outside to get fresh air, and participate in religious services or practices while residing in the facility. Review of Resident #40's active care plan last reviewed 2/25/21 revealed a focus care area of: Resident need to attend large and small group activities to provide mental and social stimulation from others and surroundings. The goal was to attend and participate in an least 2 activities weekly. The interventions to assist in meeting the goal included: Activity and Certified Nursing Assistant staff to encourage participation in activities of interest, spending time outside, games, birthdays/holiday celebrations, offer pet, volunteer, and spiritual visits when available, place calendar in room, assist with gaining access to activities where they occur, and invite and encourage family and friend to participate. Observations of Resident #40 in her room on 3/24/21 at 9:23 a.m. revealed the resident's room was located at the end of the hallway. The resident's television (TV) was on, sound was off, and the screen of the television showed an unchanging picture of an elderly woman, and read jump to a scene, cast, awards, theatrical trailer, film flash. Two additional observations of Resident #40 in her room on 3/24/21 at 12:16 p.m. and 3:29 p.m. revealed the TV continued with the title page of the movie, Driving Miss Daisy with no sound. Continued observations of Resident #40 on 3/25/21 at 7:33 a.m. and 12:12 p.m. revealed the title page of Driving Miss Daisy with no sound continued to be present on Resident #40's television. At 7:35 a.m. on 3/26/21, the title page of Driving Miss Daisy continued to be observed on Resident #40's television with no sound. Resident #40 was not in the facility at this time. At 12:54 p.m. on 3/26/21, an observation with the Activity Director of Resident #40's room was conducted. The television was not on, no sound was present in the room, and a staff member was sitting with the resident's roommate (Resident #7). The Activity Director stated she didn't know who turned the movie on, it was a personal movie, and she usually played music for the resident. Observations on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0679 3/24/21, 3/25/21, and 3/26/21 revealed no sound or music was heard in the resident's room. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/24/21 at 3:21 p.m., the Activity Director stated the facility offers 1:1 activities, does word searches, story cards, and reminiscent games. The Director identified that she was the only person in the activity department and that her documentation was written in notebooks as she was still learning the electronic record system. Residents Affected - Some On 3/25/21 at 12:04 p.m., Staff Member J, Certified Nursing Assistant (CNA), stated she sometimes brings music into Resident #40's room for her and her roommate (Resident #7) to listen to. An interview was conducted, on 3/26/21 at 12:35 p.m., with the Activity Director. She stated that she took the position a month ago. The Activity Director stated, I usually go in there and play some music for her [referring to Resident #40], will play movies for her, and took her outside for 15 minutes. She stated she usually goes to visit the resident every day and knows the resident from outside of the facility. The Director reported that she took the resident outside for 15 minutes on Tuesday (3/23/21) and played music for her about 2:30 p.m. on Monday (3/22/21). The Activity Director had a notebook next to her and without reviewing it, she stated she does not document any activities that were done with Resident #40. The staff member confirmed that she had not conducted any activity assessments for Resident #40. The Activity Participation Review, dated 9/30/20, indicated Resident #40 preferred and participated in 1:1 activities in her room [ROOM NUMBER]-3 times per week. The review did not describe any of the resident's favorite activities. The Recreation Services Assessment, dated 11/21/20, indicated Resident #40 had intact hearing and vision, limited fine motor abilities and did not participate in any activities and did not show any interest in having any in her room. 2. Review of Resident #7's admission record revealed she was admitted to the facility in 2015. The admission Record included diagnoses not limited to Huntington's Disease, dementia in other disease classified elsewhere with behavioral disturbance, and cognitive communication deficit. On 3/24/21 at 9:28 a.m., Resident #7's television was observed to be unplugged with the cord wrapped around the top of the television. An observation of the roommate's television (Resident #40) revealed it was across the room and had no sound. At 8:39 a.m. on 3/25/21, Resident #7 was observed lying partially on the floor mat next to her bed. The Certified Nursing Assistant went into the room to assist the resident. The television was still in the same state and no meaningful activities were observed. On 3/25/21 at 12:15 p.m., the cord of the resident's TV continued to be wrapped around the top of it. At 1:06 p.m. on 3/25/21, Staff Member H, Licensed Practical Nurse (LPN), confirmed that Resident #7's television cord was wrapped around top of the television and was not plugged in. She unwrapped the cord and found that the cord did not reach an electrical outlet in the room. On 3/26/21 at 