Health inspection·January 24, 2020

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and eight errors were identified for three (#49, #28, and #19) of six residents observed. These errors constituted a 32% medication error rate. Residents Affected - Few Findings included: 1. On 1/21/20 at 10:32 a.m., an observation of medication administration with Staff Member D, Registered Nurse (RN) was conducted with Resident #49. Staff Member D was observed administering the following medications: - Clonazepam 0.5 milligram (mg) tablet orally - Eliquis 2.5 mg tablet orally - Furosemide 40 mg tablet orally - Potassium Chloride Extended Release (ER) 20 milliequivalents (meq) tablet orally - Probiotic one capsule orally - Multi-Vitamin tablet orally A review of the Medication Administration Record (MAR) for Resident #49 revealed the above medications were scheduled to be administered at 9:00 a.m. A review of the Physician orders and January 2020 MAR for Resident #49 revealed the following medication orders: - Clonazepam 0.5 mg orally two times a day for generalized (gen.) anxiety. - Eliquis 2.5 mg orally every 12 hours for atrial fibrillation (afib). - Furosemide 40 mg orally one time a day for Congestive Heart Failure (CHF). - Multiple Vitamin one tablet orally for supplementation. - Potassium Chloride ER 20 meq orally one time a day for hypokalemia. - Probiotic 250 mg capsule orally two times a day for anti-diarrheal. The staff member confirmed Resident #49's medications that were scheduled to be administered at 9:00 a.m. were late. She stated, it's been one of those days, not going to get my 8 o'clock meds done till 3. At 10:39 a.m., after returning to the medication cart after administering Resident #49's medication, Staff Member D confirmed the red-colored resident electronic profile was due to medications being overdue, got a lot unexpected delays. 2. On 1/23/20 at 11:10 a.m., an observation of medication administration with Staff Member E, Licensed Practical Nurse (LPN), was conducted with Resident #28. Staff Member E was observed obtaining a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 2 of 8 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 105438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood glucose level of 222 from Resident #28. The staff member was observed to dial Resident #28's Novolog Flex pen to 16 units, return to the resident's room, and administer the 16 units of insulin in the right upper abdominal quadrant of Resident #28. A review of Resident #28's physician orders and January 2020 MAR identified the following medication order: - Novolog FlexPen Solution 100 unit/milliliter (u/mL) 12 units subcutaneously before meals for Type 2 Diabetes, hold if blood sugar is below 180. - Novolog FlexPen Solution 100 u/mL inject per sliding scale: 201-250 = 4 units. At 11:23 a.m. on 1/23/20, when asked if she primed the insulin pens before administering, Staff Member E stated she does not prime the Flexpens unless they are new. When asked about the priming of Insulin pens, on 1/23/20 at 2:39 p.m., the Registered Nurse Clinical Quality Specialist stated that the facility used manufacturers' guidelines. The manufacturers' guidelines, novomedlink.com, included the following instructions for users: - The quick guide for using a NovoLog FlexPen instructed users to prime the pen by turning the dose selector to 2 units, then press and hold the dose button, make sure a drop appears, then turn the dose selector to select the number of units to be administered. - Page 8 of the NovoLog informational insert instructed users to give an airshot before each injection due to small amounts of air may collect in the cartridge during normal use. The insert described airshots should be done to avoid injecting air and to ensure proper dosing. The information insert instructed users to turn the dose selector to select 2 units, hold the FlexPen with the needle pointed upwards and to tap the cartridge to make any air bubbles to collect at the top of the cartridge. Keeping the needle pointing upwards, press the push button all the way in until the dose selector returns to 0. The insert informed the user a drop of insulin should appear at the tip and then the user should select the correct dose of insulin. The facility policy titled, Medication Administration: Injectable, effective 1/1/04 and 11/1/19, did not include a policy or procedure for the administration of insulin via a Flex Pen. 3. On 1/23/20 at 11:45 a.m., an observation of medication administration with Staff Member E, Licensed Practical Nurse (LPN) was conducted with Resident #19. Staff Member E was observed administering the following medications: - Carbidopa Levodopa 25-100 mg, 2 tablets orally - Fexfenadine Hydrochloride (HCl) 60 mg orally - Albuterol Sulfate 2.5 mg/3 mL vial inhalation Staff Member E was observed entering Resident #19's room, she informed the resident of the dispensed medications, and placed a pulse oximeter on the finger of the resident. The staff member removed a plastic bag from the drawer of the bedside dresser, which contained a small volume nebulizer and tubing, then dispense the contents of the Albuterol vial into the nebulizer cup. The nebulizer with mouthpiece was handed to the resident, a visitor turned the machine on, and aerosol was observed emitting from the small volume nebulizer. Staff Member E left the resident's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 3 of 8 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 105438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653 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 Level of Harm - Minimal harm or potential for actual harm A review of Resident #19's physician