Health inspection·June 20, 2024

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 PICC (Peripherally Inserted Central Catheter) line dressing was changed in accordance with professional standards of practice and intravenous (IV) site was assessed for 1 resident with PICC line, Resident #122 (Photographic evidence obtained). Residents Affected - Few Findings include: Review of Resident #122's admission record showed the resident was admitted to the facility on [DATE] with diagnoses that include acute bronchitis, cellulitis of the left lower limb, sepsis, and pneumonia. During an observation on 6/17/2024 at 9:50 AM, Resident #122 had a midline IV line in his right arm. There was gauze under the transparent dressing covering the IV insertion site into the arm and the insertion site was not visible. The gauze had a small amount of dried red residue on it and the transparent dressing securing the IV and gauze to the arm was loose and raised from the arm at the bottom of the dressing. Review of Resident #122's physician order dated 6/13/2024 read, Insert midline. May use lidocaine one time only for antibiotics for 1 day. Review of the document titled IV ACCESS, INC. dated 6/13/2024 at 8:13 PM read, Patient Name: [Resident #122's name] . Reason for visit: New order, Midline . Line Placed: Y [Yes], Arm R [Right], Vein: Basilic. Review of Resident #122's physician order dated 6/13/2024 read, Ceftriaxone Sodium Injection Solution Reconstituted 1 GM [gram] (Ceftriaxone Sodium). Use 1 gram intravenously every 12 hours for Acute Bronchitis for 5 days. Review of Resident #122's physician order dated 6/14/2024 read, Normal Saline Flush Solution (Sodium Chloride Flush). Use 10 ml [milliliters] intravenously every shift for IV access. Review of Resident #122's physician order dated 6/14/2024 read, Monitor IV site for signs and symptoms of infection and report if redness, edema, warmth or drainage to MD [Medical Doctor]. every shift. Review of Resident #122's Medication Administration Record (MAR) showed that the resident received Ceftriaxone Sodium Injection Solution through the midline IV in the right arm on 6/15/2024 at 6:26 AM and 5:07 PM, on 6/16/2024 at 5:55 AM and 6:09 PM, and on 6/17/2024 at 5:31 AM. Review of Resident #122's MAR showed that the resident received Normal Saline Flush Solution through the midline IV in the right arm on 6/15/2024 at 12:12 AM, 4:01 AM, 7:54 AM, and 5:07 PM, on 6/16/2024 at 12:44 AM, 2:41 PM, 8:59 PM, and 6/17/2024 at 12:55 AM, and 2:25 PM. Review of Resident #122's MAR showed the order for changing midline dressing every shift and PRN (as needed) with the start date of 6/14/2024 and discontinuation date of 6/19/2024. There were no entries documented for 6/14/2024, 6/15/2024, and 6/16/2024 under PRN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 2 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #122's MAR showed staff initials indicating administration of monitoring IV site for signs and symptoms of infection on 6/14/2024 in the evening and night shifts, and on 6/15/2024, 6/16/2024, 6/17/2024, and 6/18/2024 in the day, evening and night shifts. During an interview on 6/19/2024 at 4:34 PM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, stated, We go by the policy for PICC dressing changes. After the midline IV is inserted, the dressing needs to be changed and the gauze covering the IV entrance site needs to be removed after 24 hours. When the dressing is changed at 24 hours, they [the nurses] do not reapply the gauze over the IV entrance site. We cannot assess the site appropriately with the gauze covering the site because the entrance into the skin and the surrounding skin is not visible. During an interview on 6/20/2024 at 6:51 AM, Staff C, LPN, stated, He [Resident #122] had gauze covering the IV entrance site under the dressing, so I couldn't assess the site initially. The bottom end of the dressing was loose, so I lifted it a little so I could see the IV entrance into the skin. I couldn't assess the entrance site for redness, swelling, or kinks in the line when it was covered with gauze. During a telephone interview on 6/20/2024 at 10:38 AM, Staff B, Registered Nurse (RN), stated, The initial midline dressing needs to be changed after a day. With the gauze covering the entrance site, you can't see to assess for patency or infection. I guess I should have changed it [Resident #122's midline IV dressing] before I administered the medication or flushed the IV. Not changing the dressing when soiled or leaving the gauze in place increases the risk of infection and the gauze being left in place obstructs the view of the entrance site. You can't appropriately assess the site with the gauze in place. During an interview on 6/20/2024 