12:47 p.m., an observation was conducted with the Activity Director of Resident #7 and #40's room. An LPN was sitting with Resident #7, who was lying curled up on her bed. The television was no longer present for Resident #7. A review of the care plan for Resident #7 last reviewed on 3/21/21 revealed the following focus care area: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0679 Impaired neurological status related to: Huntington's Chorea. Level of Harm - Minimal harm or potential for actual harm The interventions related to the focus area included involve the resident in activities that don't depend on patient's ability to communicate: music, parties, and games. Residents Affected - Some Continued review of the 3/21/21 care plan revealed an additional focus area of: Sometimes having behaviors which include hitting during care, putting self on floor, kicking, refusing privacy offered . The interventions instructed the Certified Nursing Assistant (CNA) to offer something as a diversion such as a TV program. An additional focus area on the 3/21/21 revealed the resident declined attending most group activities because of her condition and diagnosis. The goal for this focus indicated resident will choose independent activities that she has an interest in such as watching TV, reading, or spending time outside. The interventions included to offer pet, volunteer, and spirituals visits when available, place calendar in room and assist with resident ability to gain access where the activities occur. At 12:40 p.m. on 3/26/21, the Activity Director reported that Resident #7 had been in bed since she's been having changes. The Director identified that she doesn't play the television for the resident. She stated that Resident #7 heard the music that was played for her roommate, Resident #40, and she does not take the resident outside. The Activity Director did not report any activities were conducted with the resident and stated she had not documented any activities provided to Resident #7. The staff member confirmed she had not completed any activity assessments on Resident #7. A review of Resident #7's most recent annual MDS dated [DATE] and the prior annual MDS dated [DATE] revealed that the resident was rarely/never understood therefore the BIMS was not conducted. Continued review of the MDS's revealed the resident had short and long term memory impairment and was unable to participate in the activity preference interview. The staff assessment indicated the resident had no activity preferences. 3. On 03/23/21 at 11:18 a.m. and on 03/24/21 at 9:11 a.m., Resident # 42 was observed laying in bed without any activity or engagement from staff. On 3/23/21 at 3:11 p.m., Resident #42 was observed laying in bed with a filled-out crossword puzzle. Resident #42 stated she does not do have much to do sometimes. On 03/25/21 at 9:56 a.m., Resident #42 stated that she wished they played bingo more often. When asked when she last played bingo, Resident #42 stated it had been a while. Resident #42 stated that she loves crosswords and reading short books. Resident #42 said, It will be nice to be able to go to the library again. I'd like to get more books and word searches. Resident #42 stated that she also liked to watch game shows and listen to the radio. Review of Resident #42's admission record revealed the resident was admitted to the facility in September of 2020. A review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #42 had a BIMS of 13, indicating cognitively intact. A review of the most recent comprehensive MDS was an admission MDS dated [DATE]. The resident's BIMS score on the 8/14/20 assessment was 15. A review of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activity preference section of the admission MDS revealed the resident was interviewed on her preferences. The resident reported that it was somewhat important to listen to music, keep up with the news, do her favorite activities, and go outside to get fresh air when the weather was good. A review of Resident #42's care plan dated 2/23/21 revealed a focus area of: Activities Care Plan. Resident is at risk for social isolation related to COVID restriction. The goal for the care plan was resident will participate in 1 to 2 activities of choice per week. Interventions included: Encourage resident to participate in room activities such as music therapy, communion, church visits, radio, watching TV, visitors, and puzzles. Resident #42 enjoys: visitors and family, arts and crafts activities, playing games on phone, and reading. On 03/24/21 at 3:22 p.m., Staff A, Admissions Coordinator stated that she was assisting with activities and filling in for social services because the facility did not have anyone in these roles. Staff A stated she was playing multiple roles since December 2020, until about a month ago (February 2021). Staff A reported that no one was facilitating group activities and 1:1 activities were done by different individuals. Staff A stated there was no documentation kept of the 1:1 visits by the various individuals. An interview was conducted with the Activity Director on Wednesday, 03/24/21 at 4:00 p.m. The Activity Directed stated that she just started in the activity role about a month ago. The Activity Director stated that she was responsible for the activities calendar, and she