Health inspection·January 11, 2024

F 0554 have an order for self-administration. Level of Harm - Minimal harm or potential for actual harm Review of Resident #42's Order Summary Report for January 2024, confirmed Resident #42 did not have an order for self-administration of medications. Residents Affected - Few On 1/09/2024 at 1:07 PM, Resident #69 was observed in bed with lunch on the over the bed table across her lap. Next to the lunch tray was a medication cup full of a clear liquid. An interview was conducted with Resident #69, on 1/09/2024 at 1:07 PM. Resident #69 stated That is my Potassium. During an interview on 1/09/2024 at 1:15 PM, Staff D, Registered Nurse (RN) stated, I left the medication with [Resident #69], and I'll go back and check on the resident. Staff D, RN continued to state that none of the long-term residents on the hall had orders for self-administration. I should not have left the medication, stated Staff D, RN. Review of Resident #69's Order Summary Report for January 2024, confirmed Resident #69 did not have an order for self-administration of medications. Review of the facility's policy and procedure, titled Self-Administration of Medications at Bedside, Document Name: N-872 with a revision dated: 8/22/2017 revealed the following: Policy: The resident may request to keep medications at bedside for self-administration in accordance with Residents Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medications and to keep accurate documentation of these actions. Procedure: Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete self-administration of medications evaluations. The interdisciplinary team will review the evaluation and will document Section III. Approval granted must be checked yes or no. Interdisciplinary team members sign the evaluation section. If approval is not granted, a statement must be written as to reason for denial. Complete the care plan for approved self-administered drugs. Self-administration of meds is reviewed by the care plan team with each quarterly review, and with any change in status noted. The medication administration record (MAR) must identify meds that are self-administered, and the medication nurse will need to follow-up with resident as to documentation and storage of medication during each pass. If kept at bedside, the medication must be kept in a locked drawer. When a resident is unable to self-administer medications, they will be given by the nursing staff until the resident can be reevaluated by the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 2 of 18 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 01/11/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a current copy of the Advance Directive was in the resident's medical record for one resident (#68) of one resident sampled. Findings included: An interview was conducted with Resident #68's Resident Representative (RR) on 1/08/2024 at 2:11 PM. Resident #68's representative stated the resident was admitted to the facility under hospice care. The RR stated the family had implemented a Do Not Resuscitate Order (DNR) with hospice prior to admission and was told the family needed to come into the facility to sign another form. The RR tried to explain they were unable to come into the facility at this time as they had been quite ill. The RR stated they did not understand why the DNR was not able to be utilized in the facility as the hospice nurse had told them it was transferable to any institution. An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 1/08/2024 at 3:47 PM. Staff L, LPN stated Resident #68 was a Full Code and on hospice. An interview was conducted with the Social Service Director (SSD) on 1/08/2024 at 3:47 PM. The SSD stated Resident #68 came in with a bad DNR as the form had an electronic signature. The SSD continued to state the facility had taken the steps to have the resident deemed incompetent and to have the physician sign a new DNR. The facility was only waiting for the family to bring the form back into the facility, and the facility Had to follow 401 to the letter. The SSD confirmed the RR had informed the facility of the choice to enact a DNR for the resident. Review of the resident's admission Record showed the resident was admitted to the facility on [DATE]. The resident had a Power of Attorney (POA) for Financial and Health Care. The resident was being seen by Hospice. Review of the resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008), dated 11/28/2023, was signed by the Advanced Practice Registered Nurse (APRN). The form revealed the resident was a DNR. Review of the resident's physician order for 12/1/2023 revealed Resident #68 was a Full Code. Review of the Social Service admission Assessment, dated 12/06/2023, signed by the SSD showed the resident had a Durable Power of Attorney (DPOA). No other resident rights were indicated. The SSD documented, the resident has a POA for Finance and Health, would like DNR, explained need to have MDs sign Lack of Capacity and Terminal Declaration to allow him to sign, forms out for physician to sign, request sent to Psychologist. Facility will integrate services with Hospice Team. No other social service notes were presented. Review of the Certificate of Terminal Illness, dated 10/04/2023, and signed by the