Health inspection·March 14, 2024

F 0641 -Section I: Active Diagnoses-Psychiatric/ Mood Disorder revealed no documentation to show Resident #34 had depression. Level of Harm - Minimal harm or potential for actual harm A review of Resident #34's Order Summary, dated 03/13/2024, showed the following: Residents Affected - Few -Duloxetine HCI capsule Delayed release particles 30 MG by mouth one time a day for depression, A review of the care plan, dated 02/28/2024, showed the following: -Resident # 34 has impaired cognitive function/dementia related to dementia, uses antidepressants medication related to depression. -An intervention initiated on 02/28/2024, to administer medications as ordered, administer antidepressant medications as ordered by physician. 3) A review of the admission Record, dated 03/13/2024, showed Resident #245 was admitted on [DATE] with diagnoses including hydrocephalus, cognitive communication deficit, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety. A review of Resident #245's MDS, dated [DATE], showed the following: -Section C: Cognitive Function-BIMS score of 3 indicating severe cognitive impairment. -Section I: Active Diagnoses-for psychiatric/ mood disorder showed no documentation to show Resident #245 had depression. A review of Resident #245's Order Summary, dated 03/13/2024, showed the following: -Fluoxetine HCI Oral tablet 20 MG by mouth one time a day for depression, -Rivastigmine Patch 24 Hour 9.5 MG/24 HR one time a day for dementia and remove per schedule. A review of Resident #245's care plan, dated 2/29/2024 and revised on 03/13/2024, showed the following: -Resident # 245 has bladder incontinence related to dementia and muscle weakness and uses antidepressant medication. -An intervention to administer antidepressant medication as ordered by physician. An interview was conducted on 03/14/2024 at 10:56 AM with Staff A, Registered Nurse, RN/ MDS Director. She said she was responsible for putting the residents' diagnoses on their face sheets in the medical record. She stated in Section I on the MDS answers are automatically populated when the residents' diagnoses are added to their face sheet. A review of the record for Resident #11, #34 and #245 by Staff A confirmed Section I did not show a diagnosis of depression for the residents. Staff A said she did not have an answer as to why she had not updated the MDS to add the depression diagnoses. She stated the expectation was all MDS assessments were completed accurately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 2 of 29 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 03/14/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument, RAI 3.0, undated, revealed the following: -Chapter 3: MDS items [1] Section I: Active Diagnoses: Showed Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Event ID: Facility ID: 105393 If continuation sheet Page 3 of 29 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 03/14/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II assessment upon a new qualifying mental health diagnosis and/or ensure the accuracy of the PASRR Level I assessment for 9 residents (#11, #17, #24, #34, #49, #56, #67, #81, #245) of 32 sampled residents Findings included: 1. Review of the admission Face Sheet revealed Resident #17 was admitted on [DATE] and readmitted on [DATE], a diagnoses including diabetes and major depressive disorder as of 11/07/2022, single episode without psychotic features as of 09/27/2023, generalized anxiety disorder as of 11/07/2022, hypertension, and legally blind. Review of the quarterly Minimum Data Set (MDS), dated [DATE] showed in Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section I, Active Diagnoses showed anxiety and depression. Section N, Medications showed antianxiety. Review of the physician order summary report showed Ativan 0.5 mg in the evening for anxiety as of 06/07/2023. Review of the psychiatric note, dated 12/08/2023, showed medical history of depression and anxiety. Reason for initial visits were for increased behaviors, hallucinating and combative at times. Review of Resident #17's care plans showed she had depression and anxiety as of 06/13/2023. Interventions included but were not limited to administering medications as ordered. Arrange for psych consult, follow up as indicated; observe and report as needed any s/s of depression. Resident #17 uses anti-anxiety medication related to anxiety as of 11/09/2022. Interventions included but were not limited to administer anti-anxiety medications as ordered by the physician; monitor/document/report prn any adverse reaction to anti-anxiety therapy; refer to psychologist/psychiatrist as needed; and review medication for effectiveness. Review of the PASRR Level I, dated 11/01/2022, showed in Section 1A. anxiety disorder only. Section II showed all no answers. Section III showed the resident was not a provisional admission. Section IV showed no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. 2. Review of the admission Face Sheet revealed Resident #56 was admitted on [DATE] and readmitted on [DATE]. A primary diagnosis of displaced intertrochanteric fracture of the right femur, other diagnoses included Alzheimer's disease with late onset as of 11/23/2023, dementia with an unspecified severity as of 11/23/2023, major depressive disorder recurrent severe without psychotic features as of 11/27/2023 and generalized anxiety disorder as of 11/27/2023. Review of the quarterly MDS, dated [DATE], showed in Section C: Cognitive Patterns-a BIMS score of 0 resident is rarely/never understood. Section I, Active Diagnoses showed Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder and depression. Section N, Medications showed antidepressant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 4 of 29 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 03/14/2024 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 0644 Review of the Physician Order Summary Report showed: Level of Harm - Minimal harm or potential for actual harm -observe for antidepressant medications; observe for behaviors; Keppra 250 mg every 24 hours for dementia; Memantine HCL 10 mg twice a day for dementia; Mirtazapine 30 mg at bedtime for depression with poor appetite related to dementia. Residents Affected - Some Review of the psychiatric note, dated 01/02/2024, showed medical history of dementia, psychiatric history of depression. Review of Resident #56's care plans showed she had depression as of 06/13/2023. Interventions included but not limited to administering medications as ordered, Monitor / document side effects and effectiveness, Arrange for psych consult, follow up as indicated, Observe / report prn any signs and symptoms of depression, pharmacy reviews monthly or per protocol. Review of the PASRR Level I, dated 04/12/2023, showed in Section 1A. depressive disorder only. Section II showed all no answers. Section III showed the resident was not a provisional admission. Section IV showed no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. 5) Review of the admission Record, dated 03/13/2024, showed Resident #11 was admitted on [DATE] with diagnoses to include chronic kidney disease, stage 3 unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, generalized anxiety disorder, major depressive disorder, recurrent, mild. Review of Resident #11's Minimum Data Set (MDS), dated [DATE], showed: -Section C: Cognitive Abilities- 0 was coded to indicate Resident #11 was not able to complete a Brief Interview for Mental Status (BIMS). Review of Resident #11 s Preadmission Screening and Resident Review (PASRR), dated 1/10/2022, revealed no qualifying mental health diagnosis and no PASRR Level II was required. Review of the Physician Orders for Resident #11, dated 03/13/2024, showed: -Buspirone HCI oral tablet 5 MG by mouth two times a day for anxiety, -Depakote Sprinkles oral capsule delayed release sprinkle 125 MG by mouth three times a day for dementia with mood disorder, -Donepezil HCI tablet 10 MG by mouth at bedtime for dementia, and Mirtazapine tablet 15 MG by mouth at bedtime for depression. 6) Review of the admission Record, dated 03/13/2024, showed Resident #34 was admitted on [DATE] with diagnoses to include metabolic encephalopathy, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit. Review of the MDS, dated [DATE], revealed 0 was coded in Section C0600 to indicate Resident #34 was not able to complete a BIMS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 5 of 29 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 03/14/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Review of Resident #34's PASRR, dated 2/14/2024, revealed no qualifying mental health diagnosis and no PASRR Level II was required. Review of the Physician Orders, dated 03/13/2024, showed an order for Duloxetine HCI capsule Delayed release particles 30 MG by mouth one time a day for depression for Resident #34. Residents Affected - Some Review of the care plan, initiated on 02/28/2024, showed Resident #34 had impaired cognitive function/dementia related to dementia, uses antidepressants medication related to depression and an intervention initiated on 02/28/2024, to administer medications as ordered, administer antidepressant medications as ordered by physician. 