determined the activities based on prior calendars and reported that the residents like the same thing. The Activity Director stated that they have movies on Wednesdays. When asked what time the movie was scheduled for since today was a Wednesday, the Activity Director stated she did not have a time. The Activity Director stated she was working on a plan for facilitating 1:1 activities. She stated that she was new to the computer system and did not know how to document electronically. When asked for documentation of activities offered in January and February 2021, she stated she did not have any records. The Activity Director stated that she was the only one in her department and was responsible for all group and 1:1 activities in the facility. On 3/26/21 at 10:40 a.m., an interview was conducted with the Admissions Coordinator and the Activity Director related to Resident #42's activities. The Activity Director stated that she had not reviewed the activity care plan for Resident #42. The Admissions Coordinator reported that the resident liked puzzles and loved bingo among other activities. The Activity Director reported that they had not offered bingo and other group activities due to COVID and not having anyone in the activities position. During an interview on 3/26/21 at 12:35 p.m., the Activity Director reported that a staff member plays bingo on Saturdays and there were no activities in the facility on Sundays. A review of the facility's policy titled, Activities and Social services, with an issue date, 02/01/2016 and a revision date 1/2021, revealed a policy statement of: The residents have a right to choose the types of activities and social events in which they wish to participate. Policy interpretation and implementation included: (1) residents are encouraged to choose the type of recreational cultural and religious activities and social events in which they prefer to participate (2) social services director and activity staff will evaluate the individual's personal history and preferences. (3) The care planning team will develop the resident's activity and social care plans and will give the resident an opportunity to choose when, where and how he or she will participate. (7) Activities will be scheduled periodically during the day as well as evenings and weekends. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 record review, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for 2 (#1 and #15) of 2 residents. Residents Affected - Some Findings included: Review of the medical record for Resident #1showed a readmission date of 01/20/21, with an initial admission date of 09/17/20. As per the admission face sheet, diagnoses included: morbid (severe) obesity, and chronic obstructive airway disease. The minimum data set (MDS) dated [DATE], section C - cognitive patterns, revealed a brief interview for mental status (BIMS) of 15, indicating intact cognitive status; Section G - Functional status indicated resident required extensive assistance with two plus person assist for activities of daily living (ADL's) including bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Continued review of the Physician's Orders revealed Oxygen at 2 Liters PRN (as needed) for saturation below 90%, use every 24 hours as needed for shortness of breath, and observe for signs/ symptoms of respiratory complications, sore throat, and fever. notify MD (medical doctor) if any of these symptoms present. On 03/23/21 at 11:42 a.m., Resident #1's oxygen canula was observed on the floor. Staff C, PCA (Patient Care Aide) was present and confirmed the observation. Staff C stated it should not be on the floor and was observed picking the canula and tubing up and placing it on top of the concentrator. Staff C did not clean or store the cannula in a plastic bag. During an interview immediately following the observation, Resident #1 stated he uses oxygen as needed several times daily. During an interview with Staff G, Licensed Practical Nurse (LPN) on 03/23/21 at 11:55 a.m. she stated the resident will independently put on or remove his oxygen throughout the day. Staff G confirmed that the canula should not be placed on the floor and should be stored in a clean, dated bag. She stated she would replace it with a new one. Staff G further the resident would be educated on proper canula storage. A further review of the medical record for Resident #15 revealed no orders to monitor respiratory equipment's sanitation and storage. There was also no documented care of equipment, and no documentation of when the tubing and cannula were last replaced, or who was expected to ensure sanitary storage. On 03/23/21 at 12:16 p.m. and on 03/24/21 at 09:28 a.m., Resident #15's Nebulizer cannula was observed on the nightstand not covered, and placed on top of a pair of shoes. A review of the medical record for Resident #15 revealed Physician's Orders for: Albuterol sulfate nebulization solution 2.5mg (milligrams)/3ml (milliliters) 0.083% Budesonide suspension 0.5mg Ipratropium - Albuterol solution 0.5 - 2.5mg Fluticasone propionate suspension 50 mcg (micrograms) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 Oxygen at 3 liters via nasal canula to maintain oxygen saturation above 90% Level of Harm - Minimal harm or potential for actual harm Observe for signs and symptoms of respiratory