physician. The documentation additionally revealed the physician's discussion with the DPOA regarding the DNR process. The DPOA elected DNR. DNR was executed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 3 of 18 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 01/11/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the Director of Nursing (DON) on 1/08/2023 at 4:10 PM. The DON stated electronic signatures are acceptable. An interview was conducted with the SSD on 1/08/2023 at 4:30 PM. The SSD stated the family must come into the facility and sign the paperwork. The SSD stated the RR does request the resident to be a DNR but has not been able to make it into the facility. Review of the resident's medical record revealed a State of Florida Do Not Resuscitate Order, dated 10/04/2023, signed by the RR and an electronic signature of the physician. Review of the facility policy and procedure titled Advanced Directives, revision date of 11/14/2018, revealed the following: Policy: The center will abide by state and federal laws regarding Advanced Directives. The center will honor all properly executed advanced directives that have been provided by the resident and/or representative. Process: .2. Social Service Director and/or Business Development Coordinator/designee will assist the resident/resident representative to complete the Advanced Directives Discussion Document. If an advanced directive exists, the Social Services and/or Business Development Coordinator/designee will obtain a copy and place it in the resident's medical record.5. Advanced directives will be reviewed: *quarterly *Hospice admission Review of the facility policy and procedures titled Florida Do Not Resuscitate (DNR), dated 10/25/2018, revealed the following: Policy: The center will follow Florida law regarding obtaining and honoring Do Not Resuscitate orders. Procedure: 1. The State of Florida Do Not Resuscitate order (DNRO or DH form 1896) must be signed by the attending physician/covering physician or medical director and by the resident or, if the resident is incapacitated, the resident representative a. Electronic or fax physician signature is acceptable 3. The properly executed DNRO will be placed in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 4 of 18 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 01/11/2024 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 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 observations, interviews, and record review, the facility failed to ensure two of two Minimum Data Set (MDS) assessments were accurate to include an active diagnosis of trauma/Post Traumatic Stress Disorder (PTSD), for one resident (#5) of four sampled residents diagnosed with long standing trauma/PTSD. Residents Affected - Few Findings included: On 1/8/2024 at 11:00 a.m. the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Nursing Home Administrator (NHA) provided the survey team with a completed Resident Matrix tool, which contained all ninety-six facility residents with detailed problem indictors checked for each of those residents. In the Post Traumatic Stress Disorder (PTSD)/Trauma section of the matrix, Resident #5 was not indicated as having PTSD/Trauma. On 1/8/2024 at 9:30 a.m. an interview was conducted with Staff A, Certified Nursing Assistant (CNA), and Staff F, CNA who stated they were knowledgeable of Resident #5 related to her care needs. Staff A and F stated they had Resident #5 on their work assignment. Staff A and F stated Resident #5 had vision impairment and she required staff to explain where things are located throughout her room. Staff A and F stated Resident #5 had cognition impairment and she was not able to be interviewed but could answer some simple yes and no questions. Staff A and F stated Resident #5 does call out and scream at times but they were not aware of her having any type of trauma or PTSD. Staff A and F stated they would not know what to look for with relation to any type of past trauma behaviors. They stated Resident #5 screams aloud at times and is most times easily redirected. On 1/8/2024 at 9:35 a.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff D stated she was new to the facility and did not feel she would be able to explain any of the residents on her hall or what there care needs were. Staff D stated Resident #5 did present with screaming and yelling behaviors, but was not aware as to why she presented with those behaviors. On 1/8/2024 at 10:20 a.m. Resident #5 was observed seated in her wheelchair next to her bed. She was observed dressed for the day and well groomed. She was observed with her eyes closed making noises aloud and then started to yell out. She yelled out for approximately three to four minutes prior to staff responding. A staff member who was walking by the room, knocked on the door and entered the room to redirect and calm the resident. After the staff member was able to calm Resident #5, she then left the room. Resident #5 was noted in the main dining room on 1/8/2024 at 12:15 p.m., receiving assistance with her meal from Staff U, CNA. Resident #5 had no behaviors, pain or discomfort during the entire meal service. At 1:30 p.m. Staff U was asked about Resident #5's calling out and screaming behaviors and she stated she was newer to the