7) Review of the admission Record, dated 03/13/2024, showed Resident #245 was admitted on [DATE] with diagnoses to include hydrocephalus, cognitive communication deficit, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety. Review of the MDS, dated [DATE], showed a BIMS score of 3, indicating severe cognitive impairment for Resident #245. Review of Resident #245's PASARR Level I, dated 2/24/2024, revealed no qualifying mental health diagnosis and no PASARR Level II was required. Review of the Physician Orders, dated 03/13/2024, for Resident #245 showed: -Fluoxetine HCI Oral tablet 20 MG by mouth one time a day for depression, -Rivastigmine Patch 24 Hour 9.5 MG/24 HR one time a day for dementia and remove per schedule. Review of the care plan, revised on 03/13/2024, showed Resident # 245 had bladder incontinence related to dementia and muscle weakness and used antidepressant medication with an intervention created on 02/29/2024 to administer antidepressant medication as ordered by physician. 9) Review of the admission Record showed Resident #24 was admitted on [DATE] with diagnoses of Major Depressive Disorder, Anxiety Disorder, Bipolar type, Dementia, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and other comorbidities. Review of Resident #24's PASRR Level I Assessment, dated 11/7/2022, revealed a qualifying mental health diagnosis marked in section I A. Question 7. Was marked No. No Level II PASRR was required. During an interview on 3/13/2024 at 2:47 PM, Staff B, RN stated I complete the PASRR of resident's admitted from home, not from the hospital. During an interview on 3/14/2024 at 9:37 AM the admission Director stated review of the PASRR from the hospital is to ensure it is complete, not accurate. During an interview on 3/14/2024 at 10:35 AM the Social Service Director (SSD) stated she is new to the PASRR process and understanding the requirements. The SSD confirmed the PASRR's of Residents #'s 67, 17, 56, 49, 245, 11, 34, 24, and 81, were not accurate and would need to be corrected and submitted for a Level II review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 6 of 29 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 03/14/2024 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 0644 Review of the admission Criteria policy and procedure, given as the PASRR policy and procedure, undated, revealed the following: Level of Harm - Minimal harm or potential for actual harm Policy: Our facility admits only residents whose medical and nursing care needs can be met. Residents Affected - Some Policy interpretation and implementation: . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process: a. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD. he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. 1) the social worker is responsible for making referrals to the appropriate state designated authority. c. Upon completion of the Level II evaluation, the state PASRR representative determines if the individual has physical or mental conditions, what specialized rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The state PASRR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential residents that are outlined in the evaluation. f. Once a decision is made, the state PASRR representative, the potential resident and his or her representatives are notified. . 13. The administrator, through the admissions department, ensures that the resident and the facility follow applicable admission policies. 8) Resident #81 was admitted to facility on 9/19/23 with a primary diagnosis of Parkinson's Disease without dyskinesia and the following secondary diagnoses: dementia with anxiety, Bipolar II Disorder, anxiety, and major depressive disorder. A review of the Pre-admission Screening and Annual Resident Review (PASRR) completed upon admission was noted to be incomplete with diagnoses of Parkinson's disease, anxiety, Bipolar and depression not checked in Section: PASRR Screen Decision-Making. 3) Review of the admission Facesheet revealed Resident #49's original admission date was 6/13/2023 and current admission date of 3/8/2024. Diagnoses: unspecified dementia, unspecified severity, without behavioral disturbance, date of onset 6/13/2023 Review of Pre-admission Screening and Resident Review (PASRR) for Resident #49, dated 3/1/2023, revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 7 of 29 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 03/14/2024 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 0644 Level I Section 1 B Finding documented history no level II required, no attached documentation related to documentation history. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS), dated [DATE], for Resident #49 revealed: Residents Affected - Some Section A Identification information dated 12/21/2023. Section C Cognition Patterns revealed a Brief Interview for Mental Status (BIMS) 10 MDS 12/21/2023 Annual None PPS, Section I Active Diagnoses - All diagnoses in the past seven days - check all that apply - Neurological Non-Alzheimer's Dementia is checked. Section N Medications - #1 is taking and #2 indication noted - medications for antianxiety, hypnotic and antidepressant are checked for both #1 and #2. Review of Physician Orders for Resident #49, dated 3/13/2024, revealed: Observation for antidepressant medication - change in behavior/mood/cognition, agitation, and nervousness. Review of the care plan for Resident #49, revealed Focus areas, dated 7/4/2023, as follows: -Resident #49 has impaired cognitive function and impaired thought processes related to dementia. -Resident #49 has behavior issues with impulsive behaviors related to cognitively impaired. -Resident #49 uses anti-anxiety medication related to anxiety disorder. -Resident # 49 uses antidepressant medication related to depression. Review of Resident #49's Psychiatric Note, dated 1/16/2024, revealed a follow up visit for a chief complaint of dementia and anxiety. Diagnoses: Major depressive disorder recurrent severe without psych features; generalized anxiety disorder Review of Resident #49's Psychiatric Note, dated 3/13/2024, revealed a follow up visit for a chief complaint dementia and anxiety. Diagnosis: Major depressive disorder, recurrent severe without psych features and generalized anxiety disorder. Review of medical record revealed no Level II PASRR was completed for Resident #49. 4) Review of admission Face Sheet, dated 3/13/2024, for Resident #67 revealed an original admission date of 12/29/2021 and a current admission date on 12/5/2023. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Onset date 2/7/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 8 of 29 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 03/14/2024 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 0644 Review of the PASRR Level I for Resident #67, dated 12/27/2021, revealed Level of Harm - Minimal harm or potential for actual harm Level I Section 1 B Finding documented history no level II required, no attached documentation related to documentation history. Residents Affected - Some Review of the quarterly MDS, for Resident #67, dated 12/21/2023, revealed: Section C Cognition Patterns revealed a BIMS of 15 MDS, indicating intact cognition. Section I Active Diagnoses - All diagnoses in the past seven days - check all that apply - Neurological Non-Alzheimer's Dementia is checked. Review of the physician orders, dated 3/14/2024, for Resident #67 revealed: Observe for behaviors every shift restlessness, agitation, hitting, kicking, physical aggression, spitting, biting, cussing, yelling, delusions, hallucinations, psychosis, refusing care, isolation, withdrawn, depression. Consult mental health worker. Review of the care plan for Resident #67,dated 3/4/2022, revealed a focus area as Resident #67 is at risk for impaired cognitive function and or impaired thought processes related to dementia. Review of a Situation, Background, Assessment, Response form (SBAR), dated 1/28/2024, for Resident #67 revealed: Primary diagnoses - unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of a Palliative Care Note, dated 2/15/2024, for Resident #67 revealed: Active medical diagnosis - Dementia Assessment and plan - Dementia - continue to monitor for cognitive decline and functional decline, continue to monitor for behavioral disturbances. Review of a depression screen (PHQ-2 to 9 (HSM)-V2), dated 3/7/2024, for Resident #67 revealed: The score is 5 which shows mild depression. Review of medical record revealed no Level II PASRR was completed for Resident #67. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 9 of 29 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 03/14/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #3's admission Record showed admission on [DATE] with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, Type 2 diabetes, osteoarthritis, disorder of bone density and structure, and other co-morbidities. During observations on 3/11/2024 at 10:27 AM, 3/12/2024 at 10:00 AM and at 4:32 PM, 3/13/2024 at 9:59 AM and at 12:15 PM, Resident #3 was observed without any type of splint, roll, carrot splint, etc. in bilateral hands. Review of Resident #3's Care Plan, date initiated 2/24/2020, revealed Contractures: Resident #3 has contractures of the right arm and left hand. Provide skin care to keep clean and prevent skin breakdown. Uses a carrot splint for left hand. During an interview on 3/12/2024 at 4:31 PM with Staff C, Certified Nursing Assistant (CNA) stated Resident #3 does not have anything special done with her hands, we just wash them During an interview on 3/13/2024 at 10:18 AM with Staff I, Licensed Practical Nurse (LPN), confirmed resident does not wear any splints or hand rolls. During an interview on 3/14/2024 at 11:10 AM Staff E, Certified Occupational Therapy Assistant (COTA) stated Resident #3 has been seen by Occupational Therapy for positioning in the wheelchair and dining but not for the hands at this time. Staff E, COTA reviewed the care plan and found the care plan showed resident should be wearing carrot splints. Staff E, COTA confirmed Resident #3 does not have carrot splints. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, the policy is not dated and showed: Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person -centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven days of the completion of the required Minimum Data Set (MDS) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her care plan, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. received the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 5. The resident is informed of his or her right to participate in his or her treatment and provided advanced notice of care planning conferences. 6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. 7. The comprehensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 10 of 29 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 03/14/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few person-centered care plan: a. includes measurable objectives and time frames; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2) any specialized services to be provided as a result of PASRR recommendations; and 3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. build on resident's strengths; and e. reflects currently recognized standards of practice for problems areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the resident's and the resident's condition change. 12. The IDT team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. Based on observations, interviews, and record review, the facility failed to timely revise and effectively implement individualized care plans for three residents (#81, # 49 and #3) of thirty-three sampled residents. Findings included: On 3/11/24 at 09:30 a.m. an observation was made of Resident #81 in her bed next to a window with eyes closed, lights out and food tray at bedside. An observation was made on the 3/11/24 at 10:30 a.m., of Resident #81 remaining in hospital gown, eyes closed and breakfast tray removed. On 3/12/24 at 08:10 a.m. an observation was made of Resident #81 in her room sitting on the edge of the bed, leaning, rocking to her right side and then to her left. Record review revealed Resident #81 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease without dyskinesia, unspecified dementia unspecified severity with anxiety, Sarcopenia, muscle weakness, unsteadiness on feet, essential hypertension, repeated falls, other specified disorders of bone density ad structure, major depressive disorder recurrent mild, bipolar II disorder, generalized anxiety and contusion of left eyelid and periocular area. On 3/13/24 at 08:35 a.m. an observation was made of Resident #81 lying in bed with her eyes closed with a breakfast tray on bedside table. During the observation, Staff C, Certified Nursing Assistant (CNA) came into the room to set up the resident's breakfast tray. Staff C, CNA stated the resident is new to the hallway and stated, We are getting to know her she is new to our floor about a week and a half ago. Staff C, CNA stated the resident can ambulate with assistance to bathroom and other times she will not. Staff C, CNA stated the resident may have her days and nights mixed up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 11 of 29 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 03/14/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 3/13/24 at 9:30 a.m. Resident #81's bed remained in a raised position. At the time of the observation was made, unidentified nursing staff came into the room and lowered the bed down but not in its lowest position. On 3/13/24 at 11:53 a.m. Resident #81 remained in bed in the same position as observed in previous observation. On 3/13/24 at 1:30 p.m. an interview was conducted with Staff F, Registered Nurse (RN). Staff F, RN stated she has been employed since January and was not familiar with Resident #81. Staff F, RN stated Resident #81 was previously in a different hall. She said the resident would exhibit signs of sadness but could easily be calmed down and she ambulated by means of a wheelchair. On 3/13/24 at 1:35 p.m. an interview was conducted with the Psychiatric Advance Nurse Practitioner, who stated a familiarity with the resident and cited impulsiveness as a contributing factor for her falls. On 3/13/24 at 2:00 p.m. an interview was conducted with Staff D, CNA. Staff D, CNA stated Resident #81 could communicate her needs at times and could stand and pivot with queuing for toileting in the bathroom but other times she would require two persons assist for toileting or getting out of bed. Staff D, CNA stated Resident #81 was a high risk for falls and most of her falls were in the hallway or in common room A and later in the afternoon. On 3/13/24 at 2:12 p.m. an interview was conducted with the Rehab Director/Certified Occupational Therapy Assistant (COTA). The Rehab Director stated the resident initially was placed on the rehabilitative hallway and was participating in physical therapy but quickly plateaued by achieving her goal for ambulation. Falls were identified for this resident and multiple interdisciplinary team meetings were conducted with various unsuccessful interventions. The Rehab Director stated as part of the Interdisciplinary Team, the family was approached in placing the resident into a memory care unit facility but the family member declined. The Rehab Director stated the resident had no interest in activities and recently relocated to the long-term care hallway. A review of the facility's fall log from the month of September 01, 2023, to March 08, 2024, revealed Resident #81 with eighteen falls of which fourteen were unwitnessed. A review of the care plan for resident #81 showed: -A focus of actual falls with no injury related to poor balance, unsteady gait and crawling on floor at times. The Goal revealed resume usual activities without further incident through the review date. --Interventions included: appropriate footwear when out of bed as tolerated, bed in low position when in bed, continue interventions on the at-risk plan, evaluate for use of anti-rollback device to wheelchair (WC), as appropriate, for no apparent acute injury determine and address causative factors of the fall, frequent rest breaks as tolerated, frequent safety checks, encourage to attend/assist activities of choice as tolerated, medication review and psychiatric evaluation, monitor/document/report prn to Doctor (MD) for signs/symptoms : pain, bruises, change in mental status, new onset of confusion sleepiness, inability to maintain posture, agitation, non-skid material to WC, offer and assist with ambulation with 2 assist as tolerated, Occupational Therapy (OT) to evaluate and treat for positioning, provide resident center activity as tolerated, Physical Therapy (PT) to evaluate and treat for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 12 of 29 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 03/14/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ambulation and transfers as tolerated, put resident back to bed after lunch as tolerated, therapy to evaluate and treat as indicated for appropriate positioning devices such as cushions, chairs, etcetera , toilet before and after each meal, toilet up rising and at night as tolerated. On 3/14/24 at 9:00 a.m. an interview was conducted with the Director of Nursing (DON)/ Risk Manager. The DON said adverse events are discussed daily in the morning huddle. Continuing, she stated On a weekly basis we review all the incidents to discuss the progress of interventions. We had a discussion with Resident #81's family encouraging a memory care unit but the family member declined. On 3/14/24 at 10:30 a.m. an observation was made of Resident #81 in the resident common room no staff were present. Resident #81 was three-quarters of the way in a standing position. The Environmental Services Director (ESD) witnessed the resident from outside the common room and went to the resident to provide assistance. An observation on 3/14/24 at approximately 11:45 a.m. revealed Resident #81 was by herself in her wheelchair; no staff were present. On 3/11/2024 at 9:15 AM Resident #49 was observed sitting in the hallway outside her room in front of an overbed table, the resident was observed with a discoloration to her right eye, and right side of her neck. She had what appeared to be stitches over her right eye. On 3/11/2024 at 12:30 PM Resident #49 was observed sitting in the dining room eating lunch with other residents. On 3/12/2024 at 11:00 AM Resident #49 was observed sitting in a wheelchair in the common area attempting to get out of her wheelchair and using the large Lego's. On 3/14/2024 at 2:00 PM Resident #49 was observed sitting in her wheelchair in the common area watching television. She stated she was fine and wanted to get up out of her chair. An interview was conducted on 3/11/2024 at 9:20 AM with Staff G, Registered