complications, sore throat fever, notify MD (medical doctor) if symptoms persist. Residents Affected - Some On 03/25/21 at 03:00 p.m. an observation was made of the nebulizer cannula, sitting on top of a pair of shoes on the nightstand. Staff G was present and confirmed the observation. In a subsequent interview conducted immediately after the observation Staff G stated the resident's canula was recently changed and the resident moves her stuff around in her room. Staff G picked up the nebulizer cannula and placed it inside a bag. Staff G confirmed that it should not be stored in the open on top of shoes, and said, we should all keep an eye on it. A further review of the medical record for Resident #15 revealed no orders to monitor respiratory equipment's sanitation and storage. There was also no documented care of equipment, and no documentation of when the tubing and cannula were last replaced, or who was expected to ensure sanitary storage. An interview was conducted on 03/26/21 at 03:02 p.m. with Staff G, LPN and Staff H, LPN. They stated they could not locate orders to clean or change equipment for Resident #1 or Resident #15. During the interview, Staff G confirmed there should be an order to monitor care, maintenance, and storage of respiratory equipment. Staff G confirmed staff should store nasal cannulas and nebulizer mouth pieces in a clean, dated bag. A facility's policy labeled, policy & procedure Respiratory Infection Control Practices with an issue date 01/01/2014; Revision date: 01/2021 revealed a purpose to provide infection control guidelines to help prevent infections associated with respiratory therapy equipment. Section (f) and (g) states to change oxygen cannula and tubing weekly and as necessary. Keep oxygen cannula and tubing in a plastic bag when not in use. Section (e) and (f) states that the expectation is to wipe mouthpiece with damp paper towel or gauze sponge. Store in a plastic bag, marked with date and resident's name between uses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review showed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified anxiety disorder, unspecified single episode major depressive disorder, unspecified mood (affective) disorder, and unspecified dementia without behavioral disturbance. The Order Summary Report (OSR) for active physician orders as of 3/26/21 indicated the following psychotropic medications: - Buspirone HCl 5 mg - give one tablet by mouth four times a day for anxiety. Order start date: 2/8/21. - Depakote Delayed Release 250 mg - give one tablet by mouth two times a day for mood disorder. Order start date: 3/14/21. - Melatonin 3 mg tablet - Give one tablet by mouth at bedtime for insomnia. Order start date: 3/9/21. - Risperdal 0.5 mg tablet - Give one tablet by mouth in the morning for Bipolar disorder. Order start date: 3/10/21. Additionally, the OSR instructed staff to: - Behavior Monitoring - Anti-anxiety Behavior Code: 0= none, 1= Restlessness, 2= pacing, 3= Continuous crying, 4= Afraid/panic, 5= Repetitious movements, 6= Verbalization of anxiety, 7= Other (document in progress note (PN). Interventions: Document in PN every shift for antianxiety medication use. Order Date: 3/17/21. - Behavior Monitoring - Antipsychotic Behavior Code: 0=none, 1= mania, 2= Auditory hallucination, 3= visual hallucinations, 4= delusions, 5= paranoia, 6= grandiosity, 7= biting, 8- danger to self, 9= danger to others, 10= smearing feces, 11= kicking, 12= pinching, 13= extreme fear, 14= striking out/hitting, 15= other (document in PN). Interventions: Document in PN every shift for antipsychotic use. Order Date: 3/17/21. - Behavior Monitoring - sedative/hynotics. Behavior code: 0= none, 1= Inability to sleep, 2= restlessness, 3= other (document in PN) every evening shift for sedative/hypnotic use. The OSR indicated staff were to monitor for side effects related to the sedative/hypnotic, antipsychotic, and antianxiety medication use. A review of Resident #3's MAR indicated the resident had previous orders for: - Depakote sprinkles 125 mg - Give 2 capsules by mouth two times a day for mood disorder, order start date 2/18/21 and discontinued on 3/9/21. - Depakote 2 -125 mg tablets two times a day, to start on 3/9/21 and discontinued on 3/14/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Risperidone 0.25 mg - Give one talbet by mouth two times a day for mood disorder, to start on 2/18 and discontinued on 3/9/21. Further review of Resident #3's MAR indicated staff were monitoring and documenting side effects associated with the sedative/hypnotic, antianxiety, antipsychotic medications. There was no documentation related to monitoring the resident's behaviors associated with the use of the psychotropic medications. A further review of the clinical record indicated there was no documentation on the Treatment Administration Record (TAR). The Behavior Monitoring Flowsheet (BMF) indicated that staff were to start monitoring for the behaviors associated to the residents use of sedative/hypnotic, antipsychotic, and antianxiety medications as of 3/17/21; however as of 3/26/21 at 9:13 a.m., no documentation was evident on the flowsheet. On 3/26/21 at 2:01 p.m., an interview was conducted with the Director of Nursing (DON). She stated the process was every psychotropic medication should be monitored depending on