Inspection·August 29, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (culture) 6/3/2024. MRSA (+) Nares 8/4/24. Diagnosis, Assessment and Plan: Assessment: Acute UTI: Patient has completed Zosyn as directed at hospital discharge. PICC line in place in LUE (left upper extremity).During an interview on 8/26/25 at 7:10 AM, Resident #104 stated, Am I going to get anything in this (the PICC line). They haven't used it since I got here. I have not gotten any antibiotics, they don't know what to give me.During an interview on 8/26/25 at 7:11 AM, Staff M, Licensed Practical Nurse (LPN) stated that (the PICC line dressing) was done on 8/16 and it has blood under it and it is rolling up. It should have been changed.During an interview on 8/26/25 at 7:39 AM, the Director of Nursing (DON) verified that the date on the dressing was 8/16/25 and there was blood under the dressing and the dressing should have been changed.During an interview on 8/26/25 at t1:32 AM, the DON stated, I believe that the medication (Zosyn) was not on the discharge medication reconciliation list and we reached out to the doctor and they didn't think she needed it. The DON verified that the discharge medication reconciliation did contain Zosyn and all other medications were checked except the Zosyn.During an interview on 8/26/25 at 2:31 PM, the DON stated, I spoke to the provider, it wasn't the doctor but the nurse practitioner, [Nurse Practitioners name], he was aware the medication wasn't given and said not to order it and he ordered a u/a (urinalysis) and labs to be done. Ultimately, it should have been ordered. I don't know why it wasn't.During an interview on 8/27/25 at 10:01 AM, the Advanced Practice Registered Nurse (APRN) stated, I did find that she [Resident #104] had not received the medication and due to the length of time since she had been administered it (the antibiotic), I decided to do a u/a as she was not symptomatic. That was on the 20th or 21st, it just came back and is negative. They should have ordered the medication. I don't know why there were no orders for the care of the midline dressing, they are batched orders and should have been done on the day she was admitted . The site itself had no signs of infection, but there should have been dressing changes and flushes. There should have been orders for flushes to maintain the line, it may have developed a clot.During an interview on 8/28/25 at 12:20 PM, the Medical Director stated, I was not aware that she [Resident #104] did not get her medication as ordered. We do have this medication available. I understand that [Name of APRN] was made aware and chose not to administer it and obtain labs and a urine c & s (culture and sensitivity), luckily it came back negative. There should be PICC/midline care provided, there should be flushes and dressing changes provided. They should have provided the orders and care for the lines.On 8/28/25 at 1:00 PM a request of the DON was made for any policy and procedures related to medication reconciliation. None were provided. The DON stated, We don't have any related to medication reconciliation. We should review the discharge summary and medication list and request those orders from the doctor. 2. During an observation on 8/25/25 at 1:40 PM, Resident #28 was observed sitting in bed with a right upper arm midline catheter with gauze under the semi-permeable transparent dressing. The gauze had a large circular brown colored area on the gauze. The dressing was dated 8/18/25.During an observation on 8/26/25 at 7:16 AM, Resident #28 was observed sitting in wheelchair, with a right upper arm midline catheter with a dressing date of 8/18/25 with gauze under the semi-permeable dressing. The gauze had a large circular brown colored area on the gauze.Review of Resident #28's admission record documented diagnosis that include aftercare following joint replacement surgery, presence of right artificial knee joint, disruption or dehiscence of closure of other unspecified internal operation surgical wound, subsequent encounter, and infection and inflammation reaction due to internal fixation device of other sites subsequent encounter.Review of Resident #28's physician order dated 8/11/25 read, Change dressing post PICC (peripherally inserted central line) insertion and routinely one time a day every 7 day(s).Review of Resident #28's medication administration record for August 2025 documented a dressing change as completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 2 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 - Some 8/18/25.During an interview on 8/25/25 at 2:01 PM, Staff O, LPN stated, I don't know if the dressing should be changed, its dated 8/18/25. So, it's still in date. I don't know if having that gauze under it makes any difference.During an interview on 8/26/25 at 7:45 AM, the DON stated, If there is gauze under the dressing, it should have been changed before now. During an interview on 8/27/25 at 10:08 AM, the APRN stated, I would expect all nursing staff to know the policies related to the care of the line and follow all the proper protocols. There is always a risk of infection if staff are not able to assess the insertion site.During an interview on 8/27/25 at 12:13 PM, the Infection Preventionist stated, I do weekly audits for PICC/midlines to see if they are necessary and if the dressing dates are accurate. For [Resident #28's name] I did audit his dressing, and I was not aware that if there was gauze under the dressing it should be changed, so I didn't know that. Staff would not be able to assess the site when it is covered with gauze. The dressing should have been changed.3. During an observation on 8/25/25 at 9:11 AM, Resident #114 was observed in bed with head of bed elevated and on oxygen at 4 liters via nasal cannula. There was a left upper arm single lumen midline catheter with 2 different dates, one 8/11/25 and one 8/18/25 on the dressing. There was a large amount of old dried blood under the semi-permeable transparent dressing, and the dressing was lifting on all edges, exposing the insertion site.During an observation on 8/26/25 at 7:07 AM, Resident #114 was observed in bed with left single lumen PICC/midline line with 2 different dates, one 8/11/25 and one 8/18/25 on the dressing. There was a large amount of old dried blood under the semi-permeable transparent dressing, and the dressing was lifting on all edges, exposing the insertion site.During an interview on 8/26/25 at 7:07 AM, Resident #114 stated, I had a blood and lung infection and needed antibiotics. They have not changed my dressing since I got here. It has looked like that since I was in the hospital. I haven't had any antibiotics since I got here. They sent me out to the hospital and now I'm going to get them.Review of Resident #114's admission record documented an admission date of 8/22/25 with diagnosis that include hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, chronic obstructive pulmonary disease with acute exacerbation, type II diabetes mellitus without complications, essential primary hypertension, acute respiratory failure, unspecified whether with hypoxia or hypercapnia, ischemic cardiomyopathy, and unspecified atrial fibrillation,Review of Resident #114's patient discharge instruction from [Name of hospital] dated 8/22/25 at 14:48 (2:28 PM) read, Reason for visit: Acute and chronic respiratory failure, Atrial fibrillation, transient: Bacteremia; Sepsis. Medications: Printed Prescriptions: non-formulary medication Penicillin G (PCN G) 24 million units IV daily as continuous infusion through 8/31/2025.Review of Resident #114's physician order dated 8/22/25 reads, Maintain midline.Review of Resident #114's physician order dated 8/23/25 read, Change transparent dressing. Measure catheter length one time a day every 7 day(s). Observe for signs and symptoms of infection, infiltration and /or extravasation.Review of Resident #114's medication administration record documented a dressing change on 8/23/25 at 0900 (9:00 AM).During an interview on 8/26/25 at 7:20 AM, Staff M, LPN acknowledged there was blood under the transparent dressing and the dressing was compromised and lifting up, and stated that the dressing should have been changed.During an interview on 8/26/25 at 7:25 AM, the DON acknowledged that the dressing was with old blood and should be changed. It should have been changed yesterday.During an interview on 8/27/25 at 10:07 AM, the APRN stated, They (the hospital) should never have sent her here, we do not do continuous IV antibiotic administration and every 4 hours labs. The hospital shouldn't have sent her here. I found out and sent her to the ED (emergency department) to get evaluated. She needed to have the antibiotics. I can't tell you why this wasn't addressed before Monday. She should have been continued on the antibiotic and when I knew I sent her out. There was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 3 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete harm. She does need the antibiotic, I guess there could be adverse things that happen from not getting the antibiotic. I guess she could become antibiotic resistant or have worsened symptoms, but she didn't and hasn't. She just shouldn't have been allowed to come; the hospital should have known that and not sent her.During an interview on 8/27/25 at 10:56 AM, the DON stated, I called the doctor over the weekend, and she said to clarify the order. Admissions reached out to the hospital over the weekend, and we couldn't get an answer. I don't know why it took so long.During an interview on 8/27/25 at 12:13 PM, the Infection Preventionist stated, [Resident #114's name] came on Friday with orders to have a continuous IV antibiotic. We can't do that, so admissions reached out to the hospital for clarification. She never got clarification so [Name of APRN] sent her out to the hospital because she needed the antibiotic. We should change any dressing which is compromised or has blood under the dressing, I'm not sure why it wasn't changed. During an interview on 8/27/25 at 12:47 PM, Staff N, LPN stated, She [Resident #114] was admitted with orders for continuous IV antibiotics and we don't do