orders and January 2020 MAR indicated the following order in regards to the administration of the inhalation medication: - Albuterol Sulfate Nebulization Solution (2.5 mg/3 mL). Inhale orally via nebulizer four times a day for Shortness of Breath. Pre/Post treatment (tx). Residents Affected - Few The order instructed staff to document heart rate, respiratory rate, breath sounds, sputum production/cough and after the treatment staff were to include documentation of any adverse reactions to treatment, response to instructions and length of treatment. The MAR indicated length of treatment, pulse rate prior to administration, and respiratory rate. The documentation did not include breath sounds, if any sputum production/cough, any adverse reactions, or pulse oximetry pre- or post-treatment. The policy titled, Small Volume Nebulizer, effective 1/1/04, reviewed 12/1/18, and revised 11/1/19, indicated staff were to evaluate patient's heart rate, respiratory rate, pulse oximetry, and breath sounds prior to the treatment. The policy indicated staff were to encourage patient to breathe deeply and cough while the treatment was in progress and upon completion of the treatment; check patient's heart rate, respiratory rate, pulse oximetry, and breath sounds. The documentation of the treatment should include pre- and post-treatment evaluation (heart rate, respiratory rate, pulse oximetry, and breath sounds), sputum production/cough quality, and any adverse reaction. On 1/24/20 at 6:31 p.m., the Assistant Director of Nursing (ADON), who was acting as the Director of Nursing (DON), stated nurses have an hour before and after the scheduled time to administer medications. The ADON stated the procedure of administering a nebulizer treatment was for the nurse to set up the treatment, and if the resident can self-administer the nurse will come back and shut off the machine. When asked if an assessment should be conducted pre- and post- nebulizer treatment, she stated she had to check the physician orders. The ADON stated insulin pens should be primed with 2 units prior to administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 4 of 8 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 105438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653 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 medical record review and interview the facility did not ensure that 2 vials of Lorazepam (Ativan) were stored in a permanently affixed compartment of the refrigerator and the facility did not ensure that the Controlled Substance Emergency Drug Kit which contained Schedule II drugs was locked and stored in a permanently affixed compartment in 1 of 2 medication storage rooms sampled. Finding include: On 1/23/20 at 2:02 PM observation of the South unit medication storage room was performed with Staff A, Registered Nurse (RN) staff opened the unlocked refrigerator and a locked medium size plastic red box measuring approximately 6 wide x 12 long x 4 thick with a gray metal lid visibly larger than the red plastic box, was observed not to be affixed to the refrigerator (photographic evidence). Staff A removed the box from the refrigerator to open it, the box was unlocked and opened by Staff A, RN. Inside the box were two small plastic bags with one vial of Lorazepam 2mg/ml 30 ml in each bag and a small plastic box measuring approximately 4 wide x 8long x 1.5 thick (Controlled Substance Emergency Drug Kit). The Director of Nursing was present at the time and acknowledged the box was not affixed to the refrigerator and confirmed the contents of the box. An interview was conducted on 1/23/20 2:38 PM with Staff B, a nurse on the south unit. Staff B confirmed the Controlled medication box was not affixed to the refrigerator and it was possible to exit the medication room with the box. (photographic evidence) A review of Facility Policy 5.3 Storage and Expiration Dating of Medication, Biologicals, Syringes and Needles. Dated 12/01/07, last revision date 10/31/16. Page 2 section 12. Controlled Substances Storage; 12.1 Facility should ensure that schedule II-V controlled substances are only accessible to licensed nursing, pharmacy, and medical personnel designated by facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (a safe, self-locked cabinet, or locked room, in all cases in accordance with applicable Law). 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 5 of 8 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 105438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and policy review, the facility did not ensure proper cleaning and sanitation of food contact dishware and equipment such as bowls and a cutting knife stored as clean in the kitchen area. Findings Include: During the comprehensive kitchen tour, direct observation of bowls stored on the counter-top next to the steam table line on 01/23/20 at 11:00 a.m. revealed dried food debris on the inside of the dishware. At 11:10 a.m., a cutting knife stored as clean inside of the wall-mounted knife storage rack revealed dried food debris at the knife tip. The Certified Dietary Manager (CDM) stated that procedure is to rinse food contact equipment under water in the prep sink to remove debris prior to using the hot-water dishwasher. This is in place because foods such as oatmeal can stick to the inside of the dishware which the dishwasher does not always adequately remove. Policy review of Warewashing revised in September 2017 revealed Policy Statement: All dishware, serviceware, and utensils will be cleaned and sanitized after each use. Procedures: 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware, 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines, 3. Temperature and/or