specific behaviors and there should be seperate orders for monitoring for side effects and behaviors. She stated documentation would be in the electronic record, and that she was unaware of staff documenting behaviors elsewhere. The DON reviewed one of the seven resident's MAR and BMF and confirmed there was no documentation of behaviors. The DON stated an issue regarding psychotropic monitoring had been identified, and she would ensure nurses were educated on the use of the BMF. At 4:09 p.m. on 3/31/21, a telephone interview was conducted with the Consulting Pharmacist. He identified that he started in December and that the previous Pharmacist had not been in the building for 6 months. He stated he had looked into behavior monitoring, and there had been a lot to go through. He stated the facility had its own problems and he had started working on the PRN (as needed) medications and we were heading toward behavior monitoring next month. The policy titled, Psychotropic Management Resources/References, issued May 2016 and revised 1/2021, indicated the resident and responsible party have the right to be informed about resident condition, treatment options, risks, and benefits of the treatment, monitoring requirements of treatment and expected outcomes. Based on observations, interviews, record and policy review, the facility failed to ensure behavioral monitoring was conducted with the use of psychotropic medications for six (#27, #37, #55, #63, #3 and #36) out of seven residents sampled for unnecessary medications. Findings included: Record review showed Resident #27 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and major depressive disorder. The physician orders revealed orders for behavior monitoring related to anti-anxiety medications and sedative/hypnotic medications to be documented every shift. Medications prescribed for Resident #27 included Buspirone Hydrochloride 5 milligram (mg) tablet by mouth three times a day related to anxiety disorder, Zoloft 100 mg tablet two times a day related to major depressive disorder and Trazodone Hydrochloride 100 mg at bedtime related to insomnia. A review of the comprehensive care plan indicated a focus care area for sedative/hypnotic therapy related to diagnosis of insomnia with an intervention to monitor/document side effects and effectiveness every shift. A second focus care area for use of psychotropic medications for behavior disorder related to depression indicated an intervention to review behaviors, interventions and alternative therapies that were attempted and their effectiveness as per facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the March 2021 Medication Administration Record (MAR) for Resident #27 revealed on page 10 of 16 an order to monitor for side effects and behaviors related to use of psychotropic medications every shift with a start date of 11/10/20 and a discontinue date of 3/17/21. No specific behaviors are noted, and no monitoring of behaviors were recorded on the document after 3/17/21. Record review showed Resident #37 was admitted to the facility on [DATE] with diagnoses that included insomnia, major depressive disorder, and dementia. The physician orders revealed orders for behavior monitoring for sedative/hypnotic medications to be documented every shift. Medications prescribed for Resident #37 included Temazepam 15 mg capsule at bedtime related to insomnia. A review of the comprehensive care plan indicated a focus care area for sedative/hypnotic therapy related to diagnosis of insomnia with an intervention to monitor/document side effects and effectiveness every shift. A second focus care area for the use of psychotropic medications related to behavior management for dementia, depression and insomnia indicated an intervention to review behaviors, interventions and alternative therapies that were attempted and their effectiveness as per facility policy. A review of the March 2021 MAR for Resident #37 revealed on page 8 of 12 an order to monitor for behaviors and side effects related to use of psychotropic medications every shift with a start date of 08/31/20. No specific behaviors were documented. Record review showed Resident #55 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, insomnia anxiety and schizoaffective disorder. The physician orders revealed orders for behavior monitoring for anti-anxiety medications, and antipsychotic medications to be documented every shift. Medications prescribed for Resident #55 included Buspirone Hydrochloride 10 mg two times a day related to anxiety disorder, Divalproex Sodium 500 mg delayed release two times a day related to schizoaffective disorder, Lithium Carbonate 150 mg capsule give 3 capsules two times a day related to schizoaffective disorder, Quetiapine Fumarate 100 mg two times a day and 400 mg at bedtime related to schizoaffective disorder and Venlafaxine Hydrochloride 75 mg give 2 tablets two times a day related to bipolar disorder. A review of the comprehensive care plan for indicated a focus care area for use of psychotropic medications related to behavior management for bipolar, depression, insomnia, schizoaffective and anxiety disorders with an intervention to review behaviors, interventions, and alternative therapies that were attempted and their effectiveness as per facility policy. A review of the March 2021 MAR