Nurse (RN) who stated Resident #49 had a fall last week. He also stated the resident has dementia. An interview was conducted on 3/14/24 at 11:11 AM with the NHA and DON. The DON stated Resident #49 had 2 falls on 3/4/2024. The DON stated that a meeting was held with Resident #49's family to discuss the residents falls. Review of the admission record revealed Resident #49 was admitted on [DATE] and the most recent admission was 3/8/2024. Resident #49 diagnoses included unsteadiness on feet (onset date 3/11/2024), unspecified lack of coordination (onset date 3/11/2024), repeated falls (6/13/2023), unspecified dementia with unspecified severity with other behavioral disturbance (onset date 6/13/2023), muscle weakness (onset date 3/11/2024), and age-related osteoporosis without current pathological fractures (onset date 6/13/2023. Review of the Minimum Data Set (MDS) Quarterly Resident #49 dated 12/21/2023 revealed: Section A Identification information dated 12/21/2023. Section C Cognition Patterns revealed a Brief Interview for Mental Status (BIMS) 10 MDS Section I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 13 of 29 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 03/14/2024 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 0657 Active Diagnoses - Other - Repeated Falls Level of Harm - Minimal harm or potential for actual harm Review of physician orders, dated 3/13/2024, for Resident #49 revealed: Residents Affected - Few Observation: Sedative/hypnotic medication: Observe for drowsiness, fatigue, weakness, and impaired coordination. Right one-fourth siderail enablers to promote bed mobility and safety. Scoop mattress to bed Review of care plan focus areas for Resident #49 revealed: Focus - Resident #49 has impaired cognitive function revised 7/4/2023 Focus - Resident #49 has had a fall from wheelchair and has had no injury, poor balance, unsteady gait revised 6/20/2023 Goal - Resident #49 will have no interventions in place and will have reduced risk of injury revision 3/7/2024 Interventions - Anti-rollback device to wheelchair revised 7/11/2023, low bed revised 7/11/2023, nonskid material applied to wheelchair and under wheelchair cushion revised on 7/11/2023. Review of Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form (AHCA 3008) dated 3/8/2024 for Resident #49 revealed: Impaired sight and vision, primary diagnosis urinary tract infection and recurrent falls, risk alerts - pressure ulcers and falls, skin assessment - right eyebrow laceration/sutured, edema of head and neck, ambulates with assistive device, rolling walker and assist of one, resident is incontinent. Review of hospital discharge information dated 3/7/2024 for Resident #49 revealed: diagnoses of fall on same level, unspecified, initial encounter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 14 of 29 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 03/14/2024 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 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 observations, interviews, and record review the facility failed to ensure skin assessment were accurate for two residents (#63 and #72) out of 21 residents sampled. Residents Affected - Few Findings included: 1) Resident #63 was observed on 03/11/2024 at 1:23 p.m. sitting in her wheelchair in the common area with a discolored area on her right forefinger and hand. She was dressed and groomed for the day. Resident #63 was admitted on [DATE] and readmitted on [DATE], with a diagnosis including but not limited to, Hemiplegia post Cerebral Vascular Accident on the left non-dominant side, gastrostomy, nontraumatic intracerebral hemorrhage, dysphasia, Sarcopenia, dysphagia, lack of coordination, diabetes, pressure ulcer, hypertension, carotid occlusion and stenosis, nutritional deficiency, adjustment disorder with depressed mood, acute kidney failure, weakness, history of falling, long term insulin. Review of the Physician Order Summary Report showed weekly skin assessments were to be done for Resident #63 Review of the care plan for Resident #63 showed the potential for pressure ulcer development. Interventions did not include to observe for weekly skin assessments. Review of the Weekly Skin Observation, dated 03/07/2024, showed other existing skin impairment: skin tear of left antecubital and bruising right elbow. Review of the progress notes revealed no documentation regarding bruised areas for Resident #63. During interview on 03/13/20244 at 1:47 p.m. the DON stated the weekly skin sheet on 03/07/2024 showed bruising on the left hand, it was not documented as being on the right hand. The expectation was to find the correct location of the bruise in the documentation. She verified by observation of Resident #63 on 03/13/2024 at 2:00 p.m. the bruise was on the right hand, at the forefinger area. 2) Resident #72 was admitted on [DATE] and readmitted on [DATE], diagnoses including but not limited to fracture of right femur neck, diabetes with chronic kidney disease, moderate-protein calorie malnutrition, muscle weakness, urine retention, Review of the physician Order Summary Report showed weekly skin assessment were to be completed for Resident #72. Review of the care plan showed Resident #72 had potential impairment to skin integrity related to fragile skin as of 02/21/2024. Interventions did not include weekly assessments. Review of the Skin Observation, dated 03/02/2024, showed Skin Integrity: Existing bruise (no location), New Moisture-associated skin damage (MASD); No new skin issues, treatment continues. During an interview on 03/13/2024 at 1:36 p.m. the Director of Nursing (DON) reviewed the weekly skin sheet for Resident #63, dated 03/02/2024, and verified the documentation showed the resident had a bruise and lacked the location of the bruise. She reviewed the progress notes and verified there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 15 of 29 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 03/14/2024 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 Level of Harm - Minimal harm or potential for actual harm was no documentation related to a bruise. She stated she expected to find the location of the bruise documented, so they can know if it was new, old, healing or not healing. Requested policy and procedure for assessing skin integrity on 03/14/2024 from both the Nursing Home Administrator (NHA) and Director of Nursing (DON), one was not provided. Residents Affected - Few During an interview on 03/14/2024 at 9:50 a.m. the Director of Nursing (DON) stated to ask the Minimum Data Set (MDS) coordinators about the skin assessments on the care plan. She stated, they are the gurus. During an interview on 03/14/2024 at 9:55 a.m. Staff A, Registered Nurse (RN), MDS and Staff B, RN, MDS stated everyone gets a risk for wound / pressure ulcer care plan. They stated they will add care plans after they are informed of a skin problem like a bruise or a skin tear. They do not have a care plan for skin integrity with an intervention that includes assessing for skin issues weekly. The resident's have a physician order for weekly skin checks. They stated sometimes they put it (assessing) under the Activities for Daily Living care plan. Both verified Resident #72 and Resident #63 did not have skin assessments on their care plans. They stated again they do not put a care plan in place for skin unless they have a skin issue because they have skin assessments for skin observations. If an incident happens like a bruise or skin tear, they will meet with the risk manager and do a care plan and with the Interdisciplinary Team and decide on the interventions. Staff B, RN stated, The care plans are the plans of care. They put in at risk for pressure ulcer for everyone, and as it happens (skin issues) then they put in a care plan as incidents occur, then resolve the incident on the care plan as needed. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revise March 2022, showed: 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 16 of 29 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the admission Record, dated 02/08/2024, showed Resident #88 was admitted on [DATE] with diagnoses to included but not limited to Traumatic Subdural Hemorrhage without loss of consciousness, subsequent encounter, chronic obstructive pulmonary disease, unspecified, unspecified lack of coordination, nicotine dependence, cigarettes, uncomplicated. Review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. Section I Health Conditions, showed Yes were answered to question number 1 to indicate Resident #88 is a current tobacco user. Review of the care plan created and initiated on 02/09/2024 and revised on 03/07/2024 showed Resident #88 is a smoker and is at risk for smoking related injury/incident. Interventions initiated on 2/9/2024 showed to review, update the resident smoking assessment upon admission and as needed. Review of the Medical Record showed a smoking assessment was not conducted until 3/5/2024, a month after the resident was admitted to the facility. During an interview on 03/11/2024 at 9: 30 AM., with Resident #88, the resident stated she has been a smoker at the facility since her admission. She said the nurses keep her cigarettes and lighter for her because she was told that she was not allowed to have them in her room. During an interview on 03/14/2024 at 10:00 AM., the Assistant Director of Nurses stated she completed