Health inspection·February 23, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 residents (Resident #117, Resident #122) reviewed for gastrostomy tubes. Residents Affected - Some Findings include: 1. During an observation on 2/22/2023 at 9:18 AM with Staff F, License Practical Nurse (LPN), Resident #117 was lying in bed with a gastrotomy tube observed on the left side of abdomen with dressing dated 2/22/2023. Review of Resident #117's Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section K, Swallowing/ Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 02/03/2023. Review of Resident #117's MDS Medicare-5 Day assessment dated [DATE], Section K Swallowing/ Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 01/10/2023. Review of Resident #117 physician's order dated 1/11/2023 reads, Enteral Feed Order five times a day Isosource 1.5 Cal @ [at] 1 can (250ml). Minimum volume to be infused 500 ml/d [milliliters per day] with flush of free water of 100ml [milliliters] before and after each bolus feeding via feeding tube. 2. During an interview on 2/22/2023 at 10:40 AM, Staff G, License Practical Nurse (LPN), confirmed Resident #122 had a gastrostomy tube on his left side of abdomen. Review of Resident #122's MDS Quarterly assessment dated [DATE], Section K Swallowing/ Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 01/12/2023. Review of Resident #122's MDS discharged - Return Anticipated assessment dated [DATE], Section K Swallowing / Nutritional Status reads, K0510 Nutritional Approaches, B. Feeding tube-nasogastric or abdominal (PEG) [Percutaneous Endoscopic Gastrostomy] 2. While a Resident: 0. Not Checked (No). Locked and accepted on 11/18/2022. Review of Resident #122's physician order dated 11/30/2022 reads, Enteral Feed Order two times a day Isosource 1.5 Cal @ 60 ml/hr x 12 hrs/d from 1800-0600 [60 milliliters per hour times 12 hours per day from 6:00 PM - 6:00 AM]. Volume to be infused 720. During an interview on 2/22/2022 at 12:45 PM with Staff E, MDS Coordinator, stated, [Resident #117 name] and [Resident #122 name] definitely have gastrostomy tubes. I will get together with the MDS Director, I know they have to be corrected. Review of the policy titled MDS 3.0 Completion last reviewed on 1/18/2023 reads, Policy Explanation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 2 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 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 and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) specified by the State. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 3 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 4 residents reviewed for peripheral intravenous catheters (Resident #406 and Resident #413). Photographic evidence obtained. Residents Affected - Some Findings include: (1) During an observation on 2/20/23 at 9:45 AM, Resident #406 had a peripheral intravenous (IV) catheter site to the left wrist. There was tape and clear dressing over the site, but no date noted. During an interview on 2/20/23 at 9:45 AM, Resident #406 stated, This [peripheral intravenous (IV) catheter] was put in by a paramedic before I came here. During an interview on 2/20/23 at 3:20 PM, the Assistant Director of Nursing (ADON)/ Infection Preventionist confirmed there was no date on the bandage and stated, I would expect an IV site to have a date on the bandage. The intravenous site bandage should be changed every three days. I cannot tell when this was last changed. Review of the admission record documented Resident #406 was readmitted to the facility on [DATE]. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #406 from February 15, 2023 through February 20, 2023 revealed no record of care for the intravenous site. Review of the physician's orders for Resident #406 from February 15, 2023 through February 20, 2023, revealed no orders for an intravenous site or intravenous site care. Review of the readmission Nursing Assessment for Resident #406 dated 2/16/22 read, . Section 10 Integrity. A. Is the resident being admitted with impaired skin integrity? IF yes, please identify all areas below: Site: Other, left wrist. Type: IV/Sub q/Implanted Port [subcutaneous with implanted port]. Review of the policy titled Peripheral IV [Intravenous] Dressing Changes, last reviewed 1/18/23, read, Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings . General Guidelines . 2. Change the dressing at the time of catheter site rotation (every 72 to 96 hours) or immediately upon observing that the integrity of the dressing has been compromised. Steps in the Procedure. 7. Label dressing with date, time, and initials. (2) During an observation on 2/20/23 at 2:00 PM, Resident #413 had a Peripherally Inserted Central Catheter (PICC) Line dressing on the left arm dated 2/8/23. During an interview on 2/20/23 at 3:30 PM, the ADON stated, The dressing is dated 2/8/23. PICC line dressings should be changed every seven days. This one has not been changed as it should. Review of the care plan for Resident #413 read, Concern: I have a peripherally inserted central catheter for medication administration. Goal: I will remain free of complications from intravenous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 4 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 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 therapy. Interventions: . My PICC line dressing will be changed per physician orders. Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders for Resident #413 dated 2/13/23 read, Change PICC line dressing every day shift every Thursday and as needed. Residents Affected - Some Review of the MAR and TAR for February 2023 for Resident #413 read, Change PICC line dressing every day shift every Thursday. Start Date 2/16/23. There was no documentation for Thursday, February 16, 2023. Review of the policy and procedure titled PICC/Midline Dressing Changes, last reviewed 1/18/23, read, Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. General Guidelines: 1. Change catheter dressing every 5-7 days, or if it is wet, dirty, not intact or compromised in any way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 5 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5%. Thirty-eight medication administration opportunities were observed, and two errors were identified for 2 (Resident #78 and Resident #209) of 5 residents reviewed for medication administration. The medication error rate was 5.26%. Residents Affected - Some Findings include: During an observation of medication administration on 2/22/23 at 8:50 AM, Staff C, Registered Nurse (RN), injected the Peripherally Inserted Central Catheter (PICC) line of Resident #78 with contents of a syringe labeled Heparin Lock Flush Solution and then immediately injected contents of second syringe labeled Saline Flush NaCl [Sodium Chloride]. Staff C did not aspirate for blood return. Staff C then connected tubing, which had been primed with medication. During an interview on 2/22/23 at approximately 8:55 AM, Staff C, RN, stated, I injected the Heparin lock and then the Saline before the antibiotic. That is how you do this. When asked if there was an order for Heparin, she stated, Yes, there is an order for the Heparin. During an interview on 2/22/23 at 6:00 PM, the Director of Nursing (DON) stated, I would expect the nurse to flush with saline before and after the medication administration. You would not use heparin unless it was specifically ordered for the patient. Review of the physician's orders for February 2023 for Resident #78 revealed no order for Heparin. Review of the policy titled 005-J Flushing Midline and Central Line IV Catheters, last reviewed on 1/18/23 read, Flushing when giving medication with SASH (saline, administer medications, saline, heparin) method for open ended (non-valved) catheters . 3. Connect 10 mL (milliliter) syringe containing preservative free .9% normal saline (amount as ordered or per facility protocol) to catheter via needleless connection device. 4. Aspirate slowly for blood return to ensure patency of catheter. 5. Flush with preservative free .9% normal saline (amount established by pharmacy or facility protocol) using push-pause method . 8. Administer medication. 9. Disconnect medication from needleless connection device . 11. Connect another 10 mL syringe containing normal saline (amount as ordered or per facility protocol) to catheter via needleless connection device. 12. Flush with preservative free .9% normal saline (amount established by pharmacy or facility protocol) . 16. Connect 10 mL syringe containing heparin (amount and/or concentration as ordered or per facility protocol) to catheter via injection or needleless connection device. 2. During an observation of medication administration on 2/22/23 at 8:25 AM, Staff C, RN, poured Polyethylene Glycol powder into a plastic drinking cup. The cup did not contain any markings for measuring the solution. Staff C, RN mixed water with the powder and administered it to Resident #209. During an interview on 2/22/23 at 8:25 AM following medication administration, Staff C, RN, stated, I do not need to use the lid to measure the medication. I can tell by looking in the drinking cup how much is in there. During an interview on 2/23/23 at 9:10 AM, the DON stated, We expect the nurse to measure liquid or other medications that are not pre-measured in the appropriate container, that might be a medicine cup or a syringe. For MiraLax [Polyethylene Glycol], the inside of the lid has the marking for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 6 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 appropriate dose. I would expect the nurse to use that lid to measure the correct amount. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 7 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 7 medication carts (B Villa Cart #1 and A Villa Cart #1) and failed to ensure medications were secured (photographic evidence obtained). Findings include: During an observation on 2/20/2023 at 9:41 AM of B Villa Medication Cart #1 with Staff B, License Practical Nurse (LPN), there was one open Lispro insulin pen without the original pharmacy package and one opened Wixela inhalation device with no open date or original pharmacy packaging. During an interview on 2/20/2023 at 9:47 AM, Staff B, LPN, stated, Medication should be dated when opened and kept in the original pharmacy package. During an observation on 2/20/2023 at 9:48 AM of A Villa Medication Cart #1 with Staff C, Registered Nurse (RN), there was one opened bottle of Dorzolamide eye drops with no opened date, two open bottles of Timolol Maleate Ophthalmic Solution with no open date, and one Latanoprost Ophthalmic Solution 0.005% with no open date. During an interview on 2/20/2023 at 9:55 AM, Staff C, RN, stated, Eye drops should be labeled with the date they are opened. During an observation on 2/20/2023 at 10:21 AM, Resident #18 was lying in bed. On the bedside table, there was an opened tube of zinc oxide ointment. During an observation on 2/20/2023 at 10:43 AM, Resident #118 was lying in bed. On the bedside table, there was a Spiriva Respimat inhalation spray next to the television remote control. During an interview on 2/20/2023 at 10:48 AM, Staff D, LPN, stated, [Resident #118's name] should not have medication in his room. During an interview on 2/21/2023 at 2:00 PM, the Director of Nursing stated, The staff should properly label and store all medications in their individual packaging. All medication that requires an opened date should be dated upon opening. The only way a resident can have medication in their room is if the resident has a self-administration order. The nurse must educate the resident and return demonstration from the resident on how and when to use medication should be performed. Review of the facility policy titled Labeling of Medication Containers, last reviewed on 1/18/2023, reads, Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations . 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number; f. The date the medication was dispensed; g. appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Directions for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 8 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy titled Medication Storage, last reviewed on 1/18/2023 reads, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 2. During an observation on 2/21/2023 at 11:12 AM, Resident #103 had a medication cup containing three pills on the bedside table. During an interview on 2/21/2023 at 11:12 AM, Resident #103 stated, I'm sorry. I fell asleep and didn't take them. During an interview on 2/21/2023 at 11:17 AM, Staff A, Licensed Practical Nurse (LPN) stated, She [Resident #103] started taking them and I said I would come back and check on her, but I didn't. It was my fault. I should have stayed until she took them all. During a medication administration observation on 2/21/2023 at 5:23 PM, Staff H, LPN, placed Amiodarone Tablet 200 milligram (mg), Apixaban Tablet 5 mg, and Carvedilol Tablet 6.25 mg in a medication cup and placed the cup on top the medication cart. Staff H then left the cart unattended, walked around the corner of the hall to obtain a resident's blood pressure measurement. The medication cart was not in Staff H's line of vision. During an interview on 2/21/2023 at 5:23 PM, when Staff H, LPN, returned to the cart, she stated, I should not have left the medication on the cart. I would usually take the medicine with me or lock it in the cart, but I didn't. During a medication administration observation on 2/22/2023 at 8:50 AM, Staff C, Registered Nurse (RN), obtained an intravenous solution bag labeled Daptomycin Intravenous (IV) Solution and placed it on top of the medication cart. Staff C left the hall to gather supplies leaving Daptomycin solution on top of the cart. The medication cart was not in Staff C's line of vision. During an interview on 2/22/2023 at 8:50 AM, when Staff C, RN, returned to the cart, she stated, It is ok to leave it on the cart because I was going to use it right away. During an interview on 2/22/2023 at 6:00 PM, the Director of Nursing stated, Medications, whether pills or IV solutions, should not be left unattended. We expect our nurses will not leave medications unattended at the bedside or on top of the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 9 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored in the kitchen and 2 of 4 nourishment rooms in accordance with professional standards for food service safety and maintain food preparation equipment in a clean, sanitary manner (Photographic evidence obtained). Findings include: An initial tour of the kitchen was conducted on 2/20/2023 at 9:15 AM with the Certified Dietary Manager (CDM). The walk-in cooler had a full size sheet pan with 2 large raw pork roasts with no label or date, one raw pork roast hanging off the pan above a bag of raw chicken, the bag of raw chicken was sitting in a large amount of blood that had no date or label and the bag was hanging over the edge of the pan, two