Health inspection·March 28, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/25/24 at 10:14 a.m., Resident #262 stated, she usually takes the big ones first and then leisurely takes the other pills when she can. Resident #262 stated I cannot take a bunch of pills all at once, so the nurse leaves them for me to take. Resident #262 identified the pills in the medication cup as my morning meds. Review of the admission Record showed Resident #262 was admitted to the facility on [DATE] with diagnoses to include but not limited to aftercare following joint replacement surgery, presence of right artificial knee, unilateral primary osteoarthritis, right knee and hypertensive heart disease without heart failure. Review of the Medication Review Report revealed no physician order for Resident #262 for self-administration of medications. Review of the care showed no focus, goal or interventions for Resident #262 for self-administration of medications. During an interview on 03/27/24 at 9:31 a.m., Staff B Licensed Practical Nurse (LPN) stated there were no Residents including Resident #84 and #262 that could self-administer their medications. During an additional interview on 03/27/24 at 10:30 a.m., Staff B LPN stated Resident #84 did have an order for nebulizer treatments, but the order was as needed (PRN) and he was able to let staff know when he needed a treatment. Staff B LPN stated that nebulizers do contain medication and are considered treatments nurses are to be present for when being administered. Staff B LPN stated that Resident #84 was alert and oriented so she did not always stand over Resident #84 when he was being administered his breathing treatment and stated sometimes, she would be near his door while he was being provided his nebulizer treatment. During an interview on 03/27/24 at 10:50 a.m., the Director of Nursing (DON) stated even though a nebulizer order was PRN it was a medication treatment so Residents cannot use it without a nurse presence. The DON confirmed there were no resident in the facility that were permitted to self-administer their own medications. The DON stated, no pills should be left at bedside. Review of the facility's policy Self-Administration of Medications revised date February 2021 revealed Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely administer medications is reassessed periodically based on changes in the resident's medical and or decision-making status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 2 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility's policy Care Plans, Comprehensive Person-Centered the facility failed to develop a patient-centered care plan for one (Resident #84) out of twenty-two sampled residents related respiratory care and services. Findings included: An observation on 03/25/24 at 10:00 a.m., revealed a nebulizer machine on the nightstand beside Resident #84's bed. The nebulizer mask was sitting on top of the nebulizer machine and left to open air. A clear bag was sitting underneath the nebulizer machine and not being used. Photographic evidence obtained. During an interview on 03/25/24 at 10:00 a.m., Resident #84 stated the nebulizer mask was not in the bag because he was physically unable to store it in the bag after his treatment. Resident #84 stated the nurse usually started the nebulizer treatment but then went out to take care of other residents. Resident #84 stated when the nebulizer treatments were finished I put it away myself. Resident #84 stated staff did not stay the entire time while he received his breathing treatment. On 03/25/24 at 11:25 a.m., Resident #84 was observed sitting in bed and receiving a breathing treatment. Resident #84 was alone in his room and self-administering his breathing treatment with the nebulizer machine. A review of the admission Record showed Resident #84 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation and unspecified asthma uncomplicated. Review of the Medication Review Report revealed physician orders as followed: - Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG [milligrams]/3 ML [milliliters] (Albuterol Sulfate)3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath dated 02/01/24. - Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate)- 2 puff inhale orally every 4 hours as needed for shortness of breath FLUTICASONE-VILANT 200-25 MCG - 1 puff inhale orally one time a day for COPD dated 02/01/24. Review of Resident #84's care plan showed no focus, goals or interventions related to Resident #84's respiratory diagnoses of COPD or Asthma and no treatments that included an inhaler or nebulizer breathing treatments. During an interview on 03/27/24 at 11:40 a.m., the Director of Nursing (DON) stated it appears that we care planned everything under the sun except that. The DON confirmed Resident #84's care plan was not developed for his respiratory diagnoses, care, and treatment. Review of the facility's policy Care Plans, Comprehensive Person-Centered revised date March 2022 revealed, 1. The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 3 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 4 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that activities of daily living related to nail care were provided for one (Resident #9), out of five sampled residents. Residents Affected - Few The findings include: On 3/25/2024 at 10:30 AM, Resident #9 was observed sitting in the hallway, just outside of his room. Resident #9 had food on the front of his gown, facial whiskers, and his hair was not combed. He was able to answer with head nods to yes/no questions. He responded with a negative (no) head nod when asked about liking the whiskers. He responded with a yes if preferred to be clean shaven. His hands were positioned on his lap. His fingers were curled under into the palm of his hands. He was able to open his fingers slightly to both hands. When this occurred, a foul odor was noted. His fingernails were dirty with brown and white substances underneath and his fingers were dirty. On 3/26/2024 at 8:55 AM, and 10:20 AM, Resident #9 was observed out of bed sitting in the wheelchair, his hands were resting in his lap. The resident's nails were dirty, long, and had a brown and white substance underneath the nails. Resident #9 had crumbs of food on his chest and in mustache. On 3/27/2024 at 12:30 PM, Resident #9 was observed sitting up in the wheelchair with a towel over his chest (being used as a clothing protector). The towel and resident's mustache, chin, and hands had food on them. His nails were still long, dirty, and had a foul odor. (Photographic Evidence Obtained). During an interview on 3/27/2024 at 1:12 PM, Staff H, Certified Nursing Assistant (CNA) and Staff F, CNA both stated utilizing the [NAME] to know how to care for residents. Resident #9 was dependent on staff for all care. Resident #9 did not have any splints or skin problems on his buttocks. During an interview on 3/27/2024 at 9:40 AM, Staff G, CNA confirmed responsibility for Resident #9, and normally took care of the resident. Staff G confirmed Resident #9 needed assistance with all meals, bathing, hand hygiene, basically everything. Resident #9 did not have any splints or different care for his hands. Staff G stated Resident #9's buttocks did not have any skin concerns. During an interview on 3/27/2024 at 1:20 PM, Staff A, Licensed Practical Nurse (LPN) stated responsibility for the care of Resident #9. Staff A stated Resident #9 was dependent on staff for all Activities of Daily Living (ADLs). Staff A stated staff needed to clean his hands, wash his face, brush his teeth, provide nail care, et al. Staff A confirmed Resident #9 did not have splints or special care to his hands. Staff A, LPN stated Resident #9 did not have any skin concerns on his buttocks. During an interview on 3/27/2024 at 1:25 PM, the Director of Nursing (DON) confirmed Resident #9 was total care. The DON stated the CNAs should be assisting the resident with all care needs. The DON stated any nursing employee could soak and clean residents' nails. The DON observed Resident #9's fingernails and soiled clothing. The DON stated Resident #9 needed to be cleaned up and nails cleaned and trimmed. The DON stated if there was an order for a resident to have splints, then a care plan would be created. When an order was changed the expectation was for the care plan to be updated accordingly. When care changes the care plan should be updated at the same time, this would include excoriation to buttocks, as this is healed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 5 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #9's admission Record revealed current admission date of 8/12/2022 with the following diagnosis: Alzheimer's Disease, Dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), Right- and Left-hand contracture, Diabetes type 2, peripheral vascular disease (PVD), anxiety disorder and other co-morbidities. A Minimum Data Set (MDS) dated [DATE], revealed Resident #9 with a Brief Interview for Mental Status (BIMS) score of 1/15, which indicated severe cognitive impairment. The resident was coded to no behaviors. His functional abilities and goals revealed impairments on bilateral upper and lower extremities, dependent for all care. Review of Resident #9's Order Summary with an active date of 3/27/2024 showed no order for hand splints. Review of Resident #9's Care Plan revealed a care plan including the following: Focus of Contractures [Resident #9] has contracture of the right and left hands with a revision date of 2/11/2023. The interventions included but not limited to: Bilateral hand splint 3-4 hours at nights as tolerated. Alternate with rolled washed cloth as ordered. With a revision date of 10/14/2022. Provide routine skin care, wash and dry hands properly. Date initiated 10/14/2022. Focus area shows: [Resident #9] has an ADL self-care deficit and requires assistance with ADLS related to contractures, . revised on 4/3/2023. Interventions include but not limited to: hair and nail care as needed initiated on 7/21/2023. Contractures: The resident has contractures of both hands. Provide skin care to keep clean and prevent skin breakdown. Revised on 4/3/2023. Eating: Resident is an assist with meals, initiated on 9/28/2023. Focus Area: [Resident #9] has an excoriation to buttocks related to incontinence, revised on 4/10/2023. Review of the facility's policies and procedures with the subject of Fingernails/Toenails, Care of revised on February 2018. Purpose: the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Steps in the Procedure: 3. Fill the wash basin 1/2 full of warm soapy water. 4. Allow the first hand or foot to soak in the warm soapy water for approximately 5 minutes. 5. Encourage the resident to exercise his or her fingers while they are soaking. 6. Rinse the hand or foot that has been in the soapy water with clear, warm water. 7. Dry the hand or foot with the towel. 8. Place the towel under the resident's dried hand or foot. 9. Place the second hand or foot in the soak basin. 10. Gently, remove dirt from around and under each nail with an orange stick. 11. Wipe the dirt from the orange stick with a paper towel. Discard the paper towel into the trash receptacle. 12. Do not trim nails below the skin line or cut the skin. 13. Trim fingernails in an oval shape and toenails straight across. 14. Smooth the nails with the nail file or emery board. Apply lotion as permitted. 