that, so then when [Name of the DON] and admissions called or tried to call the hospital to get clarification on the medication. It was not ordered because we were waiting for the hospital to clarify. Once [Name of APRN] came in he told us to send her back because we needed to begin treating her. She is getting her antibiotics now.During an interview on 8/28/25 at 12:20 PM, the Medical Director stated, I was aware that she was received with orders for PCN infusion early Saturday morning and I think that [Name of DON] told the admissions coordinator to reach out to the hospital and get clarification on what could be administered. I reviewed the labs and ID (infection disease) notes. She had one positive culture and 2 negative cultures. I felt it was safe to wait for clarification but by Monday we decided we would not wait any additional time and sent her back for the answer. No, this was not harming her, she had no additional fever, tachycardia, no other indicators of sepsis or septic shock. I would expect staff to change midline catheter dressings as ordered.Review of the policy and procedure titled, PICC IV (intravenous) line last approval date of 8/1/25 read, Policy: It will be the policy of this facility to adhere to IV/PICC line administration guidelines set forth by infection control, state and federal regulations. Licensed nurses shall provide care according to state and federal laws. Guidelines: Dressing Changes: 1. Sterile dressing change using transparent dressing is performed: 24 hours post-insertion or upon admission if not dated upon admission, at least weekly, and if the integrity of the dressing has been compromised (wet, loose or soiled). Event ID: Facility ID: 105488 If continuation sheet Page 4 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure that adequate pain management was provided for 3 (Resident #43, Resident #86 and Resident #85) of 5 residents reviewed that were prescribed opioid pain medications. Residents Affected - Some Findings include: 1. During an interview on 08/27/2025 at 11:10 AM, Resident #43 stated, I don't remember the exact date, but when I was waiting on my pain medicine last month, pharmacy didn't bring it for a long time, and I started going through withdrawals. I was sweating and nauseous. I had a lot of anxiety. I did go to the hospital the next day for chest pains, but I don't think it was related. I was told the chest pain was due to my muscle. Review of Resident #43’s admission record documented a admission date of 4/22/2025 with medical diagnoses that included spinal stenosis, cervical region, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified fracture of right lower leg, central pain syndrome, and muscle spasm of back. Review of Resident #43’s physician order dated 7/17/2025 read, OxyCODONE HCl (hydrochloride) Tablet 5 MG (milligram) Controlled Drug Give 1 tablet by mouth every 4 hours for Non acute pain. Review of Resident #43’s care plan dated 4/23/2025 read, Focus: The resident is on opioid medication therapy. Interventions: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. Ask physician to review medication if side effects persist. Assess pain type, location, and characteristics before and after administration and document results. Encourage adequate fluid intake. Implement non-pharmacological interventions as required. Monitor bowel habits and implement bowel regimen as ordered. Monitor for increased risk for falls. Review of Resident #43’s MAR (medication administration record) for the month of July 2025, documented by Staff F, LPN (licensed practical nurse), showed oxycodone 5 mg (milligram) tablet scheduled for 7/22/25 at 0000 (midnight), 7/22/25 at 0400 [4:00 am], 7/27/2025 at 2000 [8:00 PM], 7/28/2025 at 0000 [midnight], and 7/28/25 at 0400 [4:00 AM] was coded as 9 = other/see nurses notes.” Review of #43’s eMAR (electronic medication administration record) general note, authored by Staff F, LPN dated 7/22/2025 at 2:06 AM, read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain. waiting on pharmacy. Review of #43’s eMAR general note, authored by Staff F, LPN dated 7/22/2025 at 5:02 AM, 7/27/2025 at 21:13 (9:13 PM), 7/28/2025 at 00:19 (12:19 AM), 7/28/2025 at 5:06 AM read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain. Review of Resident #43’s MAR for the month of July 2025, documented by Staff G, LPN, showed oxycodone 5 mg tablet scheduled for 7/27/25 at 1600 [4:00 PM] was coded as 9 = other/see nurses note.” Review of Resident #43’s eMAR general note, authored by Staff G, LPN, dated 7/27/2025 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 5 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 17:18 (5:18 PM) read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain. Review of Resident #43’s MAR for the month of July 2025, documented by Staff A, LPN, showed oxycodone 5 mg tablet scheduled for 7/28/2025 at 0800 [8:00 AM] and 7/28/2025 at 1200 [12:00 PM] was coded as 9 = other/see nurses note.” Review of Resident #43’s eMAR general note, authored by Staff A, LPN, dated 7/28/2025 at 10:38 AM and 7/28/2025 at 13:13 [1:13 PM], read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain Review of Resident #43’s MAR for the month of July 2025, documented by Staff B, LPN, showed oxycodone 5 mg tablet scheduled for 7/28/2025 at 2000 [8:00 PM] and 7/29/25 at 0000 [midnight] was coded as 9 = other/see nurses.” Review of Resident #43’s eMAR general note authored by Staff B, LPN dated 7/28/2025 at 21:42 [9:42 PM] and 7/29/2025 at 00:18 [12:18 AM] read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain unable to retrieve from edk [emergency drug kit], no other staff in building all agency. Review of Resident #43’s MAR for the month of July 2025 showed oxycodone 5 mg tablet scheduled for 7/29/2025 at 0400 [4:00 AM] had nothing documented on MAR for that time. Review of Resident #43’s MAR for the month of August 2025, documented by Staff H, LPN, showed oxycodone 5 mg tablet scheduled for 8/2/2025 at 0400 [4:00 AM], was coded as 7 = sleeping.” Review of Resident #43’s MAR for the month of August 2025, documented by Staff C, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/3/25 at 0000 [midnight] was coded as 7 = sleeping.” Review of Resident #43’s MAR for the month of August 2025, documented by Staff J, LPN, showed oxycodone 5 mg tablet scheduled for 8/4/2025 at 0000 [midnight] was coded as 7 = sleeping.” Review of Resident #43’s MAR for the month of August 2025, documented by Staff K, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/10/2025, at 0800 [8:00 AM], was coded as 9 =“other/see nurses.” Review of Resident #43’s MAR for the month of August 2025, documented by Staff K, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/10/2025 at 1600 [4:00 PM], was coded as 7 = sleeping.” Review of Resident #43’s MAR for the month of August 2025, documented by Staff L, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/17/2025 at 0800 [8:00 AM], was coded as 7 = sleeping.” During an interview on 08/27/2025 at 11:15 AM, Director of Nursing (DON) stated, There needs to be two nurses to pull a narcotic from the EDK [emergency drug kit]. Agency nurses do not usually have access to the EDK. If there were no other Riverwood staff in the building, the nurse should have called the on-call nurse. The on-call nurse can help them access the EDK. We have one phone number, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 6 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they always call the same number. Another option is that the medication also could have been ordered STAT (Latin for immediately) from the pharmacy. During an interview on 08/27/2025 at 1:36 PM, Staff A, LPN stated, I documented a 9 on [Resident #43's name] MAR because it was probably a time when his pain medication had run out and the script [prescription] hadn't been signed or faxed over. If the script isn't signed, we can't pull it out of the [name of electronic medication dispenser] because the pharmacy will not accept it without a signature. How the process works is we print out the script for the doctor to sign, it gets put into a book, and when the doctor comes in during the week, he signs them. The nurses are supposed to print the script when it is running low, and they are supposed to put it in the doctor's binder. Running out of medications happens a lot with agency nurses, they either don't know how to do the refills process, or they just don't want to. If one of my residents runs out of pain medication, and I can't get it, I usually call the doctor or give another PRN [as needed] pain medication if they have one ordered. I am not sure why I didn't document a note when [Resident #43's name] ran out of pain medication. I probably thought I wrote it and accidentally didn't save it, or I may have overlooked it because I was on the phone with the doctor. I did call the doctor and faxed over the script. They brought his pain medication on the next pharmacy run. I should have documented that I called the doctor. During an interview on 08/27/2025 at 1:51 PM, Staff B, LPN stated, “On the night of July 28th and July 29th [2025], I was the only nurse who could get into the EDK [emergency drug kit], and it takes two nurses with access to be able to pull narcotics. The only other staff working that night were agency nurses. I had authorization from the pharmacy for [Resident #43’s name] oxycodone, but there were no other staff that could get into the EDK. The facility does not have anyone on call for anything like that. I didn't call anyone, because there was no one to call. They knew I was the only staff in the building. I did not call the doctor; he couldn't have done anything. The medication didn't get refilled in time. The doctor has to do a new prescription. The prior nurse had called the pharmacy; the meds came the next day. I called the pharmacy when I couldn't get it out of the EDK. I told them I couldn't get it out, and they told me they couldn't help me. During an interview on 08/27/2025 at 2:33 PM, the Pharmacy Order Entry Technician stated “Stat deliveries are available to Riverwood, depending on what the medication is. Oxycodone and other common pain medications are available in