for Resident #55 revealed on page 22 of 35 an order to monitor for behaviors and side effects related to use of psychotropic medications every shift with a start date of 2/8/21 and an end date of 3/9/21. No specific behaviors were noted to be monitored. No documentation was noted after 3/7/21. On page 23 of 35 an order to monitor for behaviors and side effects related to use of psychotropic medications every shift with a start date of 3/9/21 and an end date of 3/17/21 was noted. No specific behaviors were noted to be monitored. No documentation of behavior monitoring was recorded after 3/17/21. Record review showed Resident #63 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, major depressive disorder, and impulse disorder. The physician orders revealed orders for behavior monitoring for antipsychotic medications to be documented every shift. Medications prescribed for Resident #55 included Divalproex Sodium 250 mg delayed release tablet one time a day related to bipolar disorder, Fluoxetine Hydrochloride 40 mg one time a day for schizoaffective disorder bipolar type, and Olanzapine 5 mg at bedtime for schizoaffective bipolar type disorder. A review of the comprehensive care plan indicated a focus care area for use of psychotropic medications related to behavior management for depression, mood disorder, schizoaffective and bipolar disorders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with an intervention to review behaviors, interventions, and alternative therapies that were attempted and their effectiveness as per facility policy. A review of the March 2021 MAR for Resident #63 revealed on page 11 of 15 an order to monitor for side effects and behaviors due to use of psychotropic medications every shift with a start date of 1/18/21. No specific behaviors were noted to be monitored. A review of the facility policy titled Behavioral Monitoring, and undated indicated the following: Policy Statement: Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. Policy Interpretation and Implementation: Assessment: 3 The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition including: a. onset, duration, intensity and frequency of behavioral symptoms; b. any precipitating or relevant factors, or environmental triggers and c. appearance and alertness of the resident an d related observations. 4 New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. 9 When medications are prescribed for behavioral symptoms, documentation will include: e. specific target behaviors and expected outcomes. A review of Resident #36's clinical record revealed an admission date of 10/02/20 with diagnoses that included major depressive disorder, schizoaffective disorder, and bipolar disorder. Medication orders included Haldol 2mg, Aricept 10mg, and Sertraline 100mg. A review of Resident #36 MAR for dates 03/01/21 to 03/31/21, revealed antipsychotic side effects monitoring with an effective date of 03/17/21. The side effects were noted with specified behavior documentation listed per shift, to include: monitor for stiffness, lack of movement, tardive dyskinesia, sedation, hypotension, weight gain, dizziness, seizures, constipation, restlessness, urinary retention, dry mouth, vision changes and other side effects. Review of active orders revealed an order for behavior monitoring with an effective date of 03/17/21. The order lists the following behaviors to be monitored: none, mania, auditory hallucinations, visual hallucinations, delusions, paranoia, grandiosity, biting, danger to self, danger to others, smearing feces, kicking, pinching, extreme fear, striking out / hitting, other with expected interventions documented as needed. A further review of the MAR revealed that Behavior monitoring related to antipsychotic drug use was not being conducted. An interview was conducted with the DON on 03/25/21 at 01:00 p.m. The DON confirmed that behavior monitoring should be conducted for all residents who are on antipsychotic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed, and five errors were identified for four (#47, #40, #61, and #20) of six residents observed. These errors constituted a 17.24% medication error rate. Residents Affected - Few Findings included: 1. On 3/24/21 at 10:19 a.m., an observation was made with Staff Member H, Licensed Practical Nurse (LPN) of medication administration to Resident #47. The staff member obtained a blood glucose level of 210 from the resident. She returned to the medication cart and removed a Novolog Flexpen that was prescribed to Resident #47. The LPN attached a safety needle to the Flexpen and rotated the dose selector to 2, indicating that 2 units of insulin would be administered. The staff member injected the two units of Novolog insulin into the resident. At 10:27 a.m. on 3/24/21, Staff H was asked if she primed Flexpens, she stated, you mean to see if they work, no. The staff member confirmed she did not prime the Flexpen prior to the administration of Resident #47's insulin. The policy titled, Insulin Administration, dated 2001 and revised September 2014, indicated the purpose was To provide guidelines for the safe administration of insulin to residents with diabetes. The preparation portion of the policy identified that nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. According to the manufacturer's informational package