15. Repeat the procedure for the second hand or foot. Reporting: 1. Notify the supervisor of the resident refuses the care. 2. Report other information in accordance with the facility policy and professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 6 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an assessment and documentation for discovered skin discolorations / bruising was performed for three (Residents #201, #6, and #19) of 22 sampled residents and failed to ensure wound dressings were dated and initialed for one (Resident #252) of 22 sampled residents. Residents Affected - Some Findings included: 1. On 03/26/2024 at 9:15 a.m., Resident #201 was observed sitting in her wheelchair returning to her room from the shower. She was dressed and groomed for the day. Resident #201 had a dialysis catheter present in the left chest area. She had a urinary catheter. There was a discolored bruised area on her right upper arm. She stated it was from the IV (Intravenous line) at the hospital. She stated it was [NAME] and larger. She had been re-admitted from the hospital on [DATE]. Review of Minimum Data Set, dated [DATE], Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 14 or cognitively intact. Section G, Functional Abilities and Goals showed resident dependent for toileting, showering and dressing. Resident #201 was readmitted on [DATE] with an original admission date of 08/11/2010. Review of the admission record showed diagnoses included but not limited to metabolic encephalopathy, lumbar spina bifida with hydrocephalus and shunt placement, diabetes, paraplegia, hypertensive chronic kidney disease or End Stage Renal Disease including dialysis, obstructive hydrocephalus, adjustment disorder, neuromuscular dysfunction of the bladder, anemia, anxiety, Stage IV sacral pressure ulcer, and convulsions. Review of the Skin Observation dated 03/19/2024 showed Skin Integrity: existing pressure ulcer and other existing skin impairment. New bruise and / or existing bruise was blank. Review of the Skin Observation dated 03/26/2024 showed Skin Integrity: existing pressure ulcer and existing surgical incision. New bruise and / or existing bruise was blank. Review of the nursing progress notes dated 03/19/2024 had no documentation related to the right upper arm bruising. Review of Resident #201's skin integrity care plan showed she was at risk for recurrent skin ulcers and impaired skin integrity related to limited mobility, paraplegia, diagnosis of peripheral vascular disease and diabetes. She has a history of chronic scabs to her bilateral thighs, habit to pick them open sometimes. She sometimes has itching and scratches, opening areas on her arms and upper back. Interventions included but not limited to weekly skin checks as of 11/04/2021; observe for discoloration, shiny appearance of the skin as of 11/04/2021; observe resident's skin for abnormal changes as of 11/04/2021. An interview / observation on 03/27/2024 at 9:45 a.m. with the Director of Nursing (DON) verified there was a discolored / bruise area on Resident #201's right upper arm. Resident #201 stated to the DON that it was from the hospital, and it was bigger and [NAME] before. 2. On 03/25/2024 at 1:19 p.m., Resident #19 was observed sitting in a wheelchair in the hallway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 7 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She was dressed and groomed for the day. She was unable to answer screening questions. She had a noticeable discoloration / bruise on her hands and arms. Resident #19 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Chronic Pulmonary Obstructive Disease (COPD), convulsions, diabetes, anemia, Stage II chronic kidney disease, and restless leg syndrome. Review of the MDS dated [DATE] showed a BIMS score of 01 or severe impairment. Section GG, Functional Abilities and Goals showed she was dependent for toileting and showering. Review of the Skin Observation dated 03/21/2024 showed skin intact. New bruise and / or existing bruise was blank. Review of the nursing progress notes showed no documentation related to discoloration / bruising of her hands and arms. Review of Resident #19's skin integrity care plan showed she was at risk for impaired skin integrity related to impaired mobility due to generalized weakness-incontinence. Interventions included but not limited to weekly skin checks as of 04/20/2021; use caution when transferring resident to avoid bumping skin against hard surfaces as of 02/08/2024; use geri sleeves to both upper extremities as tolerated to protect skin from injury as of 07/6/2021. 3. On 03/26/2024 at 1:25 p.m., Resident #6 was observed sitting in her wheelchair in the hallway. She was dressed and groomed for the day. She had discoloration and / or bruising noted on both of her hands and arms. Resident #6 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Chronic Pulmonary Obstructive Disease (COPD), dementia with other behavioral disturbance, atrial fibrillation, moderate protein-calorie malnutrition, anxiety, and anemia. Review of the MDS dated [DATE] showed a BIMS score of 06 or severe impairment. Section GG, Functional Abilities and Goals showed she was dependent for toileting and showering. Review of the Skin Observation dated 03/23/2024 showed skin intact. New bruise and / or existing bruise was blank. Review of the nursing progress notes showed no documentation related to discoloration / bruising of her hands and arms. Review of Resident #6's skin integrity care plan showed she was at risk for impaired skin integrity related to impaired mobility due to generalized weakness. Interventions included but not limited to weekly skin checks as of 10/24/2022. During an interview on 03/27/2024 at 12:00 p.m., Staff D, Licensed Practical Nurse (LPN) stated that if the staff found a new area on the skin, they were to document it in the progress notes. Staff D, LPN verified Resident #19 had 5 bruises on her right hand and arm and 4 bruises on her left hand and arm. Staff D, LPN verified Resident #6 had bruising on both of her hands and arms. Staff D, LPN stated Resident #201's bruising should have been documented in the progress notes when she obtained the discoloration or on her re-admission (paperwork) if she was re-admitted with it. If a bruise / discoloration was found later, it should have been documented in the facility report. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 8 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/27/2024 at 12:31 p.m., the DON stated all new skin areas should be documented in the progress note and / or on a skin assessment. She stated the skin impairment needed to be an identified incident requiring the process of investigating the cause of the injury. The DON stated they may need to put something into place to prevent further injury. The DON reviewed Resident #201's medical record and confirmed nothing was documented regarding (her discoloration of her right arm) so the DON had a facility report completed. The DON stated she would have expected to see something about the bruise in the resident' chart. The DON reviewed Resident #19's record and stated there was no documentation regarding any skin issues i.e. bruises. The DON stated they should have done a progress note and a facility report which included notifying the family and physician. They also had to document monitoring of the area for 72 hours. The DON reviewed Resident #6's medical record and stated there was no documentation regarding bruising on her arms in the record. The DON asked the ADON (Assistant Director of Nursing) to evaluate the resident and document. During an interview with the Nursing Home Administrator (NHA) on 03/28/24 at 9:32 a.m. she stated, We do not have a policy regarding skin checks, it is a standard of care that we monitor the skin. 4. During an interview on 03/25/24 at 10:37 a.m., Resident # 252 stated, I have a leg wound and they never change it daily like my doctor wants them to. Resident #252 stated she saw a wound doctor every week, but the nurses were supposed to be changing the dressing daily and did not. Resident #252 stated my wound dressing wasn't changed over the weekend. An observation on 03/25/24 at 10:37 a.m., revealed Resident #252's right leg with a dry wound gauze like dressing held closed with tape. The dry wound dressing was not dated. Photographic evidence obtained. Review of the admission Record showed Resident #252 was admitted to the facility on [DATE] with diagnoses included but not limited to multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, cellulitis of right lower limb, muscle weakness (generalized), and repeated falls. Review of the Medication Review Report revealed a physician order dated 03/15/24 that showed Cleanse ulcers to RLE [Right Lower Extremity]with NS [normal saline], apply xeroform then abd [army battle dressing] pads and wrap with kerlix. - every day shift every Mon, Wed, Fri for diabetic ulcers. The Treatment Administration Record (TAR) showed Resident #252 had received wound treatment on 03/15/24, 03/18/24, 03/20/24, 03/22/24, 03/25/24, and 03/27/24, per physician orders. During an interview on 03/27/24 at 10:35 a.m., Staff C Licensed Practical Nurse (LPN) stated that she was the wound nurse. Staff C stated that once wound treatment had been completed and the wound had been dressed All dressings you date and initial. During an interview on 03/27/24 at 10:50 a.m., the Director of Nursing (DON) stated that any wound dressing should be labeled and initialed when treatment was completed. Review of the facility's policy Dressings, Dry/Clean revised date September 2013 showed, Steps in the Procedure .10. Label tape and dressing with date and initials. Place on clean field. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 9 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to identify and educate staff of specific behaviors and triggers related to Post Traumatic Stress Disorder (PTSD) for one (Resident #77) of two sampled residents who had PTSD. Residents Affected - Few Findings included: On 3/25/2024 at 2:25 p.m., Resident #77 was observed in the hallway leading from the therapy gym to the 200 hall. He was standing up and walking with therapy staff. Resident #77 was observed pleasant to speak with and was not presenting with any behaviors, pain, or discomfort. On 3/26/2024 at 11:15 a.m., Resident #77, while he was in his room, was interviewed with his permission. He expressed he was ordered and received psychotropic medications for several psychological diagnoses, and had taken those medications for many years. He felt the medications were working well, and also expressed, If I was not on these medications, I would not be the same as I am now. Resident #77 was asked if he had any type of history related to past trauma. He confirmed he did and he was seen by psychiatric services at least once a month and also saw a psychologist. Resident #77 was asked if he felt psychiatric services had been helping when it came to his past trauma. He said he felt the services were working but did not want to speak of what trauma/PTSD he had gone through. Resident #77 was not asked any further questions related to his past trauma/PTSD. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE]. Review of the advance directives showed Resident #77 was his own responsible party. Review of the diagnosis sheet showed diagnoses to include but not limited to Post Traumatic Stress Disorder (PTSD) (onset 10/25/2023); Schizophrenia (onset 10/25/2023); Anxiety (onset 10/25/2023) Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 1/31/2024, showed a Cognition/Brief Interview for Mental Status or BIMS score of 13 of 15, which indicated intact cognition. Mood - None documented as exhibited during this assessment period. Review of he most current Physician's Order Sheet (POS), dated for the month of 3/2024 showed the following but not limited to orders: (a) Beginning Order date of 10/27/2023: Observation; Behaviors. Observe for the following: 1. Itching, picking at skin; 2. Restlessness, agitation; 3. Hitting, kicking, physical aggression; 4. Spitting, biting; 5. Cussing, yelling; 6. Delusions, hallucinations, psychosis; 7. Refusing care; 8. Isolation, withdrawn, depression; 9. Wandering, pacing; 10. Insomnia; 11. Disorganized thinking; 12. Abnormal motor behaviors; 13. Negative symptoms, avoids eye contact, lacks facial expression, monotone; 0. No Behaviors. Every shift for monitoring non pharmacological interventions: 1. Diversion, redirection; 2. Activities, music; 3. Resident expressed feelings, 1-to-1 interactions; 4. Snack, drink; 5. Calming environment, relaxation techniques, aromatherapy; 6. Alternate staff member; 0- No behavior. There was no observation criteria for behaviors including specific past Trauma/PTSD listed