the [name of automated medication dispensing machine]. If the nurse couldn’t access it or if it was absolutely necessary, we would stat it out. We have a minimum of a four hour turnaround for STAT runs, because we have to find a driver. We do three runs, one midday, which cuts off at 11:30 AM, an overnight run at 11:30 PM, and a sweep run that cuts off at 4:00 AM. Cut offs to get orders in for deliveries are 10:30 AM and 10:30 PM. If a nurse called and told us that they couldn't get oxycodone out for a patient, I don't know why the nurse would be told that we can't help. We would be able to send a stat run to the facility, although of course there is an additional cost to the facility. During an observation on 08/27/2025 at 2:44 PM, the DON logged into the automated medication dispensing machine, and showed the surveyor the emergency medications that are always available, which included oxycodone 5 mg tablets. During an interview on 8/28/2025 at 11:03 AM Staff C, LPN stated “I don’t normally hold scheduled meds when a resident is sleeping. I held [Resident #43’s name] oxycodone on August third [8/3/2025] because he didn’t have any in the card and there were no other staff in the facility to help me get it out of the [name of automated medication dispensing machine] and I don’t have access. For [Resident #85’s name], he didn’t have the Oxycodone available last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 7 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some night, it arrived on dayshift after I left. I don’t know what’s in the [name of automated medication dispensing machine], and last night we had the same staff, so we wouldn’t be able to get into the [name of automated medication dispensing machine] anyway. The supervisors should have been aware, the dayshift nurse told me the pain med wasn’t available during the day. I did not receive any education when I started working at Riverwood. If I had an issue, I would just call the DON. I did not call the DON when I couldn’t access the [name of automated medication dispensing machine], because one of her staff members called her and told her about it last night. The DON told me she would give me access to the [name of automated medication dispensing machine] going forward, even though I am agency.” During an interview on 08/28/2025 at 1:49 PM, Staff G, LPN stated, “I may have held [Resident #43’s name] oxycodone because he was running low on the medication and asked me to save the dose for later. The process when a patient is running low is to call pharmacy to see if a new prescription is needed. If a new one is needed, I call the doctor to get the prescription. If I can get the prescription from the doctor, I call pharmacy and get a verification code from the pharmacist. It takes two nurses to be able to pull meds from the [name of automated medication dispensing machine] if it is a narcotic. There have been some situations where I am the only nurse working in the facility that has access to the [name of automated medication dispensing machine]. When that happens, I call the pharmacy and see if they can send the medication stat. That is really the only option because there has to be two nurses, we can’t override it. To find out what medications are available in the [name of automated medication dispensing machine], I have to call the pharmacy and ask.” During an interview on 08/28/2025 at 12:28 PM, Dr. [NAME] stated Withdrawals could cause harm if a patient has been out of their narcotic pain medication for a long period of time, but it would take at least two days. I've been with [Resident #43's name] for a long period of time. He has chronic nausea .usually the nurses call me if [Resident #43's name] is out of pain medication or has missed a dose. Review of automated medication dispensing machine inventory log of medications to be available at all times, showed that oxycodone 5 mg tablets were stocked in the automated medication dispenser. Review of Medication Monitoring Control Record for oxycodone 5 mg tablet dated 7/22/2025 showed the last time oxycodone was signed out for Resident #43 was 7/27/25 at 4:00 PM, remaining oxycodone tablets were 0. Review of Medication Monitoring Control Record showed that the next time oxycodone 5 mg tablets were delivered from pharmacy for Resident #43 was on 7/29/2025. Review of staff education titled Pain Management Protocols read, Scripts should be printed and ready for the physician to sign before the card is empty, typically 7 days remaining….If a pain medication is unable to be retrieved through the [name of automated medication dispensing machine] or via stat delivery from the pharmacy, you must notify the physician and nurse manager or DON for review. 2. During an interview on 8/27/2025 at 3:06 PM, Resident #86 stated, My pain level is an 8 right now. When I ask for it, they bring me pain medicine. It helps some. They have brought it every time I asked, but I have to ask for it. Review of Resident #86’s admission record documented an admission date of 8/05/2022 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 8 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medical diagnoses including chronic pain syndrome, pain in left leg, pain in right leg, pain in left knee, pain in right knee, pain unspecified, restless legs syndrome, essential (primary) hypertension, and hyperlipidemia. Review of Resident #86’s physician order dated 11/15/2024 read, Percocet Oral Tablet 10-325 MG (Oxycodone with Acetaminophen milligram) Controlled Drug Give 1 tablet enterally every 6 hours for Chronic Pain Management. Please hold for lethargy. Review of Resident #86’s medication administration record (MAR) for June 2025, documented by Staff A, Licensed Practical Nurse (LPN), showed Percocet 10-325 mg tablet scheduled for 6/30/2025 at 1800 [6:00 PM] was coded as 9 = other/see nurses note.” Review of Resident #86”s electronic medication administration record (eMAR) progress note, authored by Staff A, LPN, dated 6/30/2025 at 17:27 [5:27 PM] read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for Chronic Pain Management, please hold for lethargy. Pharmacy has not arrived with medication. Review of Resident #86’s MAR for July 2025, documented by Staff E, LPN, showed Percocet 10-325 mg tablet scheduled for 7/1/2025 at 0000 [midnight] was coded as 9 = other/see nurses note.” Review of Resident #86’s eMAR progress note, authored by Staff E, LPN, dated 7/1/2025 at 01:37 AM read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management, please hold for lethargy. D/C [discontinue]. Review of Resident #86’s MAR for July 2025, documented by Staff E, LPN, showed Percocet 10-325 mg tablet scheduled for 7/1/2025 at 0600 [6:00 AM], 7/25/2025 at 0600 [6:00 AM] ,was coded as “9 = other/see nurses note.” Review of Resident #86’s eMAR progress note, authored by Staff E, LPN, dated 7/1/2025 at 05:19 [5:19 AM] read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management. please hold for lethargy. Review of Resident #86’s eMAR progress note, authored by Staff E, LPN, dated 7/25/2025 at 19:13 [7:13 PM] read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management, please hold for lethargy, resident with family. Review of Resident #86’s MAR for August 2025, documented by Staff D, LPN, showed Percocet 10-325 mg tablet scheduled for 8/5/2025 at 1200 [12:00 PM], 8/5/2025 at 1800 [6:00 PM] was coded as “5 = hold/see nurses note.” Review of Resident #86’s eMAR progress note, authored by Staff D, dated 8/5/2025 at 13:20 [1:20 PM], 8/5/2025 at 17:52 [5:52 PM read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management. please hold for lethargy. Review of Resident #86’s MAR for August 2025 showed the documentation for Percocet 10-325 mg tablet scheduled for 8/5/2025 at 0600 [6:00 AM] and 8/7/2025 at 1800 [6:00 PM] blank. Review of Resident #86’s progress notes documented no nursing notes to explain why the resident did not receive scheduled Percocet 10-325 mg tablet on 8/5/25 at 0600 [6:00 AM] and 8/7/2025 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 9 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 1800 [6:00 PM]. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/28/2025 at 10:15 AM, Staff E, LPN, stated, “I held [Resident #86’s name] Percocet in July because she refused it. She said it made her sleepy. Usually, I would write a note for that, so I am not sure why there wasn’t a note. Agency nurses don’t have access to the [name of automated medication dispensing machine], and they have mostly agency nurses in the building. You have to have two staff there to pull out narcotics with an authorization code. It has happened before where there weren’t two staff available to be able to pull medications out of the [name of automated medication dispensing machine]. If that happens we tell the supervisor, and they get it. There is an on-call number for supervisors, I have it in my phone. I have been working for them for a while, so I don’t remember how I originally got the phone number. I did receive an education packet when I first started, and I remember signing for it.” Residents Affected - Some During an interview on 8/28/2025 at 9:40 AM, Staff D, LPN, stated, “I remember [Resident #86's name], I held her Percocet on August 5th [8/5/2025] because she didn’t want it at the time, she wanted Tylenol instead. I don’t see that I put a note in. I probably was busy and forgot to document it. Normally I would put a note in. We are supposed to put a note in when a resident is refusing, or the medication is held. Review of policy and procedure titled, Pain Screening and Management reviewed 1/17/2025 read, Policy: It will be the policy of this facility to screen residents and attempt to provide effective pain and comfort management. Procedure: 3. Attempt to obtain physician's orders for pain management, if needed. 4. Administer pain medications according to physician's orders and resident request for PRN [as needed] medications. 