Resident #88 's smoking assessment on 3/5/2024 because she saw the resident on that day with cigarettes and a lighter. During an interview on 03/14/2024 at 10:00 AM., with Staff B, Registered Nurse/ MDS coordinator, she stated she created Resident #88's smoking care plan on 2/9/2024 because she was identified as a smoker during their interdisciplinary meeting. She said MDS was not aware they needed to complete the resident smoking assessment. During an interview on 03/14/2024 at 10:00 AM., with Staff A, Registered Nurse/ MDS Director. She stated the nurses on the units usually complete the residents' smoking assessments because they would know if a resident were a smoker or not. MDS would have completed the smoking assessment at the time we updated Resident #88's care plan if we were told we needed to complete it. During an interview on 03/14/2024 at 10:20 AM., the Director of Nurses stated the facility process is to identify whether a resident is a smoker during the admission screening. Resident #88 s was care planned as a smoker on 2/9/2024 but her smoking assessment wasn't done until 3/5/2024. The DON said her expectation are when the resident was identified on 2/92024 to be a smoker, and her care plan was created MDS should have completed a smoker evaluation. Review of the facility Smoking Policy & Procedure, revised dated 1/2020 showed: Purpose: To provide residents the privilege of smoking while maintaining their safety and safety of others. Policies: 2. All smokers will be assessed upon admission and as their cognitive and /or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 17 of 29 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 03/14/2024 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 0689 physical status mandates. Level of Harm - Minimal harm or potential for actual harm Procedure: 1. A License nurse will assess all smokers upon admission and as cognitive or physical status changes warrant. Residents Affected - Some Based on interviews, observations, and record review, the facility failed to provide adequate supervision to 1.) prevent falls for three residents (#81, #49 and #35) out of thirty-three sampled residents; and 2.) ensure safety related to smoking for one resident (#88) out of five residents sampled. Findings include: On 3/11/24 at 09:30 a.m. an observation was made of Resident #81 in her bed next to a window with eyes closed, lights out and food tray at bedside. An observation was made on the 3/11/24 at 10:30 a.m., of Resident #81 remaining in hospital gown, eyes closed and breakfast tray removed. On 3/12/24 at 08:10 a.m. an observation was made of Resident #81 in her room sitting on the edge of the bed, leaning, rocking to her right side and then to her left. Record review revealed Resident #81 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease without dyskinesia, unspecified dementia unspecified severity with anxiety, Sarcopenia, muscle weakness, unsteadiness on feet, essential hypertension, repeated falls, other specified disorders of bone density ad structure, major depressive disorder recurrent mild, bipolar II disorder, generalized anxiety and contusion of left eyelid and periocular area. On 3/13/24 at 08:35 a.m. an observation was made of Resident #81 lying in bed with her eyes closed with a breakfast tray on bedside table. During the observation, Staff C, Certified Nursing Assistant (CNA) came into the room to set up the resident's breakfast tray. Staff C, CNA stated the resident is new to the hallway and stated, We are getting to know her she is new to our floor about a week and a half ago. Staff C, CNA stated the resident can ambulate with assistance to bathroom and other times she will not. Staff C, CNA stated the resident may have her days and nights mixed up. During an observation on 3/13/24 at 9:30 a.m. Resident #81's bed remained in a raised position. At the time of the observation was made, unidentified nursing staff came into the room and lowered the bed down but not in its lowest position. On 3/13/24 at 11:53 a.m. Resident #81 remained in bed in the same position as observed in previous observation. On 3/13/24 at 1:30 p.m. an interview was conducted with Staff F, Registered Nurse (RN). Staff F, RN stated she has been employed since January and was not familiar with Resident #81. Staff F, RN stated Resident #81 was previously in a different hall. She said the resident would exhibit signs of sadness but could easily be calmed down and she ambulated by means of a wheelchair. On 3/13/24 at 1:35 p.m. an interview was conducted with the Psychiatric Advance Nurse Practitioner, who stated a familiarity with the resident and cited impulsiveness as a contributing factor for her falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 18 of 29 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm On 3/13/24 at 2:00 p.m. an interview was conducted with Staff D, CNA. Staff D, CNA stated Resident #81 could communicate her needs at times and could stand and pivot with queuing for toileting in the bathroom but other times she would require two persons assist for toileting or getting out of bed. Staff D, CNA stated Resident #81 was a high risk for falls and most of her falls were in the hallway or in common room A and later in the afternoon. Residents Affected - Some On 3/13/24 at 2:12 p.m. an interview was conducted with the Rehab Director/Certified Occupational Therapy Assistant (COTA). The Rehab Director stated the resident initially was placed on the rehabilitative hallway and was participating in physical therapy but quickly plateaued by achieving her goal for ambulation. Falls were identified for this resident and multiple interdisciplinary team meetings were conducted with various unsuccessful interventions. The Rehab Director stated as part of the Interdisciplinary Team, the family was approached in placing the resident into a memory care unit facility but the family member declined. The Rehab Director stated the resident had no interest in activities and recently relocated to the long-term care hallway. A review of the facility's fall log from the month of September 01, 2023, to March 08, 2024, revealed Resident #81 with eighteen falls of which fourteen were unwitnessed. A review of the care plan for resident #81 showed: -A focus of actual falls with no injury related to poor balance, unsteady gait and crawling on floor at times. The Goal revealed resume usual activities without further incident through the review date. --Interventions included: appropriate footwear when out of bed as tolerated, bed in low position when in bed, continue interventions on the at-risk plan, evaluate for use of anti-rollback device to wheelchair (WC), as appropriate, for no apparent acute injury determine and address causative factors of the fall, frequent rest breaks as tolerated, frequent safety checks, encourage to attend/assist activities of choice as tolerated, medication review and psychiatric evaluation, monitor/document/report prn to Doctor (MD) for signs/symptoms : pain, bruises, change in mental status, new onset of confusion sleepiness, inability to maintain posture, agitation, non-skid material to WC, offer and assist with ambulation with 2 assist as tolerated, Occupational Therapy (OT) to evaluate and treat for positioning, provide resident center activity as tolerated, Physical Therapy (PT) to evaluate and treat for ambulation and transfers as tolerated, put resident back to bed after lunch as tolerated, therapy to evaluate and treat as indicated for appropriate positioning devices such as cushions, chairs, etcetera , toilet before and after each meal, toilet up rising and at night as tolerated. On 3/14/24 at 9:00 a.m. an interview was conducted with the Director of Nursing (DON)/ Risk Manager. The DON said adverse events are discussed daily in the morning huddle. Continuing, she stated On a weekly basis we review all the incidents to discuss the progress of interventions. We had a discussion with Resident #81's family encouraging a memory care unit but the family member declined. On 3/14/24 at 10:30 a.m. an observation was made of Resident #81 in the resident common room no staff were present. Resident #81 was three-quarters of the way in a standing position. The Environmental Services Director (ESD) witnessed the resident from outside the common room and went to the resident to provide assistance. An observation on 3/14/24 at approximately 11:45 a.m. revealed Resident #81 was by herself in her wheelchair; no staff were present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 19 of 29 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/11/24 at 9:10 a.m., an observation was made of Resident # 35 in his bed with eyes closed, breakfast tray on bedside table, fork in hand with pureed food on the end of the fork. Resident #35 would open his eyes to verbal stimuli but would close and remained nonverbal. On 3/11/24 at 10:15 a.m., an interview was conducted with a family member of Resident #35. During the interview, Resident #35's family member disclosed a diagnosis of Parkinson's disease and dementia for the resident. Resident #35 has resided in this facility for two years. This family member voiced concern over communication among the nursing staff regarding the resident's care needs especially with eating and positioning. The family member stated, Her favorite CNA is no longer here and I feel a little anxious now about his