facility and was not totally aware why she screams out at times. She stated Resident #5 was usually easily redirected. Staff U was not aware Resident #5 had any type of past trauma or PTSD. A review of Resident #5's Care Plans, next review date of 2/28/2024, revealed a care plan problem area to include: Resident has a history of trauma that affect her negatively. On 1/9/2024 at 7:45 a.m. an interview was conducted with the NHA. The NHA stated they were changing/updating electronic systems and found the Resident Matrix was not totally accurate and would need (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 5 of 18 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 01/11/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to bring a corrected one for review. At 8:00 a.m. the NHA provided the corrected and updated Resident Matrix for review. The corrected Resident Matrix did not reflect Resident #5 as having PTSD/Trauma. The Resident Matrix reflected three other residents who have PTSD/Trauma. On 1/10/2024 at 8:15 a.m. an interview with Staff F, CNA was conducted. Staff F stated she was aware Resident #5 yells and screams at times and she requires light redirecting and she will usually stop with those behaviors. Staff F confirmed Resident #5 has vision impairment and required staff to assist her with all Activities of Daily Living (ADL) to include eating, dressing, bathing, and transferring. Staff F was not aware of Resident #5 having any type of past trauma or PTSD. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed she had a Power of Attorney (POA) in place to make her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include dementia, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type II, legal blindness, fibromyalgia, anxiety, insomnia, history of falls, pain, and major depression. The record revealed no evidence of Resident #5 having a diagnosis of any past trauma or PTSD. Review of the Social Service Trauma care evaluation, dated 11/21/2023, revealed the following: (3) - Have you ever been in a major natural or technological disaster? yes. (4) - Have you ever had a life threatening illness such as cancer, a heart attack etc.? yes. (4a) - If the event happened, did you think your life was in danger or might be seriously injured? yes. (5) - Before age [AGE], were you ever physically punished or beaten by a parent, care taker, or teacher so that you were very frightened, or thought you would be injured with injuries? yes. (7) - Has anyone ever made you pressured into some type of unwanted sexual contact? yes. (12) - Can you identify triggers that may cause you re traumatization? - Does not want personal care from male caregiver unless female staff is also present and involve in care. Resident provided limited response, stated, you know all of that, nothing has changed, and was able to repeat her preference for female care givers. She was able to add that she will accept help from male staff if female staff are present. Review of the care plan, with next review date 2/28/2024, revealed the following: Focus: Resident has a history of trauma that affect her negatively related to: Raised in an orphanage, experienced abuse, she has difficulty discussing this experience (reviewed 11/21/2023). Interventions included: Approach with calm compassion when Resident #5 is anxious, frightened and confused. Speak clearly, offer reassurance that you want to help her to feel safe; use caution with physical touch if Resident #5 pulls away; Greet verbally on approach and state name and purpose d/t Resident #5's vision loss; Resident #5 requests no male care givers for tasks of bathing, toileting and dressing. Will accept assistance with repositioning from male staff if female staff are also present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 6 of 18 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 01/11/2024 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 0641 Review of the Quarterly MDS, dated [DATE], revealed the following: Level of Harm - Minimal harm or potential for actual harm Cognition/Brief Interview Mental Status or BIMS score - 13 of 15 which indicated the resident was able to speak related to her care and services; Vision = Highly impaired; Behaviors = None exhibited during assessment period timeframe; Active Diagnosis = PTSD section was checked no. Residents Affected - Few Review of the Annual MDS, dated [DATE], revealed the following: Cognition/BIMS score - 9 of 15 which indicated the resident's cognition had declined since last assessment; Vision = Highly impaired; Behaviors = None exhibited during assessment period timeframe; Active Diagnosis = PTSD section was checked no. On 1/11/2024 at 10:40 a.m. an interview with the MDS Coordinators, Staff G and Staff H was conducted. They stated Resident #5 had long standing behaviors of screaming and yelling out but they were not aware of her having past trauma/PTSD. They confirmed after review of the current care plan, Resident #5 had a problem area to include behaviors related to trauma and PTSD. They confirmed the past three comprehensive MDS assessments did not reveal Resident #5 had a diagnosis of trauma/PTSD. They stated the resident was being seen by psychiatric services, but they were not sure if psychiatric services were assessing