3. During an interview on 8/28/2025 at 12:10 PM, Resident #85 stated that he had been told something about the facility being out of his pain medication, and that was why he had missed several doses. He has pain all the time and it had been worse over the past couple of days. Review of Resident #85's admission record documented an admission date of 12/06/2021 with medical diagnoses including nontraumatic compartment syndrome of abdomen (a painful condition that causes an increase in pressure inside a muscle which restricts blood flow), quadriplegia, C5-C7 (cervical spine 5 through cervical spine 7) incomplete (a medical condition which causes severe loss of function of the arms and legs), and chronic pain syndrome. Review of Resident #85’s care plan documented a focus that read, “The resident is on opioid (prescription pain medications) medication therapy r/t (related to) chronic pain with a goal that moderate to severe pain will be reduced to tolerable level. Interventions included administer analgesic (medications that relieve pain) medications as ordered by physician and monitor/document side effects and effectiveness Q-SHIFT (every shift). Review of Resident #85's consultation note read, “Pain Management 11-22-24, HPI (History of presenting illness): [Resident #85’s name] is a [AGE] year old male who was admitted to this facility in 2021 following acute care hospitalization for central cord syndrome. He was hit by a scooter while riding his bike and sustained multiple traumatic injuries to the head and neck. Hospital records reviewed….Plan of care: Plan of care discussed with the nursing team. Pain regimen as follows: Opioid or Narcotic Therapy - Oxycodone HCl (Hydrochloride) Oral Tablet 10 MG (milligram) Scheduled dose: 4 tablets/day = 40 mg/day; PRN (Latin for pro re nata meaning when necessary) dose: Up to 2 additional doses/day = 20 mg/day; Total maximum: 60 mg/day MME (morphine milligram (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 10 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 equivalents)/day: 60 mg oxycodone × 1.5 (conversion factor) = 90 MME/day.” Level of Harm - Minimal harm or potential for actual harm Review of Resident #85’s physician order dated 6/4/2025 read, “oxycodone HCl Oral Tablet 10 MG (milligrams) (Oxycodone HCl) Give 10 mg by mouth every 6 hours for chronic non-acute pain.” Residents Affected - Some Review of Resident #85's Medication Administration Record (MAR) for June 2025 scheduled doses for oxycodone HCl Oral Tablet 10 MG (milligrams) (Oxycodone HCl) Give 10 mg by mouth every 6 hours for chronic non-acute pain on 6/17/25 at 12:00 AM, and 6/27/25 at 12:00 PM were not documented as administered. Review of Resident #85’s progress notes for 6/17/2025 through 6/26/25 showed no documented notes regarding pain, pain medications, physician or pharmacy contact. Review of Resident #85's MAR for July 2025 schedule dose for oxycodone HCl Oral Tablet 10 MG (milligrams) (Oxycodone HCl) Give 10 mg by mouth every 6 hours for chronic non-acute pain on 7/26/25 at 12:00 AM was not documented as administered. Review of Resident #85’s progress notes for 7/26/25 showed no documented notes regarding pain, pain medications, physician or pharmacy contact. Review of Resident #85's MAR for August 2025 scheduled doses on 8/12/25 at 12:00 AM, 8/12/25 at 6:00 PM, 8/21/25 at 6:00 PM, 8/26/25 at 6:00 AM, 8/26/25 at 12:00 PM, 8/26/25 at 6:00 PM, 8/27/25 at 12:00 AM, and 8/27/25 at 6:00 AM were not documented as administered. Review of Resident #85’s progress note dated 8/26/2025 at 06:29 (6:29 AM) read, “e-Mar (electronic MAR) - General Note from e-Record Note Text: oxyCODONE HCl Oral Tablet 10 MG: Give 10 mg by mouth every 6 hours for Chronic non-acute pain awaiting pharmacy Review of Resident #85’s progress note dated 8/27/2025 at 00:54 (12:54 AM) read, “ e-Mar General Note from e-Record Note Text: oxyCODONE HCl Oral Tablet 10 MG: Give 10 mg by mouth every 6 hours for Chronic non-acute pain awaiting pharmacy delivery. Review of Resident #85’s progress notes dated 8/12/25 and 8/21/25 showed no notes regarding Oxycodone, pharmacy delays, or physician contact for pain medications. Review of the Medication Monitoring/Control Record form showed no record of available Oxycodone 10MG Tablets specifically for Resident #85 between the dates of 8/25/25 at 11:22 PM and 8/27/25 at 12:00 PM. During an interview on 8/27/2025 at 11:42 AM, the DON (Director of Nursing) stated that her expectation was that nurses administered medications as ordered, and if they were unable to administer the medication, they were to contact the physician and their supervisor or her. During an interview on 8/28/2025 at 10:42 AM, Staff D, LPN (Licensed Practical Nurse), stated that she held Resident #85's Oxycodone and marked 7 on the MAR on 8/21/25 at 6:00 PM because he appeared drowsy or lethargic, but she must have forgotten to document a note. During an interview on 8/28/2025 at 12:38 PM, Physician #1 stated that she did not recall being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 11 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some contacted earlier in the week regarding Resident #85's Oxycodone medication. If the facility had run out of the resident's prescribed Oxycodone, she thought they would obtain the necessary doses from their emergency supply until the pharmacy could refill the prescription. It was not her practice to hold a medication if the facility had run out of it. During an interview on 8/28/2025 at 1:37 PM, Staff O, LPN, stated that he was not sure whether he gave Resident #85's Oxycodone 10mg at 6:00 AM on 8/26/25. He wasn't sure why he would have documented a 9 in the EMR (electronic medical record). He had worked in the facility for a couple of months. He had not been provided any orientation or education to the facility… He didn't believe the facility had a (name of the automated medication dispensing machine), and if they did, he did not have access to it. During an interview on 8/28/2025 at 3:25 PM, Staff P, LPN, stated that she had worked in the facility one time. She did not recall Resident #85, or whether she had administered a dose of Oxycodone at 12:00 PM on 6/27/25. She had never had access to the (name of the automated medication dispensing machine) and did not receive any education or orientation from the facility. She was not provided with any information regarding an on-call nurse or a phone number for the DON (Director of Nursing). During an interview on 8/28/2025 at 3:42 PM, Staff Q, LPN, stated that she remembered Resident #85 and she believed that when she checked a 7 on 7/26/25 at midnight on his MAR, it was because he was sleeping, and she did not administer his scheduled dose of Oxycodone 10mg. She had not written a note or taken any other actions. There had been times when medications for her residents were not available. During an interview on 8/29/2025 at 12:46 PM, Staff R, LPN, stated that she remembered Resident #85 by name but did not recall taking care of him or any details regarding medication administration from 6/17/25. If she charted a 7 for his scheduled Oxycodone at midnight, she believed it would have been because he was sleeping, and she assumed that was sufficient documentation. She did not contact the doctor or take any other action steps. During an interview on 08/29/2025 at 2:10 PM, the Regulatory Compliance Consultant stated that they needed to ensure their residents received the care they needed, especially when it came to pain management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 12 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations, interviews, and record reviews, the facility failed to ensure that sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, including those employed through nurse staffing agencies, as identified through resident assessments and described in the plan of care. Findings include:1. During an interview on 8/28/2025 at 12:10 PM, Resident #85 stated that he had been told something about the facility being out of his pain medication, and that was why he had missed several doses. He has pain all the time and it had been worse over the past couple of days.Review of Resident #85's admission record documented an admission date of 12/06/2021 with medical diagnoses including nontraumatic compartment syndrome of abdomen (a painful condition that causes an increase in pressure inside a muscle which restricts blood flow), quadriplegia, C5-C7 (cervical spine 5 through cervical spine 7) incomplete (a medical condition which causes severe loss of function of the arms and legs), and chronic pain syndrome.Review of Resident #85's physician order dated 6/4/2025 read, oxycodone HCl Oral Tablet 10 MG (milligrams) (Oxycodone HCl) Give 10 mg by mouth every 6 hours for chronic non-acute pain. Review of Resident #85's Medication Administration Record (MAR) for June 2025 scheduled doses for oxycodone HCl Oral Tablet 10 MG (milligrams) (Oxycodone HCl) Give 10 mg by mouth every 6 hours for chronic non-acute pain on 6/17/25 at 12:00 AM, and 6/27/25 at 12:00 PM were not documented as administered.Review of Resident #85's progress notes for 6/17/2025 through 6/26/25 showed no documented notes regarding pain, pain medications, physician or pharmacy contact.Review of Resident #85's MAR for July 2025 schedule dose for oxycodone HCl Oral Tablet 10 MG (milligrams) (Oxycodone HCl) Give 10 mg by mouth every 6 hours for chronic non-acute pain on 7/26/25 at 12:00 AM was not documented as administered.Review of Resident #85's progress notes for 7/26/25 showed no documented notes regarding pain, pain medications, physician or pharmacy contact.Review of Resident #85's MAR for August 2025 scheduled doses on 8/12/25 at 12:00 AM, 8/12/25 at 6:00 PM, 8/21/25 at 6:00 PM, 8/26/25 at 6:00 AM, 8/26/25 at 12:00 PM, 8/26/25 at 6:00 PM, 8/27/25 at 12:00 AM, and 8/27/25 at 6:00 AM were not documented as administered.Review of Resident #85's progress note dated 8/26/2025 at 06:29 (6:29 AM) read, e-Mar (electronic MAR) - General Note from e-Record Note Text: oxyCODONE HCl Oral Tablet 10 MG: Give 10 mg by mouth every 6 hours for Chronic non-acute pain awaiting pharmacyReview of Resident #85's progress note dated 8/27/2025 at 00:54 (12:54 AM) read, e-Mar - General Note from e-Record Note Text: oxyCODONE HCl Oral Tablet 10 MG: Give 10 mg by mouth every 6 hours for Chronic non-acute pain awaiting pharmacy delivery.Review of