Inspection·March 3, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were free from medical neglect. The facility failed to ensure licensed practical nurses had the appropriate skills and competency to administer intravenous (IV) medication via central line access devices for 1 of 1 residents, Resident #197. The lack of IV certification and validation of competency for IV medication administration can result in an increased risk of infection, damage to veins and the injection sites, an air embolism (a blood vessel blockage cause by one or more bubbles of air or other gas in the circulatory system), phlebitis (inflammation of a vein), and blood clots. The lack of training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into patients' vein) can increase the spread of infection and can result in the likelihood of increased harm and/or death. Findings include: During an observation on [DATE] at 9:03 AM Resident #197 was in his room lying in bed. There is a double lumen peripherally inserted central catheter (PICC) covered with a transparent dressing observed to the resident's upper right arm. The transparent dressing was dated [DATE] written with a black marker. During an interview on [DATE] at 9:04 AM Resident #197 stated, I have this IV [intravenous catheter] for antibiotics to treat the infection I have in my big toe. Review of Resident #197's admission record documented the resident was admitted to the facility on [DATE] with a diagnosis including paroxysmal atrial fibrillation (irregular heart rhythm, osteomyelitis of ankle and foot (infection of the bone), cerebral aneurysm (a weak or think spot on an artery in the brain), depression, heart failure unspecified, and type 2 diabetes mellitus. Review of the physician order report for [DATE] through [DATE] documented an order dated [DATE] for Resident #197 that read, Normal Saline Flush [sodium chloride 0.9% flush] syringe; amt [amount to administer]: 10 ml [milliliters]; injection. Special Instructions: Flush before and after each IV medication administration. Every shift. [Dated] [DATE] Meropenem recon soln [reconstituted solution]; 1 gram; amt]: 1 gram; intravenous. Dx [diagnosis]: Other [osteomyelitis, ankle and foot]. Every 8 hours. [Dated] [DATE] Vancomycin recon soln; 1.25 gram; amt: 1.25 gram; intravenous. Dx Other [osteomyelitis, ankle and foot]. Once a day. Review of the Medication Administration History for Resident #197 documented Staff A, License Practical Nurse (LPN), administered 10 ml of sodium chloride 0.9% before and the administration of Meropenem 1 gram on [DATE] at 3:32 PM and on [DATE] at 2:00 PM. Review of the Medication Administration History for Resident #197 documented Staff G, LPN, administered 10 ml of sodium chloride 0.9% before and after the administration of the IV medication Meropenem 1 gram reconstituted solution on [DATE] at 11:56 PM, [DATE] at 10:00 PM, [DATE] at 6:00 AM, [DATE] at 10:00 PM and [DATE] at 6:00 AM. Dated [DATE] Staff G, LPN administered 1.25 grams of Vancomycin reconstituted solution IV on [DATE] at 5:31 AM. During an interview on [DATE] at 10:09 AM the Director of Nursing (DON) stated, We have no IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 2 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few certification records for Staff A, LPN. He was contacted and cannot produce a certification. If the MAR [Medication Administration Record/Medication Administration History] is initialed by a nurse, it means the medication was given by that nurse unless if there is parenthesis which means they made a note. The Staff Developer and Human Resources are responsible for verification of staff certification. During the interview a request was made for the IV Certification for Staff G. During an interview on [DATE] at 10:30 AM Staff C, Unit Manager LPN, stated, LPNs need to have IV certification. The Human Resource staff and Staff Development is responsible for making sure staff have all certifications upon hire. During an interview on [DATE] at 10:41 AM Staff A, LPN, stated, Yesterday I helped administer medication. The Assistant Director of Nursing was in the room with me. I hung medication, flushed, and cleaned the port. I was supervised. I am always supervised by an RN [Registered Nurse]. The facility did not request IV certification from me upon hire. I did not know I needed IV certification. I have done IV medication administration before. I do not know how to place an IV in an arm [to insert an IV] but I know how to hang medication. When I was hired, I was trained and shown how to administer medication via IV. The first time the nurse showed me [how to administer IV medications]. After that, she has always supervised me doing the administration and flushes. The RN is always with me at all times. Normally I will do it and chart under my name since he is my resident. During an interview on [DATE] at 12:55 PM the Human Resource/ABOM (Assistant Business Office Manager) stated, The IV certification would be kept in the employee file only if provided, it is not requested. During an interview on [DATE] at 12:55 PM the Staffing Coordinator stated, Staff is assigned to halls. I leave it up to the nursing staff to tell me if they are capable or not of treating the resident. I hold a CNA [Certified Nursing Assistant] license. I am aware that the RN is the only one who is able to do PICC lines. I do not have copies of all the nurses' certifications. I am the only one who schedules. The head nursing department is responsible to verify certifications. I assume that all the credentials have been verified by the head of nursing. We do not have a 24-hour RN on the schedule. From 7 PM to 7 AM we do not have an RN. During an interview on [DATE] at 1:21 PM the Staff Developer stated, Upon hire, I will request the