and treating for trauma/PTSD. They confirmed all three MDS assessments were not accurate and should have reflected Resident #5 having an active diagnosis of trauma/PTSD. An interview on 1/11/2024 at 11:40 a.m. was conducted with the Staff C, LPN, North Unit Manager. She stated Resident #5 did have routine behaviors of screaming and yelling, and was care planned for those behaviors. She stated she was aware Resident #5 had a history of trauma/PTSD and did not want male CNAs to care for her. She stated Resident #5 had a history of past experiences that were traumatizing and care from males brings back memories of that trauma. She stated behaviors and care planning related to trauma/PTSD have been in place since the resident's admission. She stated staff were aware not to have males care for Resident #5 but was unable to provide documentation related to education for staff working with residents who have had past trauma/PTSD. On 1/11/2024 at 2:15 p.m. an interview with the Director of Nursing was asked for an accuracy of assessment/accuracy of MDS assessment policy and procedure for review. She revealed the facility did not have a policy with that specific information. She did confirm it is expected that MDS assessments are completed timely and accurately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 7 of 18 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 01/11/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 confirm the accuracy and make corrections to the Pre-admission Screening and Resident Review (PASRR) for seven residents (#6, #26, #44, #55, #68, #50, and #28) out of thirty-five residents sampled when mental illness or suspected mental illness diagnoses were identified and/or added to the resident's medical diagnoses. Residents Affected - Some Findings included: 1) Review of Resident #6's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #6's PASRR, dated 7/8/22, revealed a diagnosis of depressive disorder and a Level II PASRR was not required. The review of Resident #6's admission Record showed the resident was admitted with diagnoses of bipolar-type schizoaffective disorder, generalized anxiety disorder, and brief psychotic disorder. The following diagnoses were added after the resident's PASRR was completed and the resident was admitted : - in-partial remission recurrent major depressive disorder, onset date 11/22/22; - Dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The onset date was 5/22/23. - mild recurrent major depressive disorder, onset date 7/10/23. The clinical record did not reveal Resident #6's PASRR was revised to include the resident's mental illnesses. 2) Review of Resident #26's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #26's PASRR, dated 1/4/21, did not reveal the resident had a diagnoses of any Mental Illness (MI), a suspected MI or a Level II PASRR was required. The review of Resident #26's admission Record showed the resident had diagnoses to include: - generalized anxiety disorder, onset date 3/28/21; - psychotic disorder with hallucinations due to known physiological condition, onset date 5/2/22; - unspecified severity vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The onset date was 6/1/22. - delirium due to known physiological condition, onset date 11/18/22. - mild recurrent major depressive disorder, onset date 11/18/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 8 of 18 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 01/11/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The onset date was 1/5/23. Review of Resident #26's clinical record did not show the resident's PASRR was revised after the addition of mental illness diagnoses or the facility received a revised PASRR prior to the readmission on [DATE] of the resident. On 1/10/24 at 4:54 p.m. the Social Service Director (SSD) confirmed Resident #26's PASRR did not show any MI illnesses and the PASRR should have been revised. 3) Resident #44 was admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction to unspecified occlusion or stenosis of unspecified cerebral artery, major depressive disorder, recurrent, mild, dementia in other disease classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized anxiety disorder. Review of Resident #44's Preadmission Screening and Resident Review (PASRR), dated 10/09/2017, revealed only one qualifying mental health diagnosis (depressive disorder), no dementia diagnosis and that no PASRR Level II was required. Review of Resident #44's Preadmission Screening and Resident Review (PASRR), dated 4/30/2021, revealed no qualifying mental health diagnoses, no dementia diagnosis and that no PASRR Level II was required. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS), score of 13 indicating cognitively intact. Further review showed, Section I Active Diagnoses Non- Alzheimer's Dementia, anxiety disorder, and depression. Review of the medical record revealed the resident was not assessed for PASRR Level II. 4) Resident #55 was admitted on [DATE] with diagnoses of generalized anxiety disorder, Bipolar II disorder, and major depressive disorder, recurrent, mild. Review of Resident #55's Preadmission Screening and Resident Review (PASRR), dated 8/25/2023, revealed no qualifying mental health diagnosis and that no PASRR Level II was required. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Further review showed Section I Active Diagnoses anxiety disorder, depression, and Bipolar disorder. Review of the medical record revealed the resident was not assessed for PASRR Level II. 5) Review of the admission Record showed Resident #28 was admitted on [DATE] and readmitted on [DATE] with diagnoses of major depressive disorder, Schizoaffective Disorder, Bipolar type, alcohol abuse, dementia, and psychotic disorder with hallucinations, due to known psychological conditions, and other comorbidities. Review of Resident #28's PASRR Level I Assessment, dated 08/04/2021, did not reveal a qualifying mental health diagnosis marked in section I A. nor was the diagnosis of dementia. A Level II PASRR should be completed due to the qualifying diagnoses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 9 of 18 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 01/11/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/10/2024 at 04:27 PM, the Social Service Director (SSD) confirmed the diagnoses should be listed on the PASRR. The SSD confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of the admission Record showed Resident #50 was admitted on [DATE] with diagnoses of dementia, mood disorder, adjustment disorder with depressed mood, major depressive disorder, and other comorbidities. Review of Resident #50's PASRR Level I Assessment, dated 06/05/2021, did not reveal a qualifying mental health diagnosis marked in section I A. nor was the diagnosis of dementia. A Level II PASRR should be completed due to the qualifying diagnoses. During an interview on 1/10/2024 at 04:27 PM, the Social Service Director (SSD) confirmed the diagnoses should be listed on the PASRR. The SSD confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of the admission Record showed Resident #68 was admitted on [DATE] with diagnoses of Alzheimer's disease, mood disorder, depression, anxiety, violent behavior, and other comorbidities. Review of Resident #68's PASRR Level I Assessment, dated 11/28/2023, revealed a qualifying mental health diagnosis marked in section I A. depressive disorder, no other diagnoses indicated. Section II: 5. Indicated resident has a primary diagnosis of dementia. 7. Indicates the resident does have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease). A Level II PASRR should be completed due to the qualifying diagnoses. During an interview on 1/10/2024 at 04:27 PM, the Social Service Director (SSD) confirmed the diagnoses should be listed on the PASRR. The SSD confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of the facilities policy and procedures titled Preadmission Screening and Resident Review (PASRR), revision date of 11/08/2021, showed the following: Policy: The center will assure that all Seriously Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agencies to conduct the screenings and obtain the results. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate section of the resident's records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 10 of 18 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 01/11/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to ensure respiratory equipment was stored in a sanitary manner for two residents (#14 and #69) of three residents sampled. Residents Affected - Few Findings included: 1) On 1/08/2024 at 09:41 AM and 1/09/2024 at 01:11 PM, Resident #14's nebulizer machine was observed on the bedside table. The tubing and pipe were sitting on the machine. A concentrator machine was next to the bed. The tubing was wrapped around the concentrator with the nasal cannula draped over the top. Neither was in a bag, or dated. (Photographic Evidence Obtained) An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 1/08/2024 at 11:25 AM. Staff A, CNA stated the tubing and pipe should be dated and in a bag. Staff A, CNA confirmed the tubing and pipe for the nebulizer and the tubing and nasal cannula attached to the concentrator were not dated and not in bags. A review of Resident #14's admission Record revealed an admission date of 6/28/2023. A review of Resident #14's Medication Administration Record (MAR) for January 2024, revealed an order for: Change and date nebulizer tubing and external bag every Thursday. The MAR did not have any signatures indicating the task was completed as ordered. 2) On 1/08/2024 at 10:19 AM, Resident #69's nebulizer machine was observed laying at the foot of the bed. The tubing and mask were laying from the foot board of the bed to the floor. The tubing on the floor was dated 11/02/2023. (Photographic Evidence Obtained) An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 01/08/2024 at 11:15 AM. Staff L, LPN confirmed Resident #69 received nebulizer treatments on a regular basis. Staff L, LPN stated the nurses change the tubing to the nebulizers and oxygen machines weekly. Staff L, LPN stated the nurses just have to remember to complete this task as the order is on some residents Treatment Administration Records (TAR) and not on others. Staff L, LPN confirmed the nebulizer was at the foot of the bed and the tubing was on the floor, dated 11/02/2023. Staff L, LPN stated this tubing and mask should be in a bag and dated. Staff L, LPN removed the nebulizer machine and discarded