Resident #85's progress notes dated 8/12/25 and 8/21/25 showed no notes regarding Oxycodone, pharmacy delays, or physician contact for pain medications.2. During an interview on 08/27/2025 at 11:10 AM, Resident #43 stated, I don't remember the exact date, but when I was waiting on my pain medicine last month, pharmacy didn't bring it for a long time, and I started going through withdrawals. I was sweating and nauseous. I had a lot of anxiety. I did go to the hospital the next day for chest pains, but I don't think it was related. I was told the chest pain was due to my muscle.Review of Resident #43's admission record documented an admission date of 4/22/2025 with medical diagnoses that included spinal stenosis, cervical region, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified fracture of right lower leg, central pain syndrome, and muscle spasm of back.Review of Resident #43's physician order dated 7/17/2025 read, OxyCODONE HCl (hydrochloride) Tablet 5 MG (milligram) Controlled Drug Give 1 tablet by mouth every 4 hours for Non acute pain.Review of Resident #43's MAR (medication administration record) for the month of July 2025, documented by Staff F, LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 13 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (licensed practical nurse), showed oxycodone 5 mg (milligram) tablet scheduled for 7/22/25 at 0000 (midnight), 7/22/25 at 0400 [4:00 am], 7/27/2025 at 2000 [8:00 PM], 7/28/2025 at 0000 [midnight], and 7/28/25 at 0400 [4:00 AM] was coded as 9 = other/see nurses notes.Review of #43's eMAR (electronic medication administration record) general note, authored by Staff F, LPN dated 7/22/2025 at 2:06 AM, read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain. waiting on pharmacy.Review of #43's eMAR general note, authored by Staff F, LPN dated 7/22/2025 at 5:02 AM, 7/27/2025 at 21:13 (9:13 PM), 7/28/2025 at 00:19 (12:19 AM), 7/28/2025 at 5:06 AM read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain.Review of Resident #43's MAR for the month of July 2025, documented by Staff G, LPN, showed oxycodone 5 mg tablet scheduled for 7/27/25 at 1600 [4:00 PM] was coded as 9 = other/see nurses note.Review of Resident #43's eMAR general note, authored by Staff G, LPN, dated 7/27/2025 at 17:18 (5:18 PM) read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain.Review of Resident #43's MAR for the month of July 2025, documented by Staff A, LPN, showed oxycodone 5 mg tablet scheduled for 7/28/2025 at 0800 [8:00 AM] and 7/28/2025 at 1200 [12:00 PM] was coded as 9 = other/see nurses note.Review of Resident #43's eMAR general note, authored by Staff A, LPN, dated 7/28/2025 at 10:38 AM and 7/28/2025 at 13:13 [1:13 PM], read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute painReview of Resident #43's MAR for the month of July 2025, documented by Staff B, LPN, showed oxycodone 5 mg tablet scheduled for 7/28/2025 at 2000 [8:00 PM] and 7/29/25 at 0000 [midnight] was coded as 9 = other/see nurses.Review of Resident #43's eMAR general note authored by Staff B, LPN dated 7/28/2025 at 21:42 [9:42 PM] and 7/29/2025 at 00:18 [12:18 AM] read, OxyCODONE HCl Tablet 5 MG Give 1 tablet by mouth every 4 hours for Non acute pain unable to retrieve from edk [emergency drug kit], no other staff in building all agency.Review of Resident #43's MAR for the month of July 2025 showed oxycodone 5 mg tablet scheduled for 7/29/2025 at 0400 [4:00 AM] had nothing documented on MAR for that time.Review of Resident #43's MAR for the month of August 2025, documented by Staff H, LPN, showed oxycodone 5 mg tablet scheduled for 8/2/2025 at 0400 [4:00 AM], was coded as 7 = sleeping.Review of Resident #43's MAR for the month of August 2025, documented by Staff C, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/3/25 at 0000 [midnight] was coded as 7 = sleeping.Review of Resident #43's MAR for the month of August 2025, documented by Staff J, LPN, showed oxycodone 5 mg tablet scheduled for 8/4/2025 at 0000 [midnight] was coded as 7 = sleeping.Review of Resident #43's MAR for the month of August 2025, documented by Staff K, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/10/2025, at 0800 [8:00 AM], was coded as 9 = other/see nurses.Review of Resident #43's MAR for the month of August 2025, documented by Staff K, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/10/2025 at 1600 [4:00 PM], was coded as 7 = sleeping.Review of Resident #43's MAR for the month of August 2025, documented by Staff L, LPN, showed oxycodone 5 mg tablet that was scheduled for 8/17/2025 at 0800 [8:00 AM], was coded as 7 = sleeping.3. During an interview on 8/27/2025 at 3:06 PM, Resident #86 stated, My pain level is an 8 right now. When I ask for it, they bring me pain medicine. It helps some. They have brought it every time I asked, but I have to ask for it.Review of Resident #86's admission record documented an admission date of 8/05/2022 with medical diagnoses including chronic pain syndrome, pain in left leg, pain in right leg, pain in left knee, pain in right knee, pain unspecified, restless legs syndrome, essential (primary) hypertension, and hyperlipidemia.Review of Resident #86's physician order dated 11/15/2024 read, Percocet Oral Tablet 10-325 MG (Oxycodone with Acetaminophen milligram) Controlled Drug Give 1 tablet enterally every 6 hours for Chronic Pain Management. Please hold for lethargy.Review of Resident #86's medication administration record (MAR) for June 2025, documented by Staff A, Licensed Practical Nurse (LPN), showed Percocet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 14 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10-325 mg tablet scheduled for 6/30/2025 at 1800 [6:00 PM] was coded as 9 = other/see nurses note.Review of Resident #86s electronic medication administration record (eMAR) progress note, authored by Staff A, LPN, dated 6/30/2025 at 17:27 [5:27 PM] read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for Chronic Pain Management, please hold for lethargy. Pharmacy has not arrived with medication.Review of Resident #86's MAR for July 2025, documented by Staff E, LPN, showed Percocet 10-325 mg tablet scheduled for 7/1/2025 at 0000 [midnight] was coded as 9 = other/see nurses note.Review of Resident #86's eMAR progress note, authored by Staff E, LPN, dated 7/1/2025 at 01:37 AM read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management, please hold for lethargy. D/C [discontinue].Review of Resident #86's MAR for July 2025, documented by Staff E, LPN, showed Percocet 10-325 mg tablet scheduled for 7/1/2025 at 0600 [6:00 AM], 7/25/2025 at 0600 [6:00 AM] ,was coded as 9 = other/see nurses note.Review of Resident #86 eMAR progress note dated 7/1/2025 at 01:37 read, [1:37 AM] Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for Chronic Pain Management Please hold for lethargy D/C [discontinue] documented by Staff E, LPN.Review of Resident #86 MAR for July 2025 showed the Percocet 10-325 mg tablet that was scheduled for 7/1/2025 at 0600 [6:00 AM] was coded as 9 other/see nurses note by Staff E, LPN.Review of Resident #86's eMAR progress note, authored by Staff E, LPN, dated 7/1/2025 at 05:19 [5:19 AM] read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management. please hold for lethargy.Review of Resident #86's eMAR progress note, authored by Staff E, LPN, dated 7/25/2025 at 19:13 [7:13 PM] read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management, please hold for lethargy, resident with family.Review of Resident #86's MAR for August 2025, documented by Staff D, LPN, showed Percocet 10-325 mg tablet scheduled for 8/5/2025 at 1200 [12:00 PM], 8/5/2025 at 1800 [6:00 PM] was coded as 5 = hold/see nurses note.Review of Resident #86's eMAR progress note, authored by Staff D, dated 8/5/2025 at 13:20 [1:20 PM], 8/5/2025 at 17:52 [5:52 PM read, Percocet Oral Tablet 10-325 MG Give 1 tablet enterally every 6 hours for chronic pain management. please hold for lethargy.Review of Resident #86's MAR for August 2025 showed the documentation for Percocet 10-325 mg tablet scheduled for 8/5/2025 at 0600 [6:00 AM] and 8/7/2025 at 1800 [6:00 PM] blank.Review of Resident #86's progress notes documented no nursing notes to explain why the resident did not receive scheduled Percocet 10-325 mg tablet on 8/5/25 at 0600 [6:00 AM] and 8/7/2025 at 1800 [6:00 PM]. During an interview on 08/27/2025 beginning at 11:15 AM, Director of Nursing (DON) stated, There needs to be two nurses to pull a narcotic from the EDK [emergency drug kit]. Agency nurses do not usually have access to the EDK. She was unaware of what was covered in their agreement with the staffing agency regarding the skill set of contract staff. She was pretty sure there were competencies they had to complete. For the agency staff that worked with them a lot, they would include them in their in-service training. She was not sure how they ensured the work assigned to contract staff was within their skill set. She was unsure whether ongoing training was provided for all staff, (permanent, temporary/contracted, etc.). During an interview on 08/27/2025 at 12:29 PM, the ADON (Assistant Director of Nursing) stated, I have not given [name of automated medication dispensing machine] access to any of the nurses. I just was given permission to give [name of medication dispensing machine] access. I cannot confirm or deny any restrictions for agency nurse access. A lot of the time, we see 'med not available' on night shift [as the reason a medication was not given].During an interview on 08/27/2025 at 1:36 PM, Staff A, LPN stated, I documented a 9 on [Resident #43's name] MAR because it was probably a time when his pain medication had run out and the script [prescription] hadn't been signed or faxed over. If the script isn't signed, we can't pull it out of the [name of electronic medication dispenser] because the pharmacy will not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 15 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some accept it without a signature. Running out of medications happens a lot with agency nurses, they either don't know how to do the refills process, or they just don't want to.During an interview on 08/27/2025 