insert, located at https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen% instructed users to give an airshot before each injection. The information indicated that before injection small amounts of air may collect in the cartridge during normal use. Users are directed to turn the doses selector to 2 units, hold Flexpen with needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top to the cartridge, and to while keeping the needle upwards press the push button all the way in. A drop of insulin should appear at the needle tip, if not the needle should be changed and repeat the procedure no more than 6 times. If after six attempts a drop of insulin is not seen the insert instruct users to not use the Flexpen and to call the manufacturer. The information indicated this process should be done to prevent infecting air and to ensure proper dosing. 2. On 3/24/21 at 12:05 p.m., an observation was conducted with Staff Member H, LPN, of Resident #40's medication administration. The staff member dispensed the following medications: - Bethanecol 50 milligram (mg) tablet - Gabapentin 300 mg capsule. The staff member crushed the Bethanecol tablet and opened the Gabapentin capsule, each medication was placed in an individual medication cup. The staff member assembled 2 additional medication cups that 5 milliliters (mL) of water was placed and the syringe bottle of 300 mL was filled with water. Staff H checked placement of Resident #40's percutaneous endoscopic gastrostomy (PEG) and assured (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no stomach residual. The staff member flushed the tube with 5 mL's of water, administered the dry contents of the Gabapentin capsule, flushed the tube again with 5 mL's of water then poured the crushed Bethanecol (dry) into the PEG, then flushed the tube with the 300 mL of water. Immediately following the observation of the administration of the undiluted medications into Resident #40's PEG tube, Staff Member H was asked if she normally put medications into the PEG dry (undiluted). She stated that normally she does dilute the medications. The physician orders for Resident #40 included nursing staff to flush with 60 mL of water before and after feeding, flush g-tube with 300 mL of water every four hours for hydration, flush g-tube with 30 cc (cubic centimeter) of water before and after medications, and flush with 5 cc of water before and after each separate medication. The policy, Administering Medications through an Enteral Tube, dated 2001 and revised November 2018, indicated the purpose was to provide guidelines for the safe administration of medications through an enteral tube. The general guidelines instructed staff to follow the medication administration guidelines in the policy entitled Administering Medications that included - Use warm, purified water for diluting medications and for flushing. The policy identified that necessary supplies included Purified warm water for diluting medications, The procedure indicated the following: - 9. Dilute medication: --a. Remove plunger from syringe. Add medications and appropriate amount of water to dilute. --b. Dilute crushed (powdered) medication with at least 30 milliliters (mL) purified water (or prescribed amount). --c. Dilute liquid medication with 30 mL or more (depending on viscosity) purified water. 12. Administer mediation by gravity flow. --a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. --b. Open the clamp and deliver medication slowly. --c. Begin flush before the tubing drains completely. A review of the article, Preventing Errors when Administering Drugs Via an Enteral Feeding Tube, by the Institute for Safe Medication Practices (ISMP) on May 6, 2010 indicated that errors for administering medications via an Enteral Feeding Tube are related to this route of administration happen more often than reported or recognized. These errors are often the result of administering medications that are incompatible with administration via a tube, preparing the medications improperly, and/or administering a drug using improper administration techniques, which can lead to an occluded feeding tube, reduced drug effect, or drug toxicity. These potential adverse outcomes can lead to patient harm or even death. The information indicated that oral medications must be prepared for enteral administration by crushing and diluting tablets and opening capsules so the contents can also be diluted. The Safe Practice Recommendations indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the tube should be flushed with at least 15 mL of purified water before and after administering each medication and at least 15 mL of purified water to ensure medications are administered and clear the tube. This information may be located at https://www.ismp.org/resources/preventing-errors-when-administering-drugs-enteral-feeding-tube#:~:text=The%20feeding% 3. On 3/25/21 at 9:08 a.m., an observation of medication administration with Staff Member G, LPN, was conducted with Resident #61. Staff G, LPN, was observed administering the following medications: - Aspirin chewable 81 mg - Vitamin D tab - Iron tablet 325 mg - Senna Plus 50-8.6 mg tablet - Furosemide 40 mg tablet - Potassium Cl 20 milliequivalent (meq) tablet - Spirolactone 25 mg tablet - Tramadol 50 mg tablet A review of the Physician's orders for Resident #61 revealed the following medication order related to the observed administered medications: - Senna (Sennosides) 8.6 mg tablet - Give one tablet by mouth one time a day for constipation. 