license, CPR [cardiopulmonary resuscitation], and any certifications. Prior to me, it was [name of the previous owner company] who was in charge of all the onboarding. Upon hire, I request the IV certification and give them up to 30 days. If the staff does not provide the certification, I have to readdress. During orientation, I asked [Staff A's name] for his certification. [Staff A's name] stated he had it. When [Staff A's name] did not provide it in the 30-day time frame, I readdressed, and we were in the process of a teachable moment. Review of the personnel record for Staff A, LPN documented the LPN's hire date as [DATE]. During an interview on [DATE] at 1:21 PM the DON stated, Newly hired staff are told upon hire if there is something that they are not able to do or do not feel comfortable there is a 24-hour RN that is on call that is able to assist. We stress constantly that if a task is not in their scope of practice or they are unable to complete ask for assistance. Upon hire, the Staff Development will do the competency and skills fair. My expectation for [Staff A's name] would be to get an RN that was on duty and assist and perform the task for him. It is not the practice of the facility to allow a non-IV Certified LPN to administer IV medications supervised. That was not the case there was no RN in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 3 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the building that approved of [Staff A's name] to administer IV medications. It would be falsification of documentation to only initial; an LPN will not be allowed to initial the task if they had not performed the task themselves. During an interview on [DATE] at 1:40 PM the ADON stated, I have not been in the room with an LPN to supervise or walk through IV medication administration for [Resident #197's name]. Onboarding is done by Staff Development and Human Resources goes behind with a checklist. I don't get an official notification of who is certified. I understand that someone will learn in school what their scope is that would be my expectation. The Staff Developer is the one who should be checking the paperwork and verifying that all LPNs have all certifications. I don't know if the Staff Developer reports to the DON since everything in the building falls under her. I will find out who is responsible for verifying agency [LPNs]. I have provided emergency cover for 7 PM-7 AM. During an interview on [DATE] at 2:05 PM the Medical Director stated, If nursing staff is non-IV certified, they should not be doing medication administration via IV. I was not aware that LPNs were administering medications via IV and were not certified. If the staff is not certified they might not know what they are doing and there is a risk for infection, mishandling of the IV port, bleeding, pain, the list can go on, but it is only a potential. During an interview on [DATE] at 10:35 AM, the DON stated, The facility does not have IV Certification for [Staff A's name] and [Staff G's name]. During an interview on [DATE] at 2:56 PM, Staff G stated, I became a nurse in the 1990s and while working at [Name of facility], I took a [Name of pharmacy] IV certification course in [Name of City], but I have not been able to locate the paperwork. During an interview on [DATE] at 2:58 PM, the DON, stated, There was an IV certified LPN, but I don't know why [Staff G's name] didn't ask for assistance. Ultimately, as far as the nursing department, I oversee nursing staff qualifications and the Staff Developer. [Staff G's name] verbally told us that she is IV certified. IV certification was requested. No documentation was provided of IV certifications for Staff A or Staff G. During an interview on [DATE] at 7:20 AM the Administrator stated, I understand there is a certification LPNs need to obtain that certifies them for IVs. The hiring process is new with all the corporate buy outs. Now we have a Human Resource Manager. Upon hire employees are ask for any and all certificates they have; if they do not produce the certifications, we assume they do not have them. During an interview on [DATE] at 9:30 AM the DON stated, It is not up to me to determine what neglect is. I would have to refer to my neglect policy. During an interview on [DATE] at 9:30 AM with Administrator stated, It would be neglect if we were aware and condoned it. Our policy does not condone. This was a [NAME] employee. We expect the staff to work within their scope of practice. During an interview on [DATE] at 9:34 AM the Director of Clinical Services, stated, I would consider it neglect if the staff worked outside their scope. We did not have a system in place to check for qualifications. We expect staff to work within their scope of practice, we trusted them. During an interview on [DATE] at 12:57 PM with the Administrator stated, We didn't have a process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 4 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in place for verification of staff qualifications. The previous company took care of the onboarding and now the new company has HR [Human Resource] in house. We have weekly meetings and daily staff meetings. During an interview on [DATE] at 12:57 PM the Staffing Coordinator stated, I depend on higher nursing staff for qualifications. I am responsible for the hours per resident care and PBJ [Payroll Based Journal, a system for facilities to submit staffing information]. I rely on the head of nursing to verify staff certifications and qualifications. I was trained on hours per resident care and PBJ. Review of the facility policy and procedure titled, Abuse, Neglect and Misappropriation of Property with a last review date of [DATE], read, Definitions of Types of Abuse: Neglect - Is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Policy Components . C. Prevention: Ensuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Responsibilities with a last reviewed date of [DATE], read, Policy . 