care. The family member stated the other day she came in and found Resident #35 in the recliner chair but he has fallen out of it in the past. When the family member talked to the agency CNA about her concern, the CNA told her that she was keeping an eye on him. The family member stated, I have to trust that she was doing the right thing for him. The family member stated, Ever since [Resident #35] has come back from the hospital a couple of weeks ago they have not gotten him out of bed. The family member stated they are waiting for a special wheelchair to prevent the [Resident #35] from slipping out of the chair. The family member stated, [Rehab Director] is trying to locate this special chair and stated, I told her I was willing to buy the chair so he can get up. The family member stated the resident needs assistance eating as well. The family member stated she tries to take a day off a week but since the CNA familiar with the resident is no longer employed, she feels the need to come every day. The family member stated, I would like him to get out of bed every day but until he gets this new wheelchair, I guess this is how it is supposed to be. On 3/11/24 at 12:45 p.m., an observation was made of the family member for Resident #35 feeding resident. The resident was positioned with head of bed at approximately ninety degrees. The resident was awake with eyes open and receptive to the family member's assistance. On 3/12/24 at 08:35 a.m., an observation was made of a staff member feeding Resident #35 the breakfast meal. An interview was conducted with this staff member at that time, who identified herself as the Rehab Director. According to the Rehab Director, Resident #35 is not waiting on a special wheelchair and the one he has now served the purpose of preventing him from sliding out of the wheelchair, stating, He just needs supervision. On 3/13/24 at 12:00 p.m. a follow-up interview was conducted with the family member of Resident #35. The resident was observed out of bed and the family member was happy he was up and stated, This is good seeing him up and awake and out of bed. The resident was seen trying to move his back away from the wheelchair and family member stated she feels he has pain which she feels contributed to his sliding out of the recliner chair and his wheelchair. On 3/13/24 at 2:12 p.m. an interview was conducted with the Rehab Director. The Rehab Director stated the resident may benefit from a wedge cushion under his legs while in his recliner. The Rehab Director stated Resident #35 has had falls in the past which were related to him sliding out of his wheelchair or recliner. Record review revealed Resident # 35 was admitted on [DATE], with a readmit date of 3/04/24 post hospitalization. Resident #35 had a primary diagnosis of paroxysmal atrial fibrillation with secondary diagnoses of Parkinson's disease without dyskinesia, dysphagia oral phase, Sarcopenia, major depressive disorder, essential hypertension, repeated falls, orthostatic hypotension, and dementia Record review of the care plan for Resident #35, dated 02/14/24 showed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 20 of 29 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm -Focus: long term care resident who is alert and occasional verbal with memory loss. He is up in wheelchair daily spending time with spouse. He enjoys watching TV in his room when spouse is not visiting. The goal for this specific care plan has the resident participating in activities of his choice daily such as spending time with spouse. The Interventions include offering hospitality visits for socialization and monthly calendar so he or spouse can plan his daily activities. Residents Affected - Some -Focus area of limited physical mobility or is at risk for decline with mobility related to Parkinson's disease, cognition and impaired thought process, poor safety awareness. The goal is to participate with mobility within physical and/pr cognitive capability and will be out of bed as tolerated. Interventions include the following to reach goal: encourage resident to perform physical activity daily as tolerated, observe for signs and symptoms of pain/discomfort with mobility and intervene as necessary, provide cues, provide encouragement and reassurance as needed with mobility tasks, direction and assist as necessary to promote safety awareness with mobility, training, as indicated, on the safe use of equipment and assistive devices to aid in locomotion/ambulation. -Focused area of at risk for falls related to gait/balance problems was care planned with goal of resident using call light and/or seeking assist with transfer wand will have intervention in place to reduce the risk of fall/injury. A focus of potential for pain related to Parkinson's disorder with the goal of the resident will express decreased pain with treatment interventions and /or therapy and will have fewer episodes of reported pain. The following interventions were developed: educate and encourage resident to voice the onset of pain, rate pain, intervene and notify the physician with unrelieved pain, encourage and assist the resident with therapy treatment regimen as a pain relief measure or to provide comfort, monitor and observe any changes in usual routine, sleep patterns, decrease in functional status, decrease in range of motion, withdrawal or resistance to care, monitor/observe any anxiety, restlessness, refusal of treatment and or withdrawal especially with therapy regimen, intervene and notify physician, monitor and observe any nonverbal signs and symptoms of pain or discomfort such as facial grimacing, shortness of breath, moaning, etcetera intervene and notify the physician. On 3/11/2024 at 9:15 AM Resident #49 was observed sitting in the hallway outside her room in front of an overbed table, the resident was observed with a discoloration to her right eye, and right side of her neck. She had what appeared to be stitches over her right eye. On 3/11/2024 at 12:30 PM Resident #49 was observed sitting in the dining room eating lunch with other residents. On 3/12/2024 at 8:15 AM Resident #49 was observed lying in bed, scoop mattress in place, resident was awake and stated she wanted to get out of bed. On 3/12/2024 at 11:00 AM Resident #49 was observed sitting in a wheelchair in the common area attempting to get out of her wheelchair and using the large Lego's. On 3/14/2024 at 2:00 PM Resident #49 was observed sitting in her wheelchair in the common area watching television. She stated she was fine and wanted to get up out of her chair. Review of the admission record revealed Resident #49 was admitted on [DATE], and a current admission date of 3/8/2024. Resident #49 diagnoses included unsteadiness on feet (onset date 3/11/2024), unspecified lack of coordination (onset date 3/11/2024), repeated falls (6/13/2023), unspecified dementia with unspecified severity with other behavioral disturbance (onset date 6/13/2023), muscle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 21 of 29 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some weakness (onset date 3/11/2024), and age-related osteoporosis without current pathological fractures (onset date 6/13/2023. Review of physician orders, dated 3/13/2024, for Resident #49 revealed: Observation: Sedative/hypnotic medication: Observe for drowsiness, fatigue, weakness, and impaired coordination. Right one-fourth siderail enabler to promote bed mobility and safety. Scoop mattress to bed Review of the Minimum Data Set (MDS) Quarterly, dated 12/21/2023, revealed: Section A Identification information dated 12/21/2023. Section C Cognition Patterns revealed a Brief Interview for Mental Status (BIMS) 10 MDS 12/21/2023 Section I Active Diagnoses - All diagnoses in the past seven days - check all that apply - Neurological Non-Alzheimer's Dementia is checked. Other - Repeated Falls Section N Medications - #1 is taking and #2 indication noted - medications for antianxiety, hypnotic and antidepressant are checked for both #1 and #2. Review of the care plan, dated 3/13/2024, for Resident #49 revealed: Focus - Resident #49 has impaired cognitive function revised 7/4/2023 Focus - Resident #49 has had a fall from wheelchair and has had no injury, poor balance, unsteady gait revised 6/20/2023 Goal - Resident #49 will have no interventions in place and will have reduced risk of injury revision 3/7/2024 Interventions - Anti-rollback device to wheelchair revised 7/11/2023, low bed revised 7/11/2023, nonskid material applied to wheelchair and under wheelchair cushion revised on 7/11/2023. An interview was conducted on 3/11/2024 at 9:20 AM with Staff G, Registered Nurse (RN) who stated Resident #49 had a fall last week. He also stated the resident has dementia. An interview was conducted on 3/14/24 at 11:11 AM with the NHA and DON. The DON stated Resident #49 had two falls on 3/4/2024. The DON stated a meeting was held with Resident #49's family to discuss the residents falls. Review of the hospital discharge information, dated 3/7/2024, for Resident #49 revealed: diagnoses of fall on same level, unspecified, initial encounter. Review of facility policy and procedure Falls - Clinical Protocol revised 2018 revealed: Assessment and Recognition: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 22 of 29 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 03/14/2024 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 0689 1. The physician will help identify individuals with a history of falls and risk factors for falling. Level of Harm - Minimal harm or potential for actual harm 2. The staff and practitioner will review each resident's risk factors for falling and document in the medical record Residents Affected - Some 3. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events. 4. Falls should be categorized as: rising from a sitting or lying to upright position, upright and attempting to ambulate or sliding out of a chair or rolling for a low bed to the floor. 5. Falls should also be identified as witnessed or unwitnessed events Cause Identification: 1. Factors contributing to the fall. 2. Evaluate cause - medications, medical diagnoses, change in condition, supervision. Treatment and Management: 1. Evaluation based on assessment, identify other interventions to implement. Monitoring and Follow-up: 1. Follow-up with assessment and care until resident is stable. 2. Monitor and document resident response to interventions. 3. Continue current approaches and if successful continue and if unsuccessful reevaluate interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 23 of 29 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 03/14/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the clinical record revealed Resident #56 was admitted on [DATE] and readmitted on [DATE], a primary diagnosis of displaced intertrochanteric fracture of the right femur, Alzheimer's disease with late onset as of 11/23/2023, dementia with an unspecified severity as of 11/23/2023, major depressive disorder recurrent severe without psychotic features as of 11/27/2023 and generalized anxiety disorder as of 11/27/2023. Review of the quarterly, MDS, dated [DATE], showed in Section C, Cognitive Patterns a BIMS score of resident is rarely/never understood. Section I, Active Diagnoses showed Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder and depression. Section N, Medications showed antidepressant. Review of Resident #56's care plans showed she has depression as of 06/13/2023. Interventions included but not limited to administering medications as ordered. Monitor / document side effects and effectiveness. Arrange for psych consult, follow up as indicated. Observe / report prn any signs and symptoms of depression, pharmacy reviews monthly or per protocol. Record review of the pharmacy recommendations showed the following: -September 2023: Alendronate Sodium 70 mg daily every Monday for Osteoporosis, take on empty stomach before eating. Medication should be taken in the morning with 6 to 8 ounces of water at least 30 minutes before any other beverage or food. Do not lie down for 30 minutes after taking meds to prevent irritation to the esophagus. Under the Physician / Prescriber Response agree was checked. The form was not signed by the physician / prescriber or dated. -October 2023: Ascorbic Acid 500 mg daily for a supplement. Suggest reviewing profile carefully and make adjustments as you deem appropriate. The response checked was, no changes at this time-medication profile reviewed and content noted. Under the Physician / Prescriber Response agree was checked. The form was not signed by the physician / prescriber or dated. Clarify the diagnosis for the Remeron order: Mirtazapine 30 mg at bedtime for depression with poor appetite related to dementia. Current diagnoses is not an FDA approved indication and may not be acceptable on survey. Suggest considering one of the following FDA approved indications: depression, off-label recommended diagnoses: benign familial tremor, pruritis, tremor. A check mark was noted on the form. Under the Physician / Prescriber Response the form had no response and it was not signed by the physician / prescriber or dated. The resident has been receiving the following medication: Magnesium Oxide 400 mg daily for supplement since 5-4-2023. Most recent chemistry results dated 5/13/23 showed Within normal limits of 2.4 mg/dl. Should this therapy be evaluated or discontinued at this time? Under the Physician / Prescriber Response disagree was checked. The form was not signed by the physician / prescriber or dated. -December 2023: Practice guidelines for major depression in primary care recommend continuing the same dose for 4-9 months following the acute phase. Whether a patient is to continue therapy in this maintenance phase depends on the established history of previous depressive episodes and the physician assessment. A trial dose reduction may be reasonable at this time. This resident as been using the following medication: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 24 of 29 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 03/14/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Mirtazapine 30 mg at bedtime for depression with poor appetite related to dementia. If the therapy is required to prevent future depressive episodes, please document to that effect in your progress notes: The response checked was, continue antidepressant therapy; dose reduction contraindicated. See progress note below or in chart. The form was not signed by the physician / prescriber or dated. -January 2024: Aspirin 81 mg daily for clot prevention. Note clot prevention alone is note a diagnoses; please clarify this diagnoses. A list of suggestions was provided. Stroke prophylaxis was checked. Under the Physician / Prescriber Response agree was checked. The form was not signed by the physician / prescriber or dated. -February 2024: Alendronate Sodium 70 mg daily every Sunday for Osteoporosis. Take on empty stomach before eating. Medication should be taken in the morning with 6 to 8 oz of water at least 30 minutes before any other beverage or food. Do not lie down for 30 minutes after taking meds to prevent irritation to the esophagus. Under the Physician / Prescriber Response the form had no response and it was not signed by the physician / prescriber or dated. During an interview on 03/13/2024 at 1:11 p.m. the Director of Nursing (DON) reviewed the pharmacy recommendations for Resident #56. She stated they receive recommendations from the pharmacy consultant. They are to review the recommendations to see if there are any recommendations. They are then to call the physician to review and check for any updates. They follow up with the physician to see if they agree or disagree with the recommendations. The DON stated she will give the recommendations to the Unit Manager also to follow up with the physician regarding possible updates or changes. She verified on the bottom of the pharmacy recommendations under the Physician / Prescriber Response the forms had no responses, and they were not signed by the physician / prescriber or dated. She stated the expectation was for the staff to document who they discussed the recommendation with including date and / or the physician would document. Review of the admission Record revealed Resident #3 was admitted on [DATE] and readmitted on [DATE], a primary diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type 2 (DM2), Chronic Diastolic (congestive) Heart Failure (CHF), and other co-morbidities. Review of the quarterly, MDS dated [DATE] showed in Section C, Cognitive Patterns a BIMS score of 12/15 (moderately impaired), Section N, Medications showed insulin, antianxiety, anticoagulant, diuretic, hypoglycemic, and antidepressant. Record review of the pharmacy recommendations showed the following: -January 2024: Valproic Acid Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via PEG-Tube two times a day for bipoloar disorder related to Bipolar II Disorder. Suggest: Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below: Under the Physician / Prescriber Response - Use is in accordance with relevant current standards of practice - was checked. The form was not signed by the physician / prescriber or dated. During an interview on 03/13/2024 at 4:00 PM the Director of Nursing (DON) reviewed the pharmacy recommendations for Resident #3. She verified the pharmacy recommendation had not been addressed. She confirmed under the Physician / Prescriber Response was checked with no explanation, no physical signature or date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 25 of 29 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 03/14/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/14/2024 at 8:56 AM the Consultant Pharmacist for the facility stated each resident is reviewed upon admission and monthly according to regulation, standards, clinical indications, diagnosis, and dosing standards. If any recommendations are needed a report of my findings is submitted to the facility DON via email, and regular mail. The facility should follow up on the recommendations in at least 30 days. The following month a record review is completed to see if the recommendations were/were not addressed. Sometimes I will give 60 days for follow up, especially if the recommendation is made near the end of one month. If the recommendation is not followed up on, I will make the recommendation again. I need to ensure the physician is aware of the recommendations. The physician does not have to agree, just acknowledge and explain rationale. Review of the facility's policy and procedure titled Consultant Pharmacist Reports, Medication Regimen Review, undated showed the following: Policy: The consultant pharmacist performs a comprehensive review of each resident's medication regimen at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and/or the administrator. Procedures: A. The facility assures the consultant pharmacist has access to the resident's and their medical records; the resident medication profiles; the facility's records of medication receipt and disposition; medication storage areas; and controlled substance records and supplies. B. The consultant pharmacist reviews the medication regimen of each resident at least monthly. 