the tubing and mask dated 11/02/2023. An interview was conducted with the Director of Nursing on 1/11/2024 at 12:00 PM. The DON stated, I expect the tubing to be changed, dated and bagged. Review of the facilities policy and procedures titled Equipment Change Schedule, revision date of 8/28/2017, revealed the following: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. Procedure: Equipment/When Changed Aerosol Tubing and Aerosol Nebulizer once every seven (7) days.Nasal Cannula every seven (7) days or when contaminated Nebulizer Set-up Once, every seven (7) days along with equipment bag labeled with name, date, and room number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 11 of 18 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 01/11/2024 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 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 reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and eleven errors were identified for three residents (#3, #42, and #76) of seven residents observed. These errors constituted a 34.38% medication error rate. Residents Affected - Some Findings included: 1) On 1/9/24 at 10:31 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #3. The staff member dispensed the following medications: - Fluoxetine 10 milligram (mg) capsule - Famotidine 20 mg over-the-counter (OTC) tablet Review of Resident #3's Medication Administration Record revealed Resident #3 was scheduled to be administered the following medications at 9:00 a.m.: - Mirtazapine 7.5 mg - Give 1 tablet by mouth one time a day for depression; - Prozac (Fluoxetine) 10 mg - Give 2 capsules by mouth one time a day for depression; - Pepcid (Famotidine) 20 mg - Give one tablet by mouth two times a day for Gastroesophageal reflux disease (GERD). The observation revealed Staff D initialed the individual medications prior to dispensing the medications. The observation revealed the staff member administered 2 oral tablet/capsule medications to Resident #3. 2) On 1/9/24 at 10:49 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #42. Staff D obtained the resident's blood pressure of 95/65. The observation revealed the staff member documenting medications were dispensed prior to dispensing the medications. The staff member dispensed the following medications: - Escitalopram 5 mg tablet - Oxybutynin 5 mg Extended Release (ER) tablet - Pantoprazole 40 mg tablet - Eliquis 2.5 mg tablet - Senna (sennosides) 8.6 mg tablet - Gabapentin 300 mg capsule Staff D confirmed dispensing 6 oral tablets/capsules. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 12 of 18 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 01/11/2024 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 Review of Resident #42's Medication Administration Record revealed the following errors in administration: Level of Harm - Minimal harm or potential for actual harm - Lexapro (Escitalopram Oxalate) 5 mg tablet - Give 10 mg by mouth one time a day for depression; Residents Affected - Some - Senna S (Sennosides-Docusate Sodium) 8.6-50 mg - Give 2 tablets by mouth one time a day for constipation; - Cardizem 120 mg tablet - Give 1 tablet by mouth one time a day for HTN; - Iron 325 mg tablet - Give 1 tablet by mouth one time a day every 2 day(s) for anemia, scheduled to be administered on 1/9/24; - Isosorbide Dinitrate 30 mg tablet - Give 1 tablet by mouth one time a day for Atrial fibrillation (Afib); - Metoprolol Tartrate 50 mg tablet - Give 1 tablet by mouth every 12 hours for hypertension (HTN); - Nifedipine Extended Release (ER) 24 hour 30 mg - Give 1 tablet by mouth every 12 hours for HTN. The review of the MAR showed the medications observed, held, and unobserved were scheduled to be administered at 9:00 a.m. Staff D reported holding the medications of Metoprolol, Cardizem, and Isosorbide due to blood pressure (95/65) and putting a zero (0) on top (of MAR) to indicate the medication was not given. Staff D reported the medications observed were due at 8-9 a.m. and having to administer medications to 30 people. The staff member did not document the Iron or Nifedipine was administered or held. The physician orders for the resident's hypertension medication did not include parameters to hold the medication for blood pressures. Staff D reported charting on the residents was done in the computer (which was not available during the survey due to the facility transitioning) which they were not doing at this time. On 1/11/24 at 12:38 p.m., the Director of Nursing (DON) stated the expectation was to call the physician before holding medications. 