Inspection·December 16, 2021

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** 2. The admission Record revealed Resident #135 was admitted to the facility on [DATE] with a re-admission date of 11/23/2021 and multiple diagnoses to include hypertension heart disease with heart failure, asymptomatic varicose veins of bilateral lower extremities and personal history of other venous thrombosis and embolism. Residents Affected - Few On 12/13/21 at 12:04 p.m. Resident #135 was observed to be self-propelling his wheelchair to his room. An observation was made of Resident #135's right hand which had an adhesive bandage undated on the upper hand, with visible dry blood underneath. The resident was asked what had happened to his right hand and he stated he injured his hand against the handrail. Resident# 135 was observed with three steri strips on his lower left leg. Resident #135 reported that he scratched his leg on the wheelchair. On 12/15/21 at 8:54 a.m. an observation was made of the resident sitting in his wheelchair at the doorway of his room. Staff D, CNA was observed wrapping rolled gauze around the left leg where he had skin tears. His right hand still had the undated adhesive bandage. An interview was held with the Director of Nursing (DON) on 12/15/21 at 10:02 a.m. in regard to having a certified nursing assistant (Staff D) apply a gauze wrapping around a skin tear. The DON said absolutely not, this is out of her scope of practice. The DON was also informed that Resident #135 still had an undated adhesive bandage on his right hand since Monday 12/13/2021, with a visible brown like substance underneath the adhesive bandage. A review of the Certified Nursing Assistant's job description revealed under #26: Observes resident skin surfaces and notifies the charge nurse of any changes promptly. Based on observations, interviews, and record reviews, the facility failed provide treatment and care in accordance with professional standards of practice by 1) not assessing one resident (#32) for new skin conditions after a shower, and 2) having one resident's (#135) skin tear treated by a Certified Nursing Assistant (CNA) for a nurse for a sample of two residents observed with skin conditions. Findings included: 1. An observation and interview with Resident #32 on 12/14/21 at 9:00 a.m. revealed the resident sitting up in her wheelchair after a shower with her hair still wet. The resident's right foot was touching the wheelchair footrest. Skin transfer was observed from the bottom of the right foot to the footrest. The top of the second toe was observed shiny and pink. The resident stated her toe hurt and no one applied lotion to her skin after the shower. An interview with Staff A, CNA on 12/14/21 at 9:12 a.m. confirmed the resident had a shower. Staff A stated she (Resident #32) did not have any open wounds on her right leg and stated she applied lotion, which she obtained from the supply closet to the resident. An interview with Resident #32 on 12/14/21 at 3:55 p.m. revealed the resident lying in bed and she pulled her covers up to expose her right lower leg. Her second toe was uncovered and revealed a pinky shiny area at the base of the nail. Her bed sheets revealed drainage that was reddish brown in appearance. The resident's foot and leg were observed dry and flaky. She stated no one came to look at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 2 of 7 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 105393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667 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 her toe that hurt or to apply lotion. Level of Harm - Minimal harm or potential for actual harm During an interview and observation with the Director of Nursing (DON) on 12/14/21 at 3:59 p.m. the DON looked at Resident #32's wheelchair and observed the skin on the foot pedal. She stated this was not acceptable and needed to be cleaned and took the foot pedal to the bathroom sink to clean it. The DON gave the foot pedal to a staff member to finish cleaning and donned gloves to look at the resident's leg. She confirmed the resident had a wound on her second toe and the outside of the right leg. The DON confirmed peeling of the skin on the right foot and leg and stated it needed lotion, and wound care to address the two areas of the right leg. Residents Affected - Few During an interview with the Staff B, Licensed Practical Nurse (LPN) on 12/14/21 at 4:07 p.m. she confirmed Staff A, CNA gave the resident a shower and did not address any skin issues on the resident. Staff B, LPN stated the resident did not have any skin issues on her right leg. During an interview with Staff C, Registered Nurse (RN)/wound nurse on 12/14/21 at 4:04 p.m. she confirmed the resident did have a wound on the right outer leg and second toe. Staff C, RN stated she would call the doctor and get orders for care. Review of the wound care notes dated 12/14/21 revealed the resident had dry skin without scale, wound #10 is an open abrasion located on the right second toe. The wound measured 0.6 cm (centimeters) x 0.5 cm on initial assessment. Wound#9 is open partial thickness abrasion located on the lower right posterior leg, measuring 2 cm x 3 cm x 0.1 cm, small amount of serous drainage noted and large amount of red granulation within the wound bed. The DON confirmed at 4:05 p.m. on 12/14/21 the resident's wounds should have been addressed after her shower and stated the skin transfer on the footrest should have never happened. The DON confirmed education will be started on assessment of the skin, notifying the nurse and completing the skin assessments. An interview with the DON on 12/14/21 at 5:00 p.m. revealed the shower sheet stated no wounds on the right leg. Review of policy for Shower/Tub Bath, revised October 2010, 3 pages, revealed: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The following information should be recorded on the resident's ADL [activities of daily living] record and/or in the resident's medical record. 3. All assessment data (any reddened areas, sores, etc. on the resident's skin) obtained during the shower/tub bath. Reporting. 