6. Maintain records of personnel qualified by education and experience who may provide infusion therapy in the facility. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Policies and Procedures with a last review date of [DATE], read, The policies and procedures of a facility may be more stringent, and duties may be more restrictive than what is permitted by state regulations but may never be more lenient. For example: The State Board of Nursing may indicate that it is within the scope of practice for LPNs to flush Central Venous Catheters in long term care facilities, but it is the individual facility's decision to allow or not allow LPNs to perform the procedure. On the other hand, if the State Board of Nursing prohibits LPNs from flushing Central Venous Catheter in long term care facilities, then a facility may NEVER allow an LPN to perform that procedure. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Legal Issues with a last review date of [DATE], read, Legal Issues . Rule of Personal Liability: No Nurse, LVN [Licensed Vocational Nurse]/LPN or RN, should perform any procedure that he or she has not been specifically trained to do. Review of the facility policy and procedure titled, Nursing Services with a last review of [DATE], read, Policy . 5. The facility will ensure that licensed nurse have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Board of Nursing Rule Chapter 64B9-12 titled Administration of Intravenous Therapy by Licensed Practical Nurse reads, Section 64B9-12.005 - Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy .(2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. [Florida Administrative Code] Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 5 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL [central venous catheters] site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnessed by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. (3) Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the Board pursuant to Rule 64B9-5.005, F.A.C. To be qualified to teach any such course, the instructor must be a currently licensed registered nurse in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying completion of the requisite number of hours and course content. (4) Educational Alternatives. The cognitive training shall include one or more of the following: (a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S. [Florida Statutes], for practical nursing programs are extensive and that every licensed practical nurse will not administer IV therapy. The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B9-12.005(1), F.A.C.(b) Credit for Previous Education. The continuing education provider may credit the licensed practical nurse or graduate practical nurse for previous IV therapy education on a post-graduate level, providing each component of the course content of subsection 64B9-12.005(1), F.A.C., is tested by and competency demonstrated to the provider. (c) Nontraditional Education. Continuing education providers may select nontraditional education alternatives for acquisition of cognitive content outlined in Rule 64B9-12.005, F.A.C. Such alternatives include: 1. Interactive videos; 2. Self-study; 3. Other nontraditional education that may be submitted to the Board for consideration and possible approval. Any continuing education providers using nontraditional education must make provisions for demonstration of and verification of knowledge. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed registered nurse. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the likelihood of harm and/or possible death as evidenced by the following: On [DATE] during interviews, 6 RNs, 4 LPNs and 5 CNAs confirmed education for abuse/neglect, scope of practice and the 30 hour IV certification requirement for LPN's, the Director of Nursing, Assistant Director of Nursing, Staff Development, Human Resources and the Scheduler confirmed education for abuse/neglect, scope of practice, the 30 hour IV certification requirement for LPN's, and the new system for scheduling per residents needs according to staff qualifications. Review of staff training documented 100% of staff were educated on abuse/neglect and 100% of RNs and LPNs were educated on scope of practice. On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and/or receiving IV medications to identify possible harm, side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 6 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On [DATE] all LPN personnel records were audited to verify training credentials. On 3/1 - [DATE], the facility educated all nursing staff related to neglect, scope of practice, and the 30-hour IV certification requirement for LPNs prior to IV medication administration. On [DATE], the Director of Clinical Services provided training to the facility administration on verification of staff competency, working within their scope of practice and abuse/neglect policy. On [DATE], the Director of Clinical Services provided training to the Staff Developer and Staff Scheduler on neglect, scope of practice and supervision of staff. On [DATE], a new system for scheduling per residents needs according to staff qualifications was developed and implemented. On [DATE] the Director of Clinical Services educated the nursing managers on the new scheduling system. Event ID: Facility ID: 105597 If continuation sheet Page 7 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan to identify a problem and approach for 1 of 5 residents, Resident #28, reviewed for unnecessary medications. Findings include: Review of the electronic face sheet