3) On 1/10/24 at 9:01 a.m., an observation of medication administration with Staff M, Registered Nurse (RN), was conducted with Resident #76. The staff member signed the medication on the MAR as removing the medication packaging from the medication cart, prior to dispensing. Staff D dispensed the following medications: - Vitamin D 25 microgram (mcg) - 5 otc tablets over-the-counter (otc) - Guaifenesin 400 mg otc tablet - Multi Vitamin with mineral otc tablet - Jardiance 25 mg tablet - 1/2 tab - Eliquis 5 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 13 of 18 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 01/11/2024 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 - Metformin 1000 mg tablet Level of Harm - Minimal harm or potential for actual harm - Lopressor 25 mg - 1/2 tablet - Flecainide 150 mg tablet Residents Affected - Some - Escitalopram 20 mg tablet - Loratadine 10 mg otc tablet - Prostat 30 milliliter (mL) The staff member confirmed dispensing 14 tablets. Staff M stated she would have to contact pharmacy as the facility did not have Resident #76's Wixela Aerosol Inhalation medication. Review of Resident #76's Medication Administration Record (MAR) revealed the following physician orders and errors in administration: - Guaifenesin Extended Release (ER) 600 mg - Give 1 tablet by mouth every 12 hours for congestion; - Wixela Inhub Inhalation Aerosol Powder Breath Activated (500-50 mcg/act) (Fluticasone-Salmeterol) - I puff inhale orally two times a day for Chronic Obstructive Pulmonary Disease (COPD). Rinse mouth and spit after use. On 1/10/24 at 9:30 a.m. Staff M reporting thinking the facility had educated staff on Monday regarding the use of paper MAR's but stated she wasn't here. On 1/11/24 at 12:40 p.m., the Director of Nursing (DON) stated if a medication was not available, the pharmacy should be called, the staff should verify the medication was not available in the emergency stock, and if not the physician be notified. On 1/11/24 at 12:33 p.m., an interview was conducted with the DON and Regional Nurse Consultant (RNC) to reveal the observations of the medication administration, at which time the Director of Nursing stated the facility had received an order from the Medical Director that it was okay for late medications during the time the facility was utilizing paper MAR's. On 1/11/24 at 1:40 p.m., the DON provided a copy of a physician order, dated 1/8/24 reading All residents medications can be late during Point Click Care (PCC) transition. The DON confirmed the order and shrugged shoulders that it did not reveal how late medications were allowed. The policy - Medication Administration - General Guidelines, dated April 2018, showed the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly orientated to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The policy revealed the following: - The procedure revealed medications were to be administered by the five rights: right resident, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 14 of 18 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 01/11/2024 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 - Some right drug, right dose, right route, and right time. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. - The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record are compared with the medication label. - If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit. - If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time or a starter dose of antibiotics is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 15 of 18 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 01/11/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure coordination of services occurred between the facility and hospice for one resident (#68) of one resident sampled for hospice. Findings included: An interview was conducted with Resident #68's Resident Representative (RR) on 1/08/2024 at 2:11 PM. Resident #68's representative stated the resident was admitted to the facility under hospice care. The RR stated the family had implemented a Do Not Resuscitate Order (DNR) with hospice prior to admission and was told the family needed to come into the facility to sign another form. The RR tried to explain they were unable to come into the facility at this time as they had been quite ill. The RR stated they did not understand why the DNR was not able to be utilized in the facility as the hospice nurse had told them it was transferable to any institution. An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 1/08/2024 at 3:47 PM. Staff L, LPN stated Resident #68 was a Full Code and on hospice. An interview was conducted with the Social Service Director (SSD) on 1/08/2024 at 3:47 PM. The SSD stated Resident #68 came in with a bad DNR as the form had an electronic signature. The SSD continued to state the facility had taken the steps to have the resident deemed incompetent and to have the physician sign a new DNR. The facility was only waiting for the family to bring the form back into the facility, and the facility Had to follow 401 to the letter. The SSD confirmed the RR had informed the facility of the choice to enact a DNR for the resident. Review of the resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008), dated 11/28/2023, was signed by the Advanced Practice Registered Nurse (APRN). The form revealed the resident was a DNR. Review of the resident physician order for 12/1/2023 reveals resident #68 was a Full Code. Review of the Social Service admission assessment dated [DATE] signed by the SSD showed the resident had a Durable Power of Attorney (DPOA). No other resident rights were indicated. The SSD documented, the resident has a POA for Finance and Health, would like DNR, explained need to have MD sign Lack of Capacity and Terminal Declaration to allow him to sign, forms out for physician to sign, request sent to Psychologist. Facility will integrate services with Hospice Team. No other social service notes were presented. Review