2. Notify the physician of any skin areas that may need to be treated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 3 of 7 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 105393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667 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 observation, interview, and record review, the facility did not ensure the medication error rate was below 5.00%. A total of thirty-two medications were observed, and two medications were verified for one resident (#5) of five residents observed. The medication errors constituted a medication error rate of 6.25 percent. Residents Affected - Few Findings included: On 12/15/2021 at 8:26 a.m., an observation was conducted of Staff B, Licensed Practical Nurse (LPN) administering medications to Resident #5. Staff B, (LPN) was observed administering the following medications: Aspirin 81 mg (milligrams) chewable one tablet Clopidogrel 75 mg one Lisinopril tablet 40 mg one Metformin 500 mg one Methenamine Hippurate 1 gram one Metoprolol Succinate extended release 24 hour 50 mg one Vitamin D3 capsule 400 unit one multivitamin one folic acid 400 mcg one Cyanocobalamin tablet 500 mcg one Sugar Free medpass 60 ml (milliliters) During the observation of medication administration, Staff B, LPN crushed the Metoprolol Succinate extended release 24 hour medication with all medications and gave an 81 mg chewable aspirin instead of a 325 mg aspirin enteric coated. Review of the active physician orders as of 12/15/21 revealed Staff B, LPN should have given Aspirin 325 mg enteric coated delayed release and Metoprolol Succinate ER tablet extended release 50 mg. Review of the active physician orders revealed: May change between oral, solids and liquids, crush meds or open capsules unless contraindicated or give via enteral tube if tube is in place. During an interview with Staff B, LPN on 12/15/21 at 8:40 a.m. she stated the resident gets her medications crushed and did not realize she gave the wrong aspirin. During an interview on 12/15/21 at 10:00 a.m. with the Director of Nursing (DON) confirmed the extended release should not have been crushed and confirmed the aspirin should have been enteric coated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 4 of 7 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 105393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667 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 and 325 mg. Level of Harm - Minimal harm or potential for actual harm A phone interview was attempted with the pharmacist three times from 12/15/21 at 4:00 p.m. to 12/16/21. The pharmacist did come in and complete an interim medication regimen review on 12/15/21 at 10:59 a.m. and documented: it is not recommended to crush, open or chew the below listed medications: suggest swallowing whole or changing to a liquid dosage for Metoprolol Succinate ER Tablet extended release 24 hour 50 mg. Give one tablet by mouth one time a day for hypertension until 12/19/20 and hold for systolic blood pressure less than or equal to 100 to heart rate less than or equal to 55 and Give one tablet by mouth one time a day for hypertension. Residents Affected - Few During an interview on 12/16/21 at 1:00 p.m. she confirmed the Metoprolol extended release was changed to regular metoprolol since the nurses were crushing the medication. Review of facility policy for Medication Administration - General Guidelines, revised August 2014, revealed: 7) a. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought. Some long-acting capsules can be opened and administered without crushing contents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 5 of 7 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 105393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one Resident #32's bed frame was inspected to ensure safety and use of a correctly fitted mattress for the bed frame of a total of 94 residents audited in the facility. Findings included: During observation and interview on 12/13/21 at 10:10 a.m. Resident #32 was observed lying on an air mattress with the top of the air mattress approximately 8 inches from the headboard and the headboard was broken on the left side of the frame at the screws. An interview was conducted with the Administrator on 12/13/21 at 10:13 a.m. and she stated she was new to the facility and would have the bed fixed immediately and would complete a facility wide bed audit for safety. During an observation of Resident #32's bed on 12/14/21 at 9:00 a.m. the frame fit the mattress and the headboard was fixed without large gaps. During an interview and observation with Resident #32 on 12/14/21 at 3:55 p.m. she was observed lying in bed with the mattress now about 7 inches away from the footboard and touching the headboard. The resident was unable to adjust her bed or move around in the bed; up and down. Review of the admission Record revealed Resident #32's diagnoses included hemiplegia and hemiparesis affecting left non-dominant side, Charcot's joint right ankle and foot, osteoarthritis right shoulder, elbow and right knee and acquired absence of left leg below knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed in Section G Functional Status the resident's bed mobility was extensive assistance with two plus person assist. The Director of Nursing (DON) was asked to come in the room to look at the position of Resident 32's mattress on 12/14/21 at 4:00 p.m. and confirmed the mattress was still readjusting too much on the frame, which was a specialty bariatric bed. The DON called the Administrator to the room where the Administrator stated she did fix the bed and was unsure why it was so far apart again. She placed a six inch bolster at the bottom of the mattress and the mattress stayed in place during bed movement. During an interview with the Maintenance Supervisor on 12/15/21 at 4:30 p.m. he stated the facility did not do routine checks on beds for maintenance issues and safety until the one completed on 12/13/21. During an interview on 12/16/21 at 1:05 p.m. the Administrator stated the facility should be completing bed audits to ensure safety as per policy. Review of the facility policy, Bed Safety, revised December 2007, one page revealed: 2. a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. b. Review that gaps within the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 6 of 7 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 105393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bed system are within the dimensions established by the FDA [U.S. Food and Drug Administration] (Note: the review shall consider situations that could be caused by the resident's weight, movement or bed position); c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications. 3. The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA [Quality Assessment and Assurance] committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and or safety committee. Event ID: Facility ID: 105393 If continuation sheet Page 7 of 7