bags of soup that were unlabeled and undated, three cases of thawed health shakes without a pulled from freezer or use by date, a box of approximately 56 raw shell eggs stored on the top shelf directly over 6 assorted cases of individual juices. There was a buildup of ice observed throughout the walk-in freezer on the walls, floor, shelves, and on the various boxes of food. The walk-in freezer had several open boxes that exposed food to the elements and potential freezer burn and compromising the integrity of the foods from the buildup of ice collected on the open food boxes. During an interview on 2/20/23 at 9:30 AM, the Certified Dietary Manager (CDM) verified raw meats should be placed on an appropriate sized pan or container without the raw product hanging over edge of the pan/container, that foods should be labeled and dated in the coolers, that all products should be labeled and dated for storage, pulled dates placed on health shakes when pulled from the freezer to thaw and that raw shell eggs should have been stored on the bottom shelf in the cooler and not over other food products. A follow up tour of the kitchen was conducted on 2/21/23 at 6:20 AM with the CDM. Six hood lights over the stove were not working, the microwave had a buildup of food particles on the back and top of the microwave, and the test strips had an expiration date of March 2021. During an interview on 2/21/23 at 6:20 AM, the CDM verified that six lights were not working under the stove hood, the test strips had an expiration date of March, 2021 and no other test strips were available for the pot and pan sink. A tour of the nourishment rooms was conducted with the CDM on 2/22/23 beginning at 8:30 AM. The F-unit nourishment room had an opened container of thickened nectar tea that was not labeled with an opened date. The A-unit nourishment room had 2 open containers of thickened cranberry juice stored in the refrigerator without an open date labeled on the containers. During an interview on 2/22/23 at 8:45 AM, the CDM confirmed F-unit nourishment room had an opened container of thickened nectar tea that was not labeled with an opened date and the A-unit nourishment room had 2 open containers of thickened cranberry juice stored in the refrigerator without an open date labeled on the containers. Review of the policy titled Floor Stock, last reviewed on 1/18/23 read, Procedure . 2. c. Rotate stock and remove outdated items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 10 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the policy titled Food Storage,, last reviewed on 1/18/23, read, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Foods will be stored at appropriate temperatures and by methods designed to prevent cross contamination or cross contamination. Review of the policy titled General Food Preparation and Handling, last reviewed on 1/18/23, read, Procedure. 3. Food Preparation. a. Meats, fish and poultry will be defrosted using safe thawing practices: in the refrigerator in a drip proof container, and in a manner that prevents cross contamination. Review of the policy titled General HACCP [Hazard, Analysis, Critical, Control, Points] Guidelines for Food Safety, last reviewed on 1/18/23, read, Procedure . 6. Safe Thawing Practices. a. Thaw meat, fish and/or poultry in a refrigerator in a drip proof container and in a way that prevents cross contamination (on a lower shelf with nothing underneath or near it). 11. Receiving. b. Label and date foods and put away promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 11 of 12 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 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete and accurate in accordance with professional standards of practice for 1 of 3 residents (Resident #203) reviewed for discharge. Findings include: Review of the admission record for Resident #203 documented the resident was admitted to the facility on [DATE]. Review of the electronic census record for Resident #203 showed stop billing date of 2/9/23. Review of the electronic medical record did not contain a transfer form or a discharge summary documenting the transfer/discharge to the hospital for Resident #203. During an interview on 2/22/23 at 12:47 PM, the Administrator stated, There was no transfer/discharge form completed for Resident #203. Review of the policy titled Transfer and Discharge (including AMA), last review 1/18/23, read, 10. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All other information necessary to meet the resident's needs .11. Non-Emergency Transfers or Discharges. A. Document the reasons for the transfer or discharge in the resident's medical record .12. Emergency Transfers/Discharges. 12. Emergency Transfers/Discharges. d. The original copies of the transfer form and Advance Directives accompany the resident. Copies are retained in the medical record. f. Document assessment findings and other relevant information regarding the transfer in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 12 of 12