1) A more frequent review may be deemed necessary, e.g., if the medication regimen is thought to contribute to an acute change in status or adverse consequence, or the resident is not expected to stay 30 days. C. While MRR's are generally conducted in the facility, off-site MRR's are acceptable when a review is requested and the following conditions are met: 1) the consultant pharmacist is not present in the facility, and 2) it is not possible for the consultant pharmacist to visit the facility within a reasonable time frame. If a consultation is needed when the pharmacist is off-site: 1) the director of nursing or charge nurse notifies the consultant pharmacist. 2) The consultant pharmacists or designee, e.g., clinical pharmacist at the provider pharmacy, works with facility personnel and electronic records to gather pertinent information related to the resident's status and/or request for consultation. 3) The findings are phoned, faxed, or emailed within (24 hours) to the director of nursing or designee and are documented and stored with the other consultant pharmacist recommendations. 4) The prescriber and/or medical director is notified if needed. 5) Any electronic communication of patient specific data (i.e., clear that emailing records or findings) must be encrypted and facilitated in a HIPAA compliant manner. D. In performing medication regimen reviews, the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards, such as the American Society of Consultant Pharmacists Practice Standards, and clinical standards such as the Agency for Healthcare Research and Quality Clinical Practice Guidelines and American Medical Directors Association Clinical Practice Guidelines. 2) A review of the clinical record revealed Resident #10 was admitted [DATE] and readmitted on [DATE], with a primary diagnosis of non-alcoholic steatohepatitis, dementia unspecified as of 3/26/2023, depression unspecified as of 3/26/2023, and anxiety disorder unspecified as of 12/21/2022. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C, Cognition Patterns a Brief Interview for Mental Status score (BIMS) of 15 indicating resident was cognitively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 26 of 29 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 03/14/2024 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 0756 intact. Level of Harm - Minimal harm or potential for actual harm A review of Resident #10's care plan revealed the following: Residents Affected - Some -Use of antidepressant medication related to depression revealed interventions included administrating medication as ordered, monitor / document side effects and effectiveness, refer to psychologist / psychiatrist as needed, and review with resident, Interdisciplinary Team (IDT), and family use of medication for positive effect, encourage participation in drug regimen therapy and review as needed (prn) for use and effectiveness. -Sedative/hypnotic therapy related to insomnia. Interventions included administer sedative/hypnotic medications as ordered by physician, monitor /document side effects and effectiveness, and monitor/document/report prn for adverse side effects. -Anti-anxiety medication(s) related to anxiety disorder. Interventions included administer anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness, refer to psychologist / psychiatrist as needed, and review with resident, Interdisciplinary Team (IDT), and family use of medication for positive effect, encourage participation in drug regimen therapy and review as needed (prn) for use and effectiveness. A review of the pharmacy recommendations showed the following: -September 2023: Ambien oral tablet 5 milligram (mg) to give one tablet by mouth every twenty-four hours as needed for at night for sleeping. Per pharmacy request to extend per Centers for Medicare and Medicaid Services (CMS) a prn psychotropic medication(s) are limited to 14 days of usage to limit their effect on the brain activities associated with mental processes and behavior- to extent the PRN order past the 14 days the prescriber must provide a rationale for continuing the order. The form was not signed by the physician / prescriber or dated. October 2023 and November 2023: Xanax 0.25 mg to give one tablet by mouth as needed for anxiety twice a day (BID). A check was made in response to discontinue the order but the physician / prescriber was not signed or dated. A review of the clinical record revealed Resident #30 was admitted on [DATE] with a primary diagnosis of hypertensive heart disease with heart failure, dementia unspecified without behavioral disturbance as of 10/01/2022, major depressive disorder severe without psychotic features as of 12/28/2022, and anxiety disorder unspecified as of 02/11/2017. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C, Cognition Patterns a Brief Interview for Mental Status score (BIMS) of 15 indicating resident was cognitively intact. A review of Resident #30's care plan for the use of antidepressant medication related to depression showed interventions included administer antidepressant medications as ordered by physician, monitor and document side effects and effectiveness, medication reviewed with psychiatrist, refer to psychologist and / or psychiatrist as needed, review medication for effectiveness, titrate and / or discontinue once stabilization has been achieved. A review of the pharmacy recommendations showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 27 of 29 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 03/14/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some October 2023: Depakote 125 mg tablet by mouth two times a day related to unspecified dementia, unspecified severity, with other behavioral disturbance with the following requests made by the pharmacist to reduce the dose at this time to verify this resident is on the lowest possible dose. The response was checked to reduce the dose daily but the form was not signed by the physician / prescriber or dated. January 2023: Pristiq 50 mg extended-release tablet give by mouth in the morning for depression with the following requests made by the pharmacist: If this therapy is required to prevent future depressive episodes, please document to the effect in your progress notes. The response section was checked to continue antidepressant therapy, dose reduction contraindicated but the form was not signed by the physician/ prescriber or dated. Based on observations, interviews, and record review, the facility failed to follow-up on pharmacy recommendations for five residents (#3, #10, #30, #49 and #56) of five residents sampled for unnecessary medications. 1) Review of the admission record for Resident #49 revealed an admission date of 6/13/2023 and a current admission date of 3/8/2024. Review of the Consultant Pharmacist's medication regime review, dated 1/1/2024 and 1/15/2024 for Resident #49 revealed the following: 1. Clonazepam tablet dispersible 0.125 Milligram (MG) give 1 tablet by mouth two times a day for anxiety. Request attempt for dose reduction to verify that resident is on lowest possible dose. 2. Mirtazapine tablet 7.5 mg give one tablet by mouth at bedtime for depression, evaluate for trial dose reduction? 3. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG related to dementia attempt dose reduction 4. Ambien Oral Tablet 10 MG attempt dose reduction Review of Consultant Pharmacist's medication regime review, dated 2/1/2024 & 2/22/2024 for Resident #49 revealed the following: 1. Alendronate Sodium Oral Tablet 70 MG at bedtime recommendation for medication to be given in the am Review of the Medication Administration Record (MAR) for Resident #49 for the month of March 2024 revealed: 1. Alendronate Sodium Oral Tablet 70 MG is still given at bedtime 2. Ambien Oral Tablet 10 MG dose remains unchanged 3. Mirtazapine Tablet 7.5 MG one tablet at bedtime dose remains unchanged 4. Clonazepam Tablet dispersible 0.125 MG one tablet by mouth two times a day remains unchanged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 28 of 29 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 03/14/2024 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 0756 5. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle two times a day remains unchanged. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders for Resident #49 revealed the following: 1. Alendronate Sodium Oral Tablet 70 MG one tablet at bedtime start date 6/20/23 Residents Affected - Some 2. Ambien Oral Tablet 10 MG by mouth at bedtime start date 7/12/2023 3. Clonazepam Tablet Dispersible 0.125 MG one tablet by mouth two times a day start date 6/28/2023. 4. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG one capsule by mouth two times a day start date 7/3/2023 5. Mirtazapine Tablet 7.5 MG one tablet by mouth at bedtime start date 6/28/2023 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105393 If continuation sheet Page 29 of 29