sanitizer concentration logs will be completed, as appropriate, 4. All dishware will be air dried and properly stored. The CDM stated that the bowls and the knife were stored as clean. The CDM acknowledged that the bowls were going to be used to serve individual portions of the lunch dessert to residents that same day. The CDM acknowledged the dried food debris on the inside of three bowls and that the knife was unclean. The CDM removed all bowls from the counter-top, and the knife from the storage rack before placing them into the dishwasher area for re-cleaning and sanitization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 6 of 8 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 105438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to maintain infection-control measures to prevent spread of influenza and upper respiratory illness on 1/21/2020 in regards to failing to maintain the correct type of precautions for a resident (Resident #81) diagnosed with influenza. Residents Affected - Some Findings included: Resident #81 was admitted on [DATE]. The admission Record included diagnoses not limited to cellulitis of left lower limb, benign neoplasm of cerebral meninges, and unspecified heart failure. An isolation caddy was observed, on 1/21/20 at 11:13 a.m., hanging from Resident #81's door. The caddy contained yellow gowns, a box of gloves, a box of masks, and a sign that read, Contact Precautions. A magnet on the frame of Resident #81's indicated visitors were to stop and see the nurse for instructions. (Photographic evidence was obtained). The facility's Infection Control Monthly Line Listing, dated January 2020, indicated Resident #81 had a diagnosis of Influenza A, date of onset 1/16/20, and contact isolation was implemented. A review of an Situation, Background, Appearance, and Review (SBAR), dated 1/17/20, indicated Resident #81 was febrile, with a temperature of 100.6. The review portion of the SBAR indicated Tamiflu was ordered and the resident was to increase oral fluids. A change in condition note, dated 1/17/20 at 10:04 a.m., identified Resident #81 had a fever, food and/or fluid intake decreased or unable to eat and/or drink adequate amounts in the morning. The note revealed the resident was resting and was aware of the positive flu swab. The electronic Medication Administration Record (eMar) note, dated 1/17/20 at 9:21 p.m., identified a medication order for Tamiflu 75 milligram (mg) two times a day for influenza A for 5 days. The physician order report identified an order, to start on 1/18 and end 1/23/20, for Tamiflu, which was completed. On 1/21/20 at 2:43 p.m., the acting Director of Nursing (DON) observed the orange Contact Precautions sign attached to the hanging caddy at the entrance to Resident #81's room, she stated the sign should be for droplet precautions, not contact and droplet precaution signs were green. The facility provided the isolation room with new signs that indicated the type of precaution initiated. The signs identified in smaller bold print that precautions were standard plus droplet to prevent the spread of infection. The signs were laid atop a set of three plastic drawers sitting next to the resident room. At 2:43 p.m. on 1/21/20, the acting DON confirmed Resident #81's roommate was able to self-ambulate and pull the privacy curtain back between herself and Resident #81's bed. When asked if the roommate was an appropriate roommate for Resident #81, the acting DON stated no and was being treated prophylactically for influenza A. On 1/22/20 at 9:25 a.m., an observation was made of a female visitor standing directly in front of Resident #81 speaking with the resident. The visitor was not wearing any PPE. When asked if the nurse knew who the visitor with Resident #81 was, Staff Member D, Registered Nurse (RN), observed the visitor, standing in front of the resident, stated, oh no, and shook her head. Staff Member D began to dress in PPE to enter Resident #81's room. Staff Member identified the visitor, on 1/22/20 at 10:00 a.m., was from (an insurance company) and was notified of the resident's infection. On 1/23/20 after the noon meal, an observation revealed a male visitor standing in front of Resident #81. The visitor was dressed in street clothes and had a stethoscope around his neck. The male visitor was not wearing any PPE. At 4:25 p.m. on 1/23/20, Staff Member D confirmed the male visitor observed in Resident #81's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 7 of 8 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 105438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the policy titled, Droplet Precautions and Respiratory Hygiene/Cough Etiquette, effective 9/1/04, revised 6/15/19, and reviewed 11/15/19, identified droplet precautions would be followed in addition to standard precautions when caring for a patient who has known or suspected infection by microorganisms that are transmitted by droplets (large particle droplets) for example, influenza. The process portion of the policy indicated if private rooms were not possible for infected residents the facility may cohort with a roommate with limited risk factors and to draw curtain between patient beds. On 1/22/20 at 7:41 a.m., an observation was made of Resident #81 from the opposite side of the hallway. The observation revealed the privacy curtain between the beds was pushed back, the resident's wheelchair was positioned next to the bed near the bottom-middle of the bed and the end of Resident #81's bed was visible. According to the Center for Disease Control (CDC), droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient was in a healthcare facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 8 of 8