at 11:17 AM, the Director of Nursing (DON) stated, Our policy for midline IVs is to change the dressing and remove the gauze 24 hours after initial placement. It is difficult to assess the entrance site of the IV with the gauze in place covering the site. Leaving the gauze in place after 24 hours creates an increased risk of infection. Review of the facility policy and procedure titled P&P PICC IV Line last reviewed on 1/17/2024 showed that it read, Policy: It will be the policy of this facility to adhere to IV/PICC line administration guidelines as set forth by infection control, state and federal regulations. Licensed nurses shall provide care according to state and federal law . Dressing changes: 1. Sterile dressing change using transparent dressings is performed: 24 hours post-insertion or upon admission if not dated upon admission; At least weekly; If the integrity of the dressing has been compromised (wet, loose, or soiled). 2. dressing changes will be documented in the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 3 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 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 - Few 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 properly stored, covered, labeled, or discarded in the areas of the kitchen walk-in cooler and walk-in freezer, and failed to maintain sanitary standards in the walk-in cooler and walk-in freezer and for the kitchen equipment (Photographic evidence obtained). Findings include: During an observation while conducting the initial walk-through of the kitchen on 6/17/2024 at 9:00 AM with the Registered Dietician (RD), there was a large amount of ice buildup on the door and walls of the walk-in freezer and on two boxes of food stored on top shelf in the walk-in freezer. There was a large metal pan containing red gelatin with a serving scoop in the container. The pan of red gelatin was covered in a clear wrap with no identifying label or date. In the walk-in cooler, there was a large pot of a liquid substance with a clear plastic cover with no identifying label or date, a gallon of almond milk with initials of MB, and a large clear container with pasta type food with no identifying label with a date of 6/7. There were six 10-pound rolls of raw ground beef stored on sheet pan with no date, with a red colored substance on the sheet pan. There were two 5-gallon containers stored on the floor of the walk-in cooler. There was a pan with lettuce and slices of tomatoes in a clear pan partially covered with a clear wrap. There was a small plate of sliced cheese in the clear pan with the lettuce and sliced tomatoes with no label or date. There was a large clear pan of raw chicken wrapped in clear plastic with a date of 6/13. The pan of wrapped chicken was placed on top of 3 cases of sliced garlic Texas toast. In the dishwashing area, there was a wad of dirty gloves in the bottom of the sanitizing portion of the 3-compartment sink. During an interview on 6/17/2024 at 9:25 AM, the RD confirmed the buildup of ice in the freezer and stated he wasn't sure why there was an ice buildup. The RD confirmed that the scoop was left in the pan of red gelatin and stated utensils should not be left stored in the food pans. The RD confirmed items of the large pot, and large clear containers, and pan of lettuce, tomato slices and cheese did not have an identifying label or date and there should have been labels and dates on each of the containers. The RD stated he could not state whether the red substance on the sheet pan with the ground beef was blood or splashes from something. The RD confirmed the pan of raw chicken was stored on top of the cases of garlic toast and stated that the raw chicken should not have been stored on the boxes of ready to serve garlic toast and should have been discarded according to the 6/13 date. The RD confirmed the 5-gallon containers were not on a shelf and stated the 5-gallon containers should not have been on the floor. The RD confirmed the gloves in the 3-compartment sink and stated the dirty gloves should not have been left in the clean sanitizing sink. During an observation while conducting the follow up walk-through of the kitchen on 6/18/2024 at 6:38 AM with the RD, the ice machine had a black/gray substance around the opening of the ice machine. There was a sign reading Do Not Use on a 3-door reach-in cooler and a sign on the top convection oven, with no lockout tagout. The 3-compartment sink was overflowing with water and when the drain was opened, the water exited to the floor and not down a drainpipe affixed to the sink. There was standing water from the 3-compartment sink area extending into the kitchen floor area. During an interview on 6/18/2024 at 6:43 AM, the RD