documented Resident #28 was admitted to the facility with diagnoses to include type II diabetes mellitus. Review of Resident #28's physician orders documented dated 12/28/22 - Levemir FlexTouch U-100 insulin (100unit/ml (milliliter) (3ml)-inject 45 units subcutaneously once a day. Dated 12/27/22-Trulicity pen injector, 1.5mg (milligrams)/0.5ml-inject 1.5mg subcutaneously once a day on Friday. Review of Resident #28's care plan did not provide for documentation of a problem and approach related to the resident's diagnosis of type II diabetes mellitus and the use of insulin and other medications to treat diabetes. During an interview conducted on 3/2/23 at 2:30 PM with the facility's Corporate Director of Clinical Services, confirmed Resident #28's care plan did not address the resident's diagnosis of type II diabetes mellitus and the use of insulin and other diabetic medications. Review of the facility's policy titled, Care Plan-Comprehensive, last reviewed on 2/16/23 read, Policy Interpretation. 1. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident .2. The Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas, b. Incorporate risk factors associated with identified problems, and d. Reflect treatment goals and objectives in measurable outcomes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 8 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, record review the facility failed to ensure the residents environment remained free of accident hazards as is possible for 1 of 3 residents, Resident #28. Residents Affected - Few Findings include: Review of Resident #28's medical record documented on the Electronic Face Sheet the resident's diagnoses of: type II diabetes mellitus, schizophrenia, cognitive communication deficit, bipolar disorder, central pain syndrome, and hypertension. Resident #28 was observed on 02/27/23 at 11:15 AM smoking in the facility's smoking area without a smoking apron. Review of Resident #28's care plan dated 1/6/23 read, [Resident #28's Name] prefers to smoke requires smoking apron. Review of Resident #28's medical record did not document a safe smoking assessment was completed which would determine the resident's safety needs while smoking. During an interview conducted on 03/02/23 at 10:33 AM, the Administrator confirmed they did not have a safe smoking assessment completed for Resident #28. Review of the policy and procedure titled, Surrey Place Nursing Center Facility Smoking Policy last reviewed on 2/16/23, read, 1. The facility will complete a safe smoking evaluation within 24 hours of admission for all residents who desire to smoke. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 9 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure licensed practical nurses (LPNs) had the appropriate skills and competencies to administer intravenous (IV) medication via central line access devices for 1 of 1 residents, Resident #197. The lack of IV certification and validation of competency for IV medication administration can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, causing tissue damage or even be life threatening. The lack of training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into patients' veins) can increase the spread of infection and can result in the likelihood of increase harm and/or death. Findings include: During an observation on [DATE] at 9:03 AM Resident #197 was in his room lying in bed. There is a double lumen peripherally inserted central catheter (PICC) covered with a transparent observed to the resident's upper right arm. The transparent dressing was dated [DATE] written with a black marker. During an interview on [DATE] at 9:04 AM Resident #197 stated, I have this IV [intravenous catheter] for antibiotics to treat the infection I have in my big toe. Review of the physician order report for [DATE] through [DATE] documented an order dated [DATE] for Resident #197 that read, Normal Saline Flush [sodium chloride 0.9% flush] syringe; amt [amount to administer]: 10 ml [milliliters]; injection. Special Instructions: Flush before and after each IV medication administration. Every shift. [Dated] [DATE] Meropenem recon soln [reconstituted solution]; 1 gram; amt]: 1 gram; intravenous. Dx [diagnosis]: Other [osteomyelitis, ankle and foot]. Every 8 hours. [Dated] [DATE] Vancomycin recon soln; 1.25 gram; amt: 1.25 gram; intravenous. Dx Other [osteomyelitis, ankle and foot]. Once a day. Review of the Medication Administration History for Resident #197 documented Staff A, License Practical Nurse (LPN), administered 10 ml of sodium chloride 0.9% before and the administration of Meropenem 1 gram on [DATE] at 3:32 PM and on [DATE] at 2:00 PM. Review of the Medication Administration History for Resident #197 documented Staff G, LPN, administered 10 ml of sodium chloride 0.9% before and after the administration of the IV medication Meropenem 1 gram reconstituted solution on [DATE] at 11:56 PM, [DATE] at 10:00 PM, [DATE] at 6:00 AM, [DATE] at 10:00 PM and [DATE] at 6:00 AM. Dated [DATE] Staff G, LPN administered 1.25 grams of Vancomycin reconstituted solution IV on [DATE] at 5:31 AM. During an interview on [DATE] at 10:09 AM the Director of Nursing (DON) stated, We have no IV certification records for Staff A, LPN. He was contacted and cannot produce a certification. If the MAR [Medication Administration Record/Medication Administration History] is initialed by a nurse, it means the medication was given by that nurse unless if there is parenthesis which means they made a note. The Staff Developer and Human Resources are responsible for verification of staff certification. During the interview a request was made for the IV Certification for Staff G. During an interview on [DATE] at 10:30 AM Staff C, Unit Manager LPN, stated, LPNs need to have IV certification. The Human Resource staff and Staff Development is responsible for making sure staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 10 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 have all certifications upon hire. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 10:41 AM Staff A, LPN, stated, Yesterday I helped administer medication. The Assistant Director of Nursing was in the room with me. I hung medication, flushed, and cleaned the port. I was supervised. I am always supervised by an RN [Registered Nurse]. The facility did not request IV certification from me upon hire. I did not know I needed IV certification. I have done IV medication administration before. I do not know how to place an IV in an arm [to insert an IV] but I know how to hang medication. When I was hired, I was trained and shown how to administer medication via IV. The first time the nurse showed me [how to administer IV medications]. After that, she has always supervised me doing the administration and flushes. The RN is always with me at all times. Normally I will do it and chart under my name since he is my resident. Residents Affected - Few During an interview on [DATE] at 12:55 PM the Human Resource/ABOM (Assistant Business Office Manager) stated, The IV certification would be kept in the employee file only if provided, it is not requested. During an interview on [DATE] at 12:55 PM the Staffing Coordinator stated, Staff is assigned to halls. I leave it up to the nursing staff to tell me if they are capable or not of treating the resident. I hold a CNA [Certified Nursing Assistant] license. I am aware that the RN is the only one who is able to do PICC lines. I do not have copies of all the nurses' certifications. I am the only one who schedules. The head nursing department is responsible to verify certifications. I assume that all the credentials have been verified by the head of nursing. We do not have a 24-hour RN on the schedule. From 7 PM to 7 AM we do not have an RN. During an interview on [DATE] at 1:21 PM the Staff Developer stated, Upon hire, I will request the license, CPR [cardiopulmonary resuscitation], and any certifications. Prior to me, it was [name of the previous owner company] who was in charge of all the onboarding. Upon hire, I request the IV certification and give them up to 30 days. If the staff does not provide the certification, I have to readdress. During orientation, I asked [Staff A's name] for his certification. [Staff A's name] stated he had it. When [Staff A's name] did not provide it in the 30-day time frame, I readdressed, and we were in the process of a teachable moment. Review of the personnel record for Staff A, LPN documented the LPN's hire date as [DATE]. During an interview on [DATE] at 1:21 PM the DON stated, Newly hired staff are told upon hire if there is something that they are not able to do or do not feel comfortable there is a 24-hour RN that is on call that is able to assist. We stress constantly that if a task is not in their scope of practice or they are unable to complete ask for assistance. Upon hire, the Staff Development will do the competency and skills fair. My expectation for [Staff A's name] would be to get an RN that was on duty and assist and perform the task for him. It is not the practice of the facility to allow a non-IV Certified LPN to administer IV medications supervised. That was not the case there was no RN in the building that approved of [Staff A's name] to administer IV medications. It would be falsification of documentation to only initial; an LPN will not be allowed to initial the task if they had not performed the task themselves. During an interview on [DATE] at 1:40 PM the ADON stated, I have not been in the room with an LPN to supervise or walk through IV medication administration for [Resident #197's name]. Onboarding is done by Staff Development and Human Resources goes behind with a checklist. I don't get an official notification of who is certified. I understand that someone will learn in school what their scope is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 11 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few that would be my expectation. The Staff Developer is the one who should be checking the paperwork and verifying that all LPNs have all certifications. I don't know if the Staff Developer reports to the DON since everything in the building falls under her. I will find out who is responsible for verifying agency [LPNs]. I have provided emergency cover for 7 PM-7 AM. During an interview on [DATE] at 2:05 PM the Medical Director stated, If nursing staff is non-IV certified, they should not be doing medication administration via IV. I was not aware that LPNs were administering medications via IV and were not certified. If the staff is not certified they might not know what they are doing and there is a risk for infection, mishandling of the IV port, bleeding, pain, the list can go on, but it is only a potential. During an interview on [DATE] at 10:35 AM, the DON stated, The facility does not have IV Certification for [Staff A's name] and [Staff G's name]. During an interview on [DATE] at 2:56 PM, Staff G stated, I became a nurse in the 1990s and while working at [Name of facility], I took a [Name of pharmacy] IV certification course in [Name of City], but I have not been able to locate the paperwork. During an interview on [DATE] at 2:58 PM, the DON, stated, There was an IV certified LPN, but I don't know why [Staff G's name] didn't ask for assistance. Ultimately, as far as the nursing department, I oversee nursing staff qualifications and the Staff Developer. [Staff G's name] verbally told us that she is IV certified. IV certification was requested. No documentation was provided of IV certifications for Staff A or Staff