4. On 3/25/21 at 9:23 a.m., an observation of medication administration with Staff Member G, LPN, was conducted with Resident #20. Staff G, LPN, was observed administering the following mediations: - Coenyzme Q10 tablet - Superlysine tablet - Gabapentin 600 mg tablet - Furosemide 20 mg tablet - Amlodipine 10 mg tablet - Venlafaxine 150 mg ER tablet - Losartan Potassium 25 mg tab - Metoprolol ER 50 mg tab (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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 - Multivitamin with mineral tablet Level of Harm - Minimal harm or potential for actual harm - Senna Plus 8.6-50 mg tablet - Vitamin D tablet Residents Affected - Few - Preservision softgel - Cetirizine 10 mg tablet A review of the Physician's orders for Resident #20 revealed the following medication order related to the observed administered medications: - Senna (Sennosides) 8.6 mg tablet - Give one tablet by mouth one time a day for constipation. A review of webmd.com (https://www.webmd.com/vitamins/ai/ingredientmono-652/senna) described Senna as a herb that is an FDA-approved laxative that contains sennosides. A review of webmd.com (https://www.webmd.com/drugs/2/drug-20755/senna-plus-oral/details) described Senna Plus as a medication that contained two medications: sennosides and docusate. The website identified that sennosides are stimulant laxatives that keeps water in the intestines and helps to cause movement of the intestines and docusate was a stool softener that helps increase the amount of water in the stool, making it softer and easier to pass. The Policy and Procedure, Administering Medications, issued 1/1/2014 and revised 1/2021, indicated the purpose was to ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. The procedure included the following: - 3. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards. During an interview, on 3/26/21 at 2:01 p.m., the Director of Nursing (DON) confirmed medications should be given as ordered, insulin pens should be primed, and the standard of practice was to dilute medications prior to administering through a PEG tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 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 105362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Wauchula 401 Orange Place Wauchula, FL 33873 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, record reviews, and interviews the facility failed to ensure one (West) out of two treatment carts were locked and inaccessible to visitors and residents when unattended, and one (North) out of three medication carts observed did not contain expired medication and insulin was refrigerated prior to opening. Findings included: On 3/25/21 at 5:14 p.m., an observation was made of an unlocked treatment cart on the [NAME] hall. The treatment cart was inside the nursing station; however the station did not provide barriers to visitors and/or residents from entering. The drawers of the treatment cart contained topical medicated lotions, creams, and gels. Staff Member I, Licensed Practical Nurse (LPN), confirmed the treatment cart was unlocked while she was elsewhere on the unit. At 2:01 p.m. on 3/26/21, the Director of Nursing (DON) stated she was aware of the situation regarding the unlocked treatment cart. She stated that medication/treatment carts should be locked when unattended and confirmed the nursing station on the [NAME] hall was accessible to visitors and residents. An observation of the North medication cart was conducted on 3/26/21 at 6:23 p.m. with Staff Member H, LPN. The medication cart contained a sealed plastic bag, labeled by the pharmacy, that held 2 Lantus SoloStar insulin pens. Staff H confirmed one pen was unopened. The pen had an attached sticker that indicated to refrigerate until open. The cart contained a Semglee insulin pen, dated 2/17/21, the bag that the pen was stored in was dated, 3/4/21. Staff H stated the medication was expired, had been removed from the cart last week with pharmacy, and did not know how it got back into the cart. During the observation of the North medication cart, the DON arrived to the location and confirmed the findings. The DON instructed the Staff Member H if medication (Semglee) had been expired it needed to be destroyed at that time. The dates of 2/17/21 and 3/4/21 on the Semglee insulin pen indicated a difference of fifteen days. The website, goodrx.com, indicated Semglee pens were to be thrown away after 28 days, even if it still contained insulin. A count of days between 2/17/21 and of the observation date of 3/26/21 indicated a difference of 37 days. At 4:09 p.m. on 3/31/21, an interview was conducted by telephone with the Consultant Pharmacist. He indicated that he was aware of the concerns discovered during the visit. He stated he was not to concerned with the Lantus pens not being refrigerated if the resident who was to receive used a pen within 2-3 days. He said he believed the open life of Semglee was 28 days and would expect expired medications to be removed from the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105362 If continuation sheet Page 17 of 17