at 1:51 PM, Staff B, LPN stated, On the night of July 28th and July 29th [2025], I was the only nurse who could get into the EDK [emergency drug kit], and it takes two nurses with access to be able to pull narcotics. The only other staff working that night were agency nurses. I had authorization from the pharmacy for [Resident #43's name] oxycodone, but there were no other staff that could get into the EDK. The facility does not have anyone on call for anything like that. I didn't call anyone, because there was no one to call. They knew I was the only staff in the building. I did not call the doctor; he couldn't have done anything. The medication didn't get refilled in time. The doctor has to do a new prescription. The prior nurse had called the pharmacy; the meds came the next day. I called the pharmacy when I couldn't get it out of the EDK. I told them I couldn't get it out, and they told me they couldn't help me. During an interview on 8/27/2025 at 2:02 PM, the staffing coordinator stated that staffing levels are determined by census. When asked about call ins and unanticipated staffing shortages she stated, I send messages out to staff or call agency staff. I don't deal with the competencies. The agency staff is educated by the agency. No one in particular is responsible for confirming their competencies.During an interview on 8/28/2025 at 11:03 AM Staff C, LPN stated I don't normally hold scheduled meds when a resident is sleeping. I held [Resident #43's name] oxycodone on August third [8/3/2025] because he didn't have any in the card and there were no other staff in the facility to help me get it out of the [name of automated medication dispensing machine] and I don't have access. For [Resident #85's name], he didn't have the Oxycodone available last night, it arrived on dayshift after I left. I don't know what's in the [name of automated medication dispensing machine], and last night we had the same staff, so we wouldn't be able to get into the [name of automated medication dispensing machine] anyway. The supervisors should have been aware, the dayshift nurse told me the pain med wasn't available during the day. I did not receive any education when I started working at [the facility's name].During an interview on 8/28/2025 at 1:37 PM, Staff O, LPN, stated that he had not been provided with any orientation or education to the facility, only the information posted through his agency. He worked for [Nurse Staffing Agency's Name], and said, Let me check now what is posted. It says to clock in at the beginning of the shift, take a 30-minute break, and clock out at the end of the shift. He didn't believe the facility had a [name of automated medication dispensing machine], and if they did, he did not have access to it.During an interview on 8/28/2025 at 1:49 PM Staff G, LPN stated, I may have held [Resident #43's name] oxycodone because he was running low on the medication and asked me to save the dose for later. It takes two nurses to be able to pull meds from the [name of automated medication dispensing machine] if it is a narcotic. There have been some situations where I am the only nurse working in the facility that has access to the [name of automated medication dispensing machine]. When that happens, I call the pharmacy and see if they can send the medication stat. That is really the only option because there has to be two nurses, we can't override it. To find out what medications are available in the [name of automated medication dispensing machine], I have to call the pharmacy and ask.During an interview on 8/28/2025 at 3:25 PM, Staff P, LPN, stated that she had worked in the facility one time. She had never had access to the [name of the automated medication dispensing machine] and did not receive any education or orientation from the facility. She was not provided with any information regarding an on-call nurse or a phone number for the DON. During an interview on 08/29/2025 at approximately 11:30 AM, the Regional Regulatory Compliance Consultant stated that they had not heard back from the Customer Service Representative from [Nurse Staffing Agency's Name], and they were not able to provide any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 16 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete confirmation that the agency staff members had received any orientation or education regarding the facility.During an interview on 8/29/2025 at 12:46 PM, Staff R, LPN, stated that she believed she was in the position of the Night Shift Supervisor on 6/17/25. To the best of her knowledge, the agency nurses really were not oriented or educated to the processes in the facility. She had been under the impression that the agency nurses were not provided with access to the [automated medication dispensing machine]. There were times when there was only 1 regular staff nurse on, and the others were all agency nurses.Review of the packet titled, Education Packet, provided to agency staff, both nurses and CNAs, included a cover page that read, I, acknowledge and understand that I am required to read and refer to the following handouts: Preventing/Minimizing injury during resident transfers; Gait/Transfer belts; Accident prevention and body mechanics; Resident's Rights; The club policy prohibiting abuse, neglect, and misappropriation; Alzheimer's disease and related dementias; 12 Steps to prevent antimicrobial resistance among LTC residents; Blood and body fluids exposure policy; Work practices policy; Hand washing/hand hygiene policy; Exposure reporting and investigating policy; Standard precautions policy; Employee's notice of reportable conditions; Time and attendance policy; Risk Management; HIV/AIDS - Page 1 of 45 There was no page 2. Each of the above listed policies were in the packet, all running together as one continuous document. There was no attestation page included in the packet. During an interview on 8/29/25 at 9:08 AM, the DON stated that she was not able to provide any attestation statements from the agency nurses working in the facility to demonstrate receipt and understanding of the education packet provided to them by the facility. The documents provided by the DON representing the process for booking staff from the [Nurse Staffing Agency's name] agency were reviewed. Included were a document titled, Workplace Rules Quiz (Pre-booking Quizzes) FAQs [frequently asked questions] that read, This feature is available to all Long Term Care facilities and Schools, as well as select other facilities. What is this? When professionals book a shift at your workplace for the first time they'll be required to read the rules and expectations that your workplace has shared in the Workplace Rules Quiz section. The rules you enter will be used to automatically generate a customized quiz for your workplace. Professionals must then pass the quiz before they are eligible to book a shift at your workplace. A document titled, Workplace Quiz, contained 5 questions, with multiple choice options for responses. It read, 1. Where should you report a fall incident? 2. Where is the timeclock located? 3. What must employees review on their first shift? 4. Who should be contacted for a change of condition or medication access issues? 5. Where is parking located for the building?There were no similar quizzes provided for the other 2 agencies utilized by the facility for staffing. During an observation on 08/29/2025 at 11:40 AM there was a binder at the nurses' station for the 100, 200, and 300 halls; it was titled, Agency Education. It contained the packet titled, Education Packet. It did not contain any telephone numbers or any information regarding the processes for accessing the automated medication dispensing system, contacting the Pharmacy to obtain access, or contacting the on-call manager or the DON. There were some guidelines for certain situations, such as 'Change in Condition,' and 'Resident Transfer' in the front of the Narcotic Medication binder. There was a sheet that listed telephone numbers for some support services or vendors, such as radiology. There was a section that listed telephone numbers for administrative staff, such as the Administrator and the Director of Nursing, but they were not current. The names and telephone numbers were from previous personnel, not any of the current management team members. Event ID: Facility ID: 105488 If continuation sheet Page 17 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the nurse staffing data was posted on a daily basis. Findings include:During an observation on 8/25/2025 at approximately 9:00 AM, the Daily Nursing Staffing Form, was dated August 22, 2025. (photographic evidence)During an interview on 8/28/2025 at approximately 8:45 AM, the DON (Director of Nursing) stated that the Staffing Coordinator was responsible for posting the daily staffing report. On the weekend, it was the Weekend Receptionist's responsibility to post the staffing report. Her expectation was that the staffing report would be posted 1st thing in the morning.During an interview on 8/28/2025 at 8:50 AM, the Staffing Coordinator stated that on Fridays she put the staffing reports up for Friday, and places the Saturday and Sunday reports behind it. The Weekend Receptionist switches them out each day. She puts the staffing report up daily before day shift starts at 6:45 [AM]. She confirmed that the correct staffing report was not posted at 9:00 AM on Monday. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 18 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure food products were stored and maintained in a safe and sanitary manner in 2 of 2 nourishment rooms. Findings include:During an observation of nourishment room [ROOM NUMBER] on 8/25/2025 at 9:32 AM, there were 5 chocolate milks with an expiration date of 8/21/2025 in the bottom drawer of the refrigerator. There was a Tupperware container and a bag of sandwiches that were undated and unlabeled.During an interview on 8/25/2025 at 9:32 am, the Certified Dietary Manager in training stated that she was unaware of who is responsible to ensure all food is dated and labeled in the nourishment rooms.During an observation of nourishment room [ROOM NUMBER] on 8/25/2025 at 9:40 AM, there was a 20 ounce cup half full of liquid that was unlabeled and undated and there were two fortified nutritional shakes that were undated.During an interview on 8/28/2025 at 2:42 PM, the Administrator stated, Nursing staff should be responsible for dating/labeling food items in the refrigerators/freezers in the nourishment rooms for residents and visitors. The kitchen is responsible for dating the shakes. During an interview on 8/28/2025 at 2:34 PM, the Regional Food Service Manager stated, t we [dietary] are responsible for cleaning the refrigerators/freezers in the nourishment rooms daily and the facility is responsible for dating and labeling food items.Review of the policy titled Food: Safe Handling for Food from Visitors, last review 8/1/2025, read, Policy Statement: Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. 4. When food items are intended for later consumption, the responsible facility staff member will: ensure that the food is stored separate or easily distinguishable from the facility, ensure that food are in a sealed container to prevent cross contamination, label foods with the resident name and current date. Event ID: Facility ID: 105488 If continuation sheet Page 19 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 observation, interview and record review the facility failed to accurately and completely document resident information in the medical record for 1 (Resident #122) of 3 closed records reviewed.Findings include:Review of the admission record for Resident #122 documented an admission date of [DATE] with diagnosis that included essential (primary) hypertension, iron deficiency anemia unspecified, pain unspecified, other specified depressive episodes, heart failure unspecified, constipation unspecified, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, schizoaffective disorder bipolar type, anemia in other chronic diseases classified elsewhere, deficiency of other specified b group vitamins, other specified disorders of bone density and structure unspecified site, personal history of covid-19, tachycardia unspecified, tremor unspecified, and anxiety disorder unspecified. Review of Resident #122's nursing progress notes on [DATE] showed there was no documentation of resuscitation efforts, no progress notes, and no documentation of Resident #122's death in the facility.Review of Resident #122's form titled, SNF (skilled nursing facility)/NF(nursing facility) to Hospital Transfer Form dated [DATE] at 07:47 (7:47 AM) read, Report called into [NAME] County EMS (Emergency Medical Services).During an interview on [DATE] at 11:14 AM, Staff Q, Registered Nurse (RN) stated, I had a page code to the front in room [ROOM NUMBER]. When I got there, they were already doing CPR (cardiopulmonary resuscitation) and ambuing (commonly refers to meaning using an ambu bag to provide air to a person who is not breathing) at the time. We continued until EMS arrived, they take over once they get here. He was pronounced dead by EMS while he was here. There are code documentation sheets that document what happens. The form was completed and I gave it to the DON (Director of Nursing). He (Resident #122) was not transferred to the hospital.During an interview on [DATE] at 11:17 AM, Staff R, RN stated, I had responded to the code and assisted [Nurses name] with compressions (performing CPR). EMS arrived and pronounced the resident. We should have a detailed note in the chart about what happened. He (Resident #122) was not transferred to the hospital he was pronounced here. EMS left and we do the rest.During an interview on [DATE] at 11:50 AM, the Director of Nursing (DON) stated we do not have any code sheet documentation. We checked medical records, there isn't one we can find. There should be a note in his record that he was coded and expired after EMS came.Review of the policy and procedure titled, Charting and Documentation last approval date of [DATE] read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure:1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical record. 2. Incidents, accidents, or changes in the resident's condition should be recorded in the clinical record. 3. Entries into the clinical record should be made by the appropriate staff members. Staff providing care and services to the resident may contribute to the overall documentation in the clinical record in accordance with state and federal laws. Event ID: Facility ID: 105488 If continuation sheet Page 20 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 Based on observation, interview, and record review and policy and procedure review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions, failed to perform hand hygiene when administering medications in 7 of 11 observations of medication administration, when obtaining vital signs and when caring for respiratory care equipment to prevent the possible spread of infection and communicable diseases.Findings include: Residents Affected - Some 1.During an observation on 8/25/2025 at 1:40 PM, Resident #28 was observed sitting in bed with a right upper arm midline catheter with gauze under transparent dressing dated 8/18/2025. There was a completed Intravenous (IV) bag of antibiotics attached to the midline. There was enhanced barrier precaution signage on the doorway and available PPE (personal protective equipment) in the hallway. Staff O, Licensed Practical Nurse (LPN) entered the residents room to flush the midline catheter. Staff O did not don a gown, without performing hand hygiene Staff O, donned gloves and administered 10 milliliters of normal saline flush and did not clean the hub of the needleless connector. After removing the IV tubing, the hub of the needless connector fell onto the bed linens and residents arm. Staff O, LPN, removed gloves and returned to medication cart without performing hand hygiene and began to prepare medications for another resident. Review of Resident #28’s admission record documented diagnosis that include aftercare following joint replacement surgery, presence of right artificial knee joint, disruption or dehiscence of closure of other unspecified internal operation surgical wound, subsequent encounter, and infection and inflammation reaction due to internal fixation device of other sites subsequent encounter. Review of Resident #28's comprehensive care plan documented a focus: “Resident is at risk for infection and enhanced barrier precautions (EBP) are indicated due to: Indwelling medical devices with interventions that included employ enhanced barrier precautions when performing high contact resident care (dressing, bathing, transferring in room/shower/therapy, personal hygiene assistance, changing linens, changing briefs, toileting, device care, wound care, therapy services). During an interview on 8/25/2025 at 2:01 PM, Staff O), LPN, stated, “I did not wash my hands before I put on the gloves. He [Resident #28] is on enhanced barrier precautions because of his line. I thought I didn't need to put on a gown. I guess I should have done that.” 2. During an observation on 8/27/2025 ending at 7:09 AM, Staff S, Certified Nursing Assistant (CNA) performed incontinence care on Resident #10 without gown, signage for enhanced barrier precautions was on the door and PPE (personal protective equipment) supplies were in hallway. Staff S, CNA entered the room with supplies, donned gloves without performing hand hygiene, provided care, removed gloves and exited room without performing hand hygiene. During an interview on 8/27/2025 at 7:15 AM ,Staff S, CAN, stated, “I should have put a gown on, I thought I did use hand sanitizer.” 3. During an observation on 8/27/2025 at 7:12 AM, Staff T, CNA, entered Resident #10’s room, obtained vital signs without performing hand hygiene and without putting on a gown. Staff T, CAN, left the residents room at 7:14 AM and went to med cart without performing hand hygiene. Staff T, CAN, returned to Resident #10’s room without performing hand hygiene and rechecked blood pressure and exited the residents room without performing hand hygiene and went to another residents room to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 21 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 obtain a blood pressure. On 8/27/2025 at 7:20 AM, Staff T, CAN, entered Resident #16’s room without performing hand hygiene and obtained blood pressure on Resident #16. Staff T assisted resident to reposition and took residents blood pressure, exited the room without performing hand hygiene. On 8/27/2025 at 7:25 AM, Staff T, CNA, entered Resident #63’s room without performing hand hygiene and obtained a blood pressure on the resident and exited the room without performing hand hygiene. On 8/27/2025 at 7:27 AM, Staff T, CNA, entered Resident #23’s room without performing hand hygiene, obtained residents blood pressure and exited the room without performing hand hygiene. During an interview on 8/27/2025 at 8:10 AM, Staff T, CNA, stated, “I didn't realize that I didn't use hand sanitizer, I should have.” 4. During an observation of medication administration on 8/28/2025 at 5:05 AM, Staff U, LPN, wheeled medication cart down hallway, retrieved keys from their pocket, unlocked the medication cart, activated and typed on the computer and prepared medication without performing hand hygiene, entered Resident #38’s room without performing hand hygiene, touched bed controls, administered medication and exited the room returning to the medication without performing hand hygiene. 5. During an observation of medication administration on 8/28/2025 at 5:13 AM Staff U, LPN, returned to medication cart, retrieved keys from their pocket, unlocked the medication, activated and typed on the computer, and prepared medications without performing hand hygiene. Staff U, LPN, entered Resident #113’s room without performing hand hygiene, removed a bipap (bilevel positive airway pressure) mask from the resident, adjusted the bed control to a higher position and administered the oral medications without performing hand hygiene, donned gloves without performing hand hygiene, prepared the nebulized medications and adjusted the face mask on Resident #113, doffed gloves and exited the room returning to the medication cart without performing hand hygiene and began preparing medications for another resident. 