G. During an interview on [DATE] at 7:20 AM the Administrator stated, I understand there is a certification LPNs need to obtain that certifies them for IVs. The hiring process is new with all the corporate buy outs. Now we have a Human Resource Manager. Upon hire employees are ask for any and all certificates they have; if they do not produce the certifications, we assume they do not have them. During an interview on [DATE] at 9:34 AM the Director of Clinical Services stated, We did not have a system in place to check for qualifications. We expect staff to work within their scope of practice, we trusted them. During an interview on [DATE] at 12:57 PM with the Administrator stated, We didn't have a process in place for verification of staff qualifications. The previous company took care of the onboarding and now the new company has HR [Human Resource] in house. We have weekly meetings and daily staff meetings. During an interview on [DATE] at 12:57 PM the Staffing Coordinator stated, I depend on higher nursing staff for qualifications. I am responsible for the hours per resident care and PBJ [Payroll Based Journal, a system for facilities to submit staffing information]. I rely on the head of nursing to verify staff certifications and qualifications. I was trained on hours per resident care and PBJ. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Responsibilities with a last reviewed date of [DATE], read, Policy . 6. Maintain records of personnel qualified by education and experience who may provide infusion therapy in the facility. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Policies and Procedures with a last review date of [DATE], read, The policies and procedures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 12 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 - Immediate jeopardy to resident health or safety of a facility may be more stringent, and duties may be more restrictive than what is permitted by state regulations but may never be more lenient. For example: The State Board of Nursing may indicate that it is within the scope of practice for LPNs to flush Central Venous Catheters in long term care facilities, but it is the individual facility's decision to allow or not allow LPNs to perform the procedure. On the other hand, if the State Board of Nursing prohibits LPNs from flushing Central Venous Catheter in long term care facilities, then a facility may NEVER allow an LPN to perform that procedure. Residents Affected - Few Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Legal Issues with a last review date of [DATE], read, Legal Issues . Rule of Personal Liability: No Nurse, LVN [Licensed Vocational Nurse]/LPN or RN, should perform any procedure that he or she has not been specifically trained to do. Review of the facility policy and procedure titled, Nursing Services with a last review of [DATE], read, Policy . 5. The facility will ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Board of Nursing Rule Chapter 64B9-12 titled Administration of Intravenous Therapy by Licensed Practical Nurse reads, Section 64B9-12.005 - Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy .(2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. [Florida Administrative Code] Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL [central venous catheters] site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnessed by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. (3) Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the Board pursuant to Rule 64B9-5.005, F.A.C. To be qualified to teach any such course, the instructor must be a currently licensed registered nurse in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying completion of the requisite number of hours and course content. (4) Educational Alternatives. The cognitive training shall include one or more of the following: (a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S. [Florida Statutes], for practical nursing programs are extensive and that every licensed practical nurse will not administer IV therapy. The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B9-12.005(1), F.A.C.(b) Credit for Previous Education. The continuing education provider may credit the licensed practical nurse or graduate practical nurse for previous IV therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 13 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few education on a post-graduate level, providing each component of the course content of subsection 64B9-12.005(1), F.A.C., is tested by and competency demonstrated to the provider. (c) Nontraditional Education. Continuing education providers may select nontraditional education alternatives for acquisition of cognitive content outlined in Rule 64B9-12.005, F.A.C. Such alternatives include: 1. Interactive videos; 2. Self-study; 3. Other nontraditional education that may be submitted to the Board for consideration and possible approval. Any continuing education providers using nontraditional education must make provisions for demonstration of and verification of knowledge. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed registered nurse. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the likelihood of harm and/or possible death as evidenced by the following: On [DATE] during interviews, 6 RNs, 4 LPNs and 5 CNAs confirmed education for abuse/neglect, scope of practice and the 30 hour IV certification requirement for LPN's, the Director of Nursing, Assistant Director of Nursing, Staff Development, Human Resources and the Scheduler confirmed education for abuse/neglect, scope of practice, the 30 hour IV certification requirement for LPN's, and the new system for scheduling per residents needs according to staff qualifications. Review of staff training documented 100% of staff were educated on abuse/neglect and 100% of RNs and LPNs were educated on scope of practice. On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and/or receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On [DATE] all LPN personnel records were audited to verify training credentials. On 3/1 - [DATE], the facility educated all nursing staff related to neglect, scope of practice, and the 30-hour IV certification requirement for LPNs prior to IV medication administration. On [DATE], the Director of Clinical Services provided training to the facility administration on verification of staff competency, working within their scope of practice and abuse/neglect policy. On [DATE], the Director of Clinical Services provided training to the Staff Developer and Staff Scheduler on neglect, scope of practice and supervision of staff. On [DATE], a new system for scheduling per residents needs according to staff qualifications was developed and implemented. On [DATE] the Director of Clinical Services educated the nursing managers on the new scheduling system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 14 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 1 of 2 medication carts (East Cart) and unsecured medications observed at resident's bedside, Resident #33. (Photographic evidence obtained). Findings include: During an observation on 02/27/2023 at 9:25 AM of the East Medication Cart with Staff A, License Practical Nurse (LPN), there were three dark color circular pills in an unlabeled medication cup in the top draw of the cart. During an interview on 2/27/2023 at 9:37 AM Staff A, LPN, stated, These are iron pills. I didn't place them there. I don't know why the medication is there. During an observation on 2/27/2023 at 9:25 AM of Resident #33's room there was a bottle of Nutribiotic throat spray with grapefruit seed extract plus zinc and menthol, a medicated anti-itch spray, a calamine clear lotion, a round orange circular unlabeled pill on top of the bedside table, and a clear plastic cup with a lid, on the lid it was labeled 2/25 For Rash and contained a white cream. During an interview on 2/27/2023 at 9:26 AM Resident #33 stated, I am itchy and my throat is sore at times. This pill on my bedside table is gum. During an interview on 2/27/2023 at 9:55 AM the Director of Nursing (DON) stated, Medication should not be out unlabeled. The DON confirm Resident #33 had unsecure medications in the room and stated, I am not able to say where the labeled cup came from. Review of the policy and procedures titled, Self-Administration of Medication with a last reviewed date of 2/16/2023 read, General Guidelines .2b. storage of medications in the resident's room must be such that it will prevent access by other residents; 2c. Only the medications permitted for self-administration shall be left at the bedside; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 15 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure assistive adaptive devices for provided for 1 of 1 residents, Resident #145. Residents Affected - Few Findings include: During an observation on 02/28/23 at 12:31 PM of Resident #145 for the adaptive equipment of a high sided separated or divided plate was not provided and was listed on the meal tray ticket. During an observation on 3/01/23 at 8:35 AM of the breakfast tray served to Resident #145 for the adaptive equipment of a high sided separated or divided plate showed it was not provided and was listed on the tray ticket. During an interview with the Certified Dietary Manager (CDM) conducted on 3/01/2023 at 1:30 PM related to the adaptive equipment for Resident #145. The CDM stated the dietary department did not have a high sided divided or separated plate for Resident #145. The CDM verified that orders for adaptive equipment allows residents to maintain independence while dining and should be provided as ordered. The CDM confirmed she had not discussed the lack of adaptive equipment or an alternative with the Registered Dietician (RD) or therapy department. During an interview with the Speech Therapist (ST) on 3/02/23 at 12:11 PM related to adaptive and assistive devices. The ST confirmed that adaptive or assistive devices are ordered to promote independence for a resident that has restricted movement, visual impairment, tremors, or other conditions that may benefit from adaptive or assistive devices. The ST stated that her expectations would be for the therapy department to be notified if equipment is not available in the dietary department so that an equivalent substitute can be recommended until the needed equipment can be ordered. Review of the document titled, Resident Adaptive Equipment Report, dated 2/27/23 read, Resident #145 [resident named] adaptive equipment high-sided partition plate, breakfast, lunch and dinner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 16 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to ensure food is stored, covered, labeled, and discarded in the kitchen and failed to maintain sanitary standards for equipment used to prepare, cook, and serve the residents. (Photographic evidence obtained). Findings include: A walk-through tour of the kitchen was conducted on 02/27/23 at 09:10 AM with the Certified Dietary Manager (CDM). The walk-in cooler had a large container labeled Chili and labeled with a prepared date of 02/19/23 and a use by date of 02/22/23. A sheet pan was located on the bottom shelf of the walk in cooler and the sheet pan was observed to have a bag of thawed raw chicken and a roll of raw ground beef with no separation of the two items to prevent cross contamination. An observation was made of two quart containers of raw liquid eggs stored directly over an opened box of raw bacon. An observation was made in the walk-in