of the Certificate of Terminal Illness, dated 10/04/2023, signed by the physician. The documentation revealed the physician's discussion with the DPOA regarding the DNR process. The DPOA elected DNR. A DNR was executed. An interview was conducted with the Director of Nursing (DON) on 1/08/2023 at 4:10 PM. The DON stated electronic signatures are acceptable. An interview was conducted with the SSD on 1/08/2023 at 4:30 PM. The SSD stated the family must come into the facility and sign the paperwork. The RR did request the resident to be a DNR but has not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 16 of 18 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 01/11/2024 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 0849 been able to make it into the facility. Level of Harm - Minimal harm or potential for actual harm Review of the resident's medical record revealed a State of Florida Do Not Resuscitate Order, dated 10/04/2023, signed by the RR and an electronic signature of the physician. Residents Affected - Few An interview was conducted with Staff L, LPN and Staff J, LPN on 1/09/2024 at 4:12 PM. Staff J, LPN and Staff L, LPN both stated, they did not receive anything from hospice after the initial communication binder, although they did not have a binder for Resident #68. They stated If they need to communicate with the hospice nurse, they call them. An interview was conducted on 1/10/2024 at 11:57 AM with Registered Nurse (RN) from Hospice who follows Resident #68 at the facility. The Hospice RN stated when visiting with Resident #68 communication occurs between the nurse on the cart at the facility. The Hospice RN stated, I don't have anything to do with the facility receiving paperwork. My manager drops off the care plan and other documentation on a routine basis to the facility. An interview was conducted on 1/10/2024 at 12:10 PM with the SSD. The SSD confirmed responsibility for the coordination of communication with the Hospice vendor. We have binders for the [Vendor] Hospice here in my office. The Hospice manager drops off the paperwork and places the documents in the binder. The hospice nurse who visits and the manager do not necessarily speak with me upon their visits. [Vendor] hospice has not given us paperwork since September 2023. [Vendor] hospice has been going through several personnel changes and informing of us of a rollout of a new system, but this has not happened. The SSD confirmed no additional documentation has been provided to the facility on Resident #68. Review of the [Vendor] hospice binder provided by the SSD revealed the most current signature sheet was dated September 2023. An interview was conducted on 1/10/2024 at 12:15 PM with the [Vendor] hospice RN Clinical Care Manager. The RN Clinical Care Manager confirmed responsibility for overseeing the coordination of communication with the facility. RN Clinical Care Manager stated a new system was implemented at the facility on 12/4/2023. The [Vendor] hospice liaison met with DON at the facility. The facility agreed to participate in the new data sharing of documentation on the new data platform as the facility is familiar with the platform already. On 12/8/2023, the RN Clinical Care Manager created the account and uploaded the [Vendor] hospice residents who are at the facility. This platform has the updated care plan, DNR, medications etc This is how we share data and ensure coordination of services. RN Clinical Care Manager confirmed no one has followed up with the facility after the rollout. An interview was conducted on 1/10/2024 at 12:17 PM with the SSD. The SSD stated no-one had confirmed the roll out of the platform had occurred. Review of the facility Inpatient Services Agreement between [Vendor] hospice and facility dated December 5, 2017 with an automatic renewal for successive one-year terms, unless terminated with written notice. Under section 2. Responsibilities of Facility page 5 of 18, sub section (e) Coordination of Care. Facility shall participate in any meetings, when requested, for the coordination, supervision and evaluation by Hospice of the provision of Inpatient Services. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Page 7 of 18, sub section (iii) Coordination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105438 If continuation sheet Page 17 of 18 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 01/11/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and Evaluation. Hospice shall retain responsibility for coordinating, evaluating and administering the hospice program, as well as ensuring the continuity of care of Hospice Patients, which shall include coordination of Inpatient Services. Methods used to evaluate the care may include: [a] periodic supervisory visits; [b] review of qualifications of personnel providing services; [c] review of documentation; [d] evaluation of of the response of Hospice Patient to the Plan of Care; [e] discussion with patient and patient's caregivers; . (e) Provision of Information. Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Inpatient Services under this Agreement is in accordance with the Hospice Patient's Plan of Care, assessments, treatment planning and care coordination. Event ID: Facility ID: 105438 If continuation sheet Page 18 of 18