6. During an observation of medication administration on 8/28/2025 at 5:16 AM, Staff U, LPN, removed keys from pocket, unlocked the medication cart, activated and typed on computer keyboard, prepared medications for Resident #85, unlocked narcotic drawer with keys, signed narcotic out on the sheet without performing hand hygiene. Staff U, LPN, entered Resident #85’s room without performing hand hygiene, touched a specialty cup that was positioned on the floor with a long straw that resident used, administered the medication and exited the room without performing hand hygiene and went to the medication cart and began to prepare medications for another resident. During an interview on 8/28/2025 at 7:15 AM, Staff U, LPN, stated, “I should have used hand sanitizer more.” 7. During an observation of medication administration on 8/28/2025 at 5:25 AM, Staff W, LPN, donned gloves without performing hand hygiene and obtained Resident #14’s blood pressure, doffed gloves without performing hand hygiene and returned to the medication cart, removed keys from their pocket, unlocked the medication cart, activated and typed on the computer keyboard and prepared medications. Staff donned gloves without performing hand hygiene, did not don gown, entered Resident #14’s room and administered gastrostomy tube medications after verifying placement. Staff W, LPN removed gloves without performing hand hygiene and returned to the medication cart to administer another residents medications. 8. During an observation of medication administration on 8/28/2025 at 5:43 AM, Staff W, LPN, removed keys from their uniform pocket and unlocked the medication cart, activated the computer and typed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 22 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 on the keyboard without performing hand hygiene. Staff W, LPN, prepared medications and entered Resident #115’s room without performing hand hygiene, administered the medication and exited the room without performing hand hygiene returning to the medication cart and began preparing medications for another resident. 9. During an observation of medication administration on 8/28/2025 at 5:51 AM, Staff W, LPN, returned to the medication cart without performing hand hygiene, removed keys from their uniform pocket and unlocked the medication cart, activated the computer and typed on the keyboard without performing hand hygiene. Staff W, LPN donned gloves, and prepared medications, entered Resident #103’s room with gloves, removed gloves, donned new gloves without performing hand hygiene, administered oral medications and doffed gloves, donned new gloves without performing hand hygiene, obtained blood sample for blood sugar, doffed gloves and returned to medication without performing hand hygiene. Staff W, LPN, removed keys from their uniform pocket, unlocked the medication cart, activated and typed on keyboard of computer, and attempted to find insulin but was unable to locate in medication cart. Staff W locked the medication cart went to and unlocked medication room, unlocked the medication refrigerator, obtained Resident #103’s insulin returned to the medication cart, prepared the insulin, donned gloves without performing hand hygiene. Staff W, LPN, entered Resident #103’s room, administered the insulin in the left arm, doffed gloves, and returned to the medication cart without performing hand hygiene and began to prepare medications for another resident. 10. During an observation of medication administration on 8/28/2025 at 6:00 AM, Staff P, LPN, donned gloves without performing hand hygiene, assembled supplies entered the Resident #114’s room without donning gown, removed intravenous tubing from the midline catheter, cleansed the needleless connector with alcohol and provided a 10 milliliter (ML) flush. Staff P, LPN, doffed gloves without performing hand hygiene and returned to the cart and began to prepare medications for another resident. During an interview on 8/28/2025 at 6:10 AM Staff P, LPN stated, “I don't think I would have changed anything that I did during this observation. Well, I put on gloves, and I did the flush. I don't think that I need to put on a gown. I don't think she is on enhanced barrier precautions (EBP). I don't know what the rules for the EBP are. I don't think that I'm supposed to use a gown. I should have used hand sanitizer, I don't know why I didn't. Review of the policy and procedure titled “ Enhanced Barrier Precautions” last revision date of 8/1/2025, read, “Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or target multidrug-resistant organisms (MDRO). Procedure: 2. Initiation of Enhanced Barrier Precautions - b. An order for enhanced barrier precautions will be obtained for residents with any of the following: ii. Indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ ventilator,. etc.) regardless of MDRO status colonization status. 4. For residents for whom EBP are indicated, EBP is employed when performing the high-contact resident care activities: g. Device care or use: central lines…” Review of Policy and Procedure titled, “ Hand hygiene” last revision date of 8/1/2025 read, “Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 2. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. 5. Use an alcohol-based hand rub containing at least 62 % alcohol; or alternatively, soap (antimicrobial or non antimicrobial) and water for the following situations. B. Before and after direct contact with residents. C. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 23 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 Before preparing or handling medications: e. Before and after handling an invasive device (e.g. urinary catheters, IV access sites); After contact with residents intact skin; l. After contact with objects (medical equipment) in the immediate vicinity of the resident; m. After removing gloves. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.” 11. During an observation of Resident #38’s room on 8/25/25 at 8:30 AM, the oxygen concentrator next to his bed had the water humidification bottle sitting on the floor connected to concentrator. (photographic evidence obtained) During an interview on 8/26/25 on 8:53 AM, the Infection Preventionist stated that the water humidification bottle should not be on the floor. 12. During an observation on 8/27/2025 at 8:27 AM, Staff M, CNA, took a breakfast tray into Resident #26’s room, asked if she was ready to eat and proceeded to close the door. She did not perform hand hygiene before entering the room or before assisting Resident #26 with her breakfast. During an observation on 8/27/2025 at approximately 8:40 AM, Staff M, CNA, picked up Resident #26's breakfast tray, returned it to the food cart, removed another resident's tray, without performing hand hygiene, and carried the tray into Resident #94’s room. During an interview on 8/27/2025 at 8:45 AM, Staff M, CNA, stated that she knew she was supposed to wear gloves all the time and sanitize [her hands] before and after performing patient care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 24 of 25 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 105488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverwood Healthcare & Rehabilitation Center 808 S Colley Rd Starke, FL 32091 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call device was within reach for 1 (Resident #6) out of 8 residents evaluated for call device accessibility. During an observation on 08/25/2025 at 10:14 am Resident #6 was observed laying on his back, on a pad in bed, wearing nothing except a brief.The call device was hanging on the wall on the side of the resident's feet, not in reach.During an observation on 08/25/2025 at 10:26 AM Resident #6 was observed laying in the same position, on his back in bed, wearing nothing but a brief, with no call device in reach. No blankets on the bed. The overbed table containing the breakfast tray was in the same position, over the bed in the area of the resident's lap.During an observation on 08/25/2025 at 11:00 AM Resident #6 was laying in bed on his back, wearing only a brief. There was a fitted sheet and a pad on the bed, with no blankets. The breakfast tray was removed, and the over bed tablet was on the side of the bed. The call device was hanging on the wall on the left side of the resident's feet, not in reach. During an observation on 08/26/2025 at 9:04 AM Resident #6 was observed laying on his back in bed, dressed in a gown, with a blanket on. The resident appeared well-groomed, and his beard contained a white flaky substance. The call device was hanging on the wall by his feet, not in reach. During an observation on 08/27/2025 at 8:22 AM Resident #6 was observed laying flat in bed on his back, dressed in a gown, with a blanket on. The call device was on the floor at the foot of the bed. During an observation on 08/27/2025 at 8:37 AM, Resident #6 was observed sitting up in bed eating breakfast consisting of hash browns, oatmeal, and biscuits with gravy. There was a clear plastic cup containing a yellow liquid. The call device was on the floor at the foot of the bed. During an interview on 08/28/2025 at 2:48 AM, The Director of Nursing confirmed that Resident #6 should have had his call device within reach. I expect the staff to place the call devices in reach of the residents at all times. Review of Resident #6 care plan dated 6/19/2025 read, Focus: ADL [activities of daily living] CARE PLAN: The resident has an ADL/self-care performance deficit r/t ADL needs and participation may vary, cognitive impairment. Interventions:.Encourage to use call bell for ADL assist. Review of policy and procedure titled, Call Lights, reviewed 1/17/2025 read, Policy: It will be the policy of this facility to respond to the resident's requests and needs via notification with the call light system.4. When the resident is in bed or confined to a chair, the call light should be within easy reach of the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105488 If continuation sheet Page 25 of 25