in this Behavior observation order. Also, there were no other Trauma/PTSD behavior monitoring orders within the 3/2024 order sheet/treatment sheet. Review of the past and current Psychiatric notes/assessments revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 10 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (1) 10/31/2023 Psychiatric follow up assessment - History note - history anxiety and depression and schizoaffective disorder. Fall from home. Army Veteran, Past psychiatric history of PTSD, depression and substance abuse. Past Suicide attempt via drug overdose on psychiatric medications and past attempt of cutting himself past use of psychotropic medications. (2) 11/28/2023 Psychiatric follow up assessment - Notes - Past Suicide attempt via drug overdose on psychiatric medications and past attempt of cutting himself past use of psychotropic medications. Army Veteran, Past psychiatric history of PTSD, depression and substance abuse. Trauma history included serving in [name] war, war flashbacks. (3) 12/26/2023 Psychiatric follow up assessment - Notes - Past Suicide attempt via drug overdose on psychiatric medications and past attempt of cutting himself past use of psychotropic medications. Army Veteran, Past psychiatric history of PTSD, depression and substance abuse. Trauma history included serving in [name] war, war flashbacks. None of the above assessments from psychiatric services mentioned how Resident #77 would be assisted and further evaluated with relation to past Trauma/PTSD, specifically related to past suicidal attempt and war flashbacks. Review of the nurse progress notes dated from 10/30/2023 through to 3/28/2024 did not reveal any documentation related to Resident #77 presenting with any type of behaviors that may be triggered or related to past Trauma/PTSD. Review of the current care plans with a next review date of 5/2/2024 revealed the following but not limited to; Resident #77 is Pre admission Screen Record Review (PASRR) positive MI/ID/DD related to Schizophrenia, PTSD, and with interventions in place. There was nothing related to specific interventions to either reduce or identify areas of past Trauma/PTSD. Resident #77 has a psychosocial well-being problem and actual related to history of anxiety, depression and psychotic, Chronic PTSD and Schizoaffective disorder, with interventions in place to include but not limited to: Monitor for changes in psychosocial well-being increased from baseline such as, but not limited to increased behaviors, sadness, irritability, anger, agitation, distress, crying, screaming, moaning, combativeness, fear, anxiety, withdraw, psychomotor retardation (slowed speech, thinking, and body movements; increased pauses before answering) self-isolation, change in appetite, etc. and notify social services/psych services and physician immediately for further intervention. (Date onset 10/26/2023). There was nothing related to specific interventions to either reduce or identify areas of past Trauma/PTSD. Resident #77 has history of Trauma related to history of sprained Left ankle. And has history of PTSD with interventions to include but not limited to: Staff to provide a trauma-informed care approach that involves understanding, recognizing and responding to the effects of all types of trauma; Recognizing the widespread impact and signs and symptoms of trauma in residents; and avoiding re-traumatization. (Date onset 10/26/2023). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 11 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few This care plan problem area did not reflect what specific type of PTSD/Trauma Resident #77 had, nor did the care plan problem area have interventions to reduce or identify behaviors specifically related to PTSD/Trauma. This care plan problem area was more related to trauma related to a sprained Left ankle. On 3/27/2024 at 11:20 a.m., an interview with Staff I, Certified Nursing Assistant (CNA) revealed she had Resident #77 on her assignment most days and she knew him and his care and services. Staff I also revealed she knew him well enough to know that he had not been presenting for awhile with any types of behaviors. Staff I revealed Resident #77 usually stayed in his room most of the day and came out when he was scheduled for rehabilitation therapy. She did not believe he participated in resident group activities. She also verified the resident had family visits at times. She said the resident had not had any behaviors in awhile that she could remember, but would report behaviors to the nurse if he exhibited any. Staff I was asked if she was aware if the Resident #77 had any past Trauma or Post Traumatic Stress Disorder (PTSD) behaviors that she might need to watch for. She revealed she did not believe that he did. She was asked if she was provided with any training or education related to residents having Trauma/PTSD. She said she did, but it might have been a long time ago. Staff I revealed the training was most likely basic and revealed how to identify certain behaviors and how to report them. Staff I confirmed she had never been educated on what PTSD/Trauma behavior or triggers to look out for and report when it came to Resident #77. On 3/27/2024 at 11:30 a.m., an interview with Staff B, Licensed Practical Nurse (LPN) revealed she had Resident #77 on her assignment on a daily basis and knew him and what his care expectations were. Staff B revealed Resident #77 stayed in his room most of the time and he usually only came out when he had therapy. She revealed he had electronic devices in his room, television shows to watch and had visits from family at times. Staff B revealed Resident #77 did not like to go to scheduled group activities, and he normally ate in his room for all three meals. Staff B said the resident had not had any documented behaviors during the past couple of months that she could remember, but he and his roommate would sometimes disagree with one another. They were really close roommate friends, and almost like family. Staff B said the resident could not remember