stated he was not sure why the equipment was not working. The RD confirmed the black/gray substance was visible around the opening of the ice machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 4 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 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 - Few During an interview on 6/18/2024 at 6:45 AM, the Morning [NAME] stated the former dietary director had taken the shelves out of the oven, had cleaned the oven, and when it was turned back on, smoke was observed, so the sign was put on the oven. During an interview on 6/19/2024 at 12:03 PM, the Administrator stated she was not aware of the problems with the equipment in the kitchen. Review of the facility policy and procedure titled P&P Refrigerated Storage revised on 10/1/2023 read, Policy: Foods and Nutrition Services (FNS) staff should maintain safe refrigerated storage areas. Refrigerated items should be properly stored, labeled and maintained by dietary staff . Procedure . 3. Dietary staff will store raw food (e.g. beef, fish, lamb, pork, and poultry) separate from each and on shelves below fruit, vegetables, or other ready-to-eat foods to prevent meat juices from dripping onto these foods. 4. Dietary staff will label, date, and monitor refrigerated food, including but not limited to leftovers to ensure use by use-by-dates, or frozen (where applicable) or discarded. Review of the facility policy and procedure titled Standards and Guidelines: Ice Machine cleaning/sanitizing dated 11/22 read, Standard: It is the policy of this policy to ensure ice machines are cleaned and sanitized on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 5 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 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 record review and interview, the facility failed to ensure complete medical records were maintained for 2 of 3 residents reviewed for laboratory result reporting, Residents #34 and #128. Findings include: Review of Resident #34's admission record showed the resident was admitted on [DATE] with diagnoses that include multiple sclerosis, other sequelae following unspecified cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, stage 2 (mild) chronic kidney disease, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, neuromuscular dysfunction of bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and unspecified dementia. Review of Resident #34's physician order dated 6/12/2024 read, U/A [urinalysis] with C&S [Culture and Sensitivity] one time only for odor. Review of Resident #34's lab results reported on 6/15/2024 at 12:18 PM read, Urine Culture: Growth/col [colony]/cnt [count]. Greater than 100,000 colony forming unit per ml [milliliter]. Organism. Providencia stuartii. Review of Resident #34's nursing progress notes from 6/15/2024 through 6/19/2024 showed no notes related to physician notification of urine culture results. During an interview on 6/19/2024 at 2:20 PM, the Director of Nursing (DON) stated, The doctor was actually here and reviewed the resident when he was notified of the blood sugar of 36. I was here that day, and I actually called the doctor about his urine test results and he didn't want them treated because he felt he was colonized and on hospice. I did not document my call to the doctor, and I really should have documented this in the record. Review of Resident #128's admission record showed the resident was admitted on [DATE] with the diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, other seizures, unspecified osteoarthritis, major depressive disorder, sequelae of cerebral infarction, and urinary tract infection. Review of Resident #128's physician order dated 5/21/2024 read, U/A with C&S one time only for 1 day. Review of Resident #128's lab results reported on 5/24/2024 at 2:46 PM read, Urine Culture: Growth/col/cnt greater than 100,000 colony forming units per ml. Organism Escherichia coli. Review of Resident #128's nursing progress notes from 5/22/2024 through 5/28/2024 showed no notes related to physician notification of urine culture results. During an interview on 6/19/2024 at 2:29 PM, the Director of Nursing (DON) stated, The doctor told me he was aware of her urine culture, and I don't know why he decided to treat it after that. The nurse should have documented that she called him. I do expect the nurses to fully document any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 6 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 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 communication with the doctor. The DON stated there was no policy and procedure for documentation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105434 If continuation sheet Page 7 of 7