the reason for his Trauma/PTSD and she did not know of what type of behaviors to look out for and report that were specifically related to his past Trauma/PTSD. She did not know what types of triggers would cause him to present with PTSD/Trauma behaviors. Staff B confirmed she had Trauma/PTSD education in the past, but was not made aware of what specific Trauma behaviors Resident #77 may or may not present with. Staff B also confirmed the floor CNAs were not aware of what specific behaviors of past Trauma to look out for and to report to her. On 3/27/2024 at 1:26 p.m., an interview with Staff J, Staff Developer revealed she was generally the person who was initially responsible for providing education and inservices related to Trauma/PTSD. She revealed initial training was provided to staff during their orientation process. Staff J also revealed the Director of Nursing and the Assistant Director of Nursing would also provide training related to PTSD/Trauma as need. Staff J provided a blank orientation packet that was provided to new staff which included a power point presentation. Page 17 of the power point presentation revealed two slides dedicated to Trauma informed care. The slides indicated how to generally observed, report and identify trauma in residents. There was a computer based website the staff had to watch to include review of the slides. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 12 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few J said the PTSD/Trauma education was provided on a yearly basis to all staff. Staff J confirmed the DON, ADON, and psychiatric services were responsible for identifying, assessing, and monitoring residents for triggers and symptoms related to Trauma/PTSD, They were also responsible for passing down information to direct care staff related to specific behaviors related to Trauma/PTSD. A second interview with Staff J was conducted on 3/28/2024 at 8:30 a.m., and she provided the last facility wide Trauma/PTSD training, dated 7/25/2023. The training subject matter revealed; Trauma Informed Care, and was signed and dated by all direct care staff. Staff were provided with an informational Trauma Informed Care Handout. Staff J again could not speak to what triggers affected Resident #77 with regards to past Trauma/PTSD. She confirmed all staff should be aware of what type of behaviors to look for so they could be reported to the Nurse Manager, DON, and psychiatric services, in order to find ways to reduce those behaviors. Staff J confirmed Resident #77's medical record to include the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not have a specific order or monitoring system for specific behaviors/triggers related to PTSD. On 3/28/2024 at 10:00 a.m., an interview with the Nursing Home Administrator and the DON confirmed though Resident #77 had care plans related to Trauma/PTSD behaviors, and orders for general behavior monitoring; there was no evidence in the medical record to include nurse progress notes, nursing quarterly assessments, and care plans that spoke to what type of past Trauma/PTSD he had. The DON confirmed the psychiatric assessments showed a note on 10/31/02023, 11/28/2023, and 12/26/2023 that the resident had a past history of trauma related to military war background. The DON said the information was not carried over to the current Trauma/PTSD care plan, nor were staff educated and inserviced on what types of triggers might induce those specific trauma behaviors. On 3/28/2024 at 11:00 a.m. the Nursing Home Administrator revealed the facility did not have a specific Trauma/PTSD policy and procedure. However, she provided a Behavioral Assessment, Intervention and Monitoring policy and procedure for review. She revealed this policy is used for residents who have Trauma/PTSD. The policy was last revised on March 2019 and revealed; 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. 3. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or Post Traumatic Stress Disorder (PTSD) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable. General Guidelines; (1) Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental clauses. a. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 13 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0699 Level of Harm - Minimal harm or potential for actual harm b. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. (2) As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: Residents Affected - Few a. The resident's usual patterns of cognition, mood and behavior. b. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers, and c. The resident's previous patterns of coping with stress, anxiety, and depression. (3) The nursing staff will identify, document, and inform the physician about specific details regarding change in an mental status, behavior, and cognition, including: a. Onset, duration, intensity and frequency of behavioral symptoms; b. Any recent precipitating or relevant factors or environmental triggers (e.g. medication changes, infection, recent transfer from hospital), and c. Appearance and alertness of the resident and related observations. Management (1) The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. (2) Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. (3) Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reason s for the behavior. The care plan will include, as a minimum: (a) Frequency; (b) Intensity; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 14 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 0699 (c) Duration; Level of Harm - Minimal harm or potential for actual harm (d) Outcomes; (e) Location; Residents Affected - Few (f) Environment; and (g) Precipitating factors or situations. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms. The rational for the interventions and approaches; The rationale for the interventions and approaches; Specific and measurable goals for targeted behaviors; and How the staff will monitor for effectiveness of the interventions. Monitoring IF the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 15 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 observation, interview, and record review, the facility failed to ensure infection control practices and procedures were followed during medication administration for four (Residents #260, #259, #13 and #35) of seven sampled residents and one (Resident #84) of one sampled resident related to proper storing of a nebulizer mask. Residents Affected - Some Findings included: 1. On 03/26/2024 at 8:35 a.m., Staff B, Licensed Practical Nurse (LPN) was observed passing medications to Resident #260. Staff B, LPN failed to perform hand hygiene after passing the medications. 2. On 03/26/2024 at 9:30 a.m., Staff B, LPN and the Regional Registered Nurse (RN) were observed passing medications to Resident #259 via a gastrostomy tube. Staff B moved the resident in his wheelchair, but did not hand sanitize prior to starting medication administration. Staff B touched the medication cart, her pen, her computer, dated the wrapper of the large syringe then started removing the medications from the medication cart. Staff B removed seven medications and placed them individually into medication cups. She placed the medication cups onto a Styrofoam barrier. Staff B crushed two medications and then turned and hand sanitized. Staff B then crushed four more medications. Staff B donned gloves and opened the medication in capsule form and poured it into the medication cup. Staff B did not hand sanitize after glove removal. Staff B removed an alcohol wipe from the medication cart and cleaned her stethoscope hanging around her neck. She then locked the medication cart and turned off the computer. Staff B had gathered a plastic cup and spoon from the medication cart. Staff B gathered the cup with a spoon in it, and the medications on the barrier and entered the room. Staff B entered the bathroom, poured water into the cup, washed her hands and applied gloves. Staff B was standing in the room and the Regional Registered Nurse (RRN) exited the room and brought a towel back in and laid it on the bed. The RRN then went around the bed and closed the blinds. RRN did not hand sanitize her hands. Staff B placed the Styrofoam barrier onto the towel on the bed. The RRN told Staff B she needed to place a barrier on the resident's lap under the g-tube. They removed the towel from the bed and placed it on the resident's lap. Staff B placed the Styrofoam barrier with the medications on it onto the bed. The RRN continued to hold the water cup with the spoon in it. Staff B opened the package the large syringe was in and used it to aspirate the g-tube. Staff B listened with the stethoscope as she infused air into the g-tube with the syringe. Staff B then flushed the g-tube with water. Staff B poured the first medication into the g-tube without putting any water into the medication cup and dissolving the medication. Staff then followed the pouring of the dry medication with water. Staff B with the assistance of RRN placed water into the remaining medication cups and poured them into the g-tube. Staff B did not consistently stir the medications after adding water before pouring them into the g-tube. Staff B flushed the g-tube with water after finishing the medication administration. Staff B went to the bathroom to rinse the syringe and throw away the plastic cup and spoon. Staff B removed her gloves and washed her hands. Staff B replaced the syringe into the dated plastic wrap and placed it onto the bedside table. RRN washed her hands. RRN coached Staff B throughout the procedure. 3. On 03/26/2024 at 10:55 a.m., Staff E, Registered Nurse (RN) was observed performing glucose monitoring for Resident #13. Staff E had placed the blood glucose meter, bottle of strips, lancet and alcohol wipe into a plastic cup. Staff E hand sanitized her hands and applied gloves in the resident's room. Staff E placed the plastic cup with the items inside of it onto the bedside table. Staff E removed the alcohol wipe and cleaned the left ring finger of the resident. Staff E removed the bottle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 16 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of strips and removed one and placed it in the blood glucose meter. Staff E then closed the lid on the strips, set it on the bedside table and placed the blood glucose meter on top of it. Staff E placed a drop of blood on the strip and the results were 113. Staff E, using her gloved hands removed a pen from her pocket as well as a piece of paper and documented the blood sugar results on it. Staff E then replaced the pen and paper in her pocket. Staff E gathered the glucose monitor and placed it into the plastic cup and placed it in one of her pockets. Staff E placed the bottle of strips into her other pocket. Staff E removed her gloves and went into the resident's restroom to wash her hands. Staff E walked down the hallway to the medication room. Staff E applied gloves and removed a wipe from the blue top canister and wiped the blood glucose meter she had removed from the plastic cup. Staff E removed a second wipe and placed it around the blood glucose meter and placed it back into the cup she had used in the resident's room. Staff E removed her gloves but did not hand sanitize her hands in or upon leaving the medication room. Staff E was observed going down the hallway with another blood glucose meter set-up to another resident room. 4. On 03/26/2024 at 1:10 p.m., Staff A, LPN was observed administering 5 cc normal saline via Intravenous to Resident #35. Staff A hand sanitized and gathered the normal saline syringe, alcohol wipes and IV cap for the administration. Staff A applied gloves touched the overbed table, curtains and overbed table again. Staff A removed her gloves and reapplied gloves without hand sanitizing. Staff A cleaned the port and flushed the IV with the 5 cc of normal saline. She removed her gloves and washed her hands after the infusion. During an interview on 03/28/2024 at 12:49 p.m., the Director of Nursing (DON) stated hand hygiene was to be performed before starting to prepare medications, upon entering the resident's room with medications, they might need to hand sanitize while in the room and upon exiting the resident room. Staff E should not have taken a bottle of strips into the resident's room. Staff E should not have placed the clean blood glucose meter into the cup she had brought from the resident room. The DON shook her head when informed Staff E's pockets. The DON stated the medications should not be placed into the g-tube without being diluted with water because the medications could stick to the g-tube. Review of the facility's policy, Handwashing / Hand Hygiene, revised August 2019 showed this facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing 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. 6. 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; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive devices; i. After contact with a resident's intact skin; l After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 17 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 m. After removing gloves Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy, Administering Medications, revised April 2019 showed 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Residents Affected - Some Review of the facility's policy, Blood Sampling - Capillary (Finger Sticks) revised September 2014 showed the purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. General Guidelines: 1. Always ensure that blood glucose meters are intended for reuse are cleaned and disinfected between resident uses. Steps in the Procedure: 1. Perform hand hygiene. 2. [NAME] gloves. 3. Place blood glucose monitoring device on clean field. 4. Place a new lancet and disposable platform on the spring-loaded finger-stick device. 5. Wipe the area to be lanced with an alcohol pledget. 6. obtain the blood sample, following the manufacturer's instructions for the device. 7. Discard the lancet and platform into the sharps container. 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and / or device after each use. 9. Remove gloves, and discard into appropriate receptacle. 10. Perform hand hygiene. 11. Replace blood glucose monitoring device in storage area after cleaning. Review of the facility's policy, Enteral Tube Medication Administration, not dated showed the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Procedure: Prepare one medication at a time. Put on examination gloves. Note: Medication administration via tube requires flushing with water at several steps in the procedure. Prepare medications for administration. 2. Crush each immediate-release tablets, one at a time, into a fine powder, and dissolve in at least 15 ml (or prescribed amount) of water. 3. Open each immediate release capsules, one at a time, crush contents into a fine powder, and dissolve in at least 15 ml (or prescribed amount) of water. Elevate the head of the bed. With gloves on, check for proper tube placement using air and auscultation only. Never check placement with water. Administer each medication separately and flush the tubing between each medication: 1. Place 15 ml (or prescribed amount) of water in syringe and flush tubing using gravity flow. Clamp tubing after the syringe is empty, allowing water to remain in the tube. 2. Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity. 3. Flush tube with 15 ml (or prescribed amount) of water between each medication. Pinch tubing below the syringe tip when each volume of liquid clears the syringe to avoid excessive air from entering the stomach. This can cause discomfort and emesis. 4. Clamp tubing and detach syringe. Cleans reusable equipment per facility infection control. Perform hand hygiene. 5. An observation on 03/25/24 at 10:00 a.m. revealed a nebulizer machine on the nightstand beside Resident #84's bed. The nebulizer mask was sitting on top of the nebulizer machine and left open to air. A clear bag was sitting underneath the nebulizer machine and not being used. Photographic evidence obtained. During an interview on 03/25/24 at 10:00 a.m., Resident #84 stated the nebulizer mask was not in the bag because he was physically unable to store it in the bag after his treatment. Resident #84 stated the nurse usually started the nebulizer treatment but then went out to take care of other residents. Resident #84 stated when the nebulizer treatments were finished I put it away myself. Resident #84 stated he would store the nebulizer mask in the bag if he physically could do so. A review of the admission Record showed Resident #84 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease (COPD) with (acute) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 18 of 19 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 105385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525 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 exacerbation and unspecified asthma uncomplicated. Level of Harm - Minimal harm or potential for actual harm Review of the Medication Review Report revealed a physician order dated 02/01/24 showed, Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG [milligrams]/3 ML [milliliters] (Albuterol Sulfate)- 3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath. Residents Affected - Some Review of Resident #84's care plan showed no focus, goals or interventions related to Resident #84's respiratory diagnoses of COPD or Asthma and no treatments that included a nebulizer breathing treatment. During an interview on 03/27/24 at 10:30 a.m., Staff B Licensed Practical Nurse (LPN) stated, all nebulizer masks should be placed in the bag for storage when not in use. During an interview on 03/27/24 at 11:40 a.m., the Director of Nursing (DON) stated nebulizer masks should have been placed in the bag after treatment. Review of the facility's policy Nebulizer- Administering Medications through a small volume (handheld) Nebulizer not dated revealed Store in plastic bag with the resident's name and the date on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105385 If continuation sheet Page 19 of 19