freezer of ice buildup and open boxes exposing food. There was an observation in the dry storage area of three dented cans stored on the ready to use shelving and not in the designated dented can area. There was an observation of four storage bins with black garbage bags being used as liners to hold the bulk foods. There was a soiled, wet cloth resting on the stainless table next to the food tray line. An interview was conducted with the CDM on 2/27/23 at 9:30 AM. The CDM confirmed the walk-in cooler had a large container labeled Chili and showing a prepared date of 02/19/23 and with a use by date of 02/22/23. The CDM stated the chili should have been discarded after 2/22/23. The CDM confirmed the sheet pan containing the large bag of thawed raw chicken and a five pound roll of raw ground beef did not have a separation of the two items to prevent cross contamination. The CDM confirmed the raw ground beef and raw chicken should not be stored together on the same pan. The CDM confirmed there were two-quart containers of raw liquid eggs stored directly over an opened box of raw bacon and that eggs should be stored below other raw foods to prevent cross-contamination. The CDM verified in the walk-in freezer there is an ice buildup and open boxes exposing food with the potential for freezer burn and compromising the integrity of the food stored for preparation of menu items. The CDM confirmed in the dry storage area, the three dented cans stored on the ready to use shelf and not in the designated dented can area. The CDM confirmed four storage bins had black garbage bags being used as liners to hold the bulk foods and garbage bags were not a food grade container for bulk products. The CDM confirmed that all wiping cloths should be kept in a sanitizer bucket when not in use. A review of the policy and procedure titled, Food Storage: Cold Foods last reviewed on 02/16/23 read, Procedures: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the policy and procedure titled, Receiving last reviewed on 02/16/23 read, Procedures: 4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal as appropriate. During an observation on 2/28/23 at 6:45 AM with the CDM the meat slicing equipment was covered. The CDM removed the covering and the meat slicer was observed to have rust-colored debris and food particles on the center connector of the blade. An observation was made of a knife holder on the wall that had a clear plexiglass covering. Food crumbs were observed in the base of the knife holder. An observation of the convection oven showed it had a thick buildup of food and debris on the external (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 17 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 and internal parts of the oven. Level of Harm - Minimal harm or potential for actual harm During an interview with the CDM on 2/28/23 at 6:53 AM the CDM confirmed the meat slicer had a rust-colored debris and food particles on the center connector of the blade. The CDM stated that a covered piece of equipment should designate that the equipment is clean and ready for use. Residents Affected - Many During an interview with the CDM on 3/01/23 at 1:45 PM the CDM verified the convection oven had a thick covering of debris and food on the inside and outside of the oven and stated it should be cleaned and not have a buildup of food and debris. The CDM stated there should not be breadcrumbs in the knife container. Review of the policy and procedure titled, Equipment was last reviewed on 02/16/2023 read, Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 18 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility by allowing unqualified facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 1 of 1 residents, Resident #197, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Residents Affected - Few Findings include: Review of the job description titled, Administrator read, Summary: Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and company policies to maintain excellent care for the residents while achieving the facility's business objective. Essential Duties and Responsibilities: Planning Function: Work with the facility management staff and consultants in planning all aspects of facility operations, including setting priorities and job assignments. Monitor each department's activities, communicate policies, evaluate performance, provide feedback, and assist, coach and discipline as needed. Continuous Quality Improvement Function: Conduct regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of facility, morale of staff and to ensure residents needs are being addressed in a proactive manner. Regulatory Compliance Function: Maintain a working knowledge of and ensure compliance with all governmental regulations. Educational Function: Supervise, conduct, and participate in department and facility education activities and staff meetings. Maintain professional competence through participation in continuing education programs, seminars, and training programs. Review of job description titled, Director of Nursing [DON] read, Summary: Lead and direct the overall nursing operation of the Center in accordance with residents' needs, government regulations, and company policies to maintain excellent care for the residents while achieving the Center's business objectives. Essential Duties and Responsibilities: Work with the nursing management staff, Administrator, and Consultants in planning all aspects of the nursing operation, including setting priorities and job assignments. Monitor each unit's activities, communicate policies, evaluate performance, provide feedback, and assist, coach, and discipline as needed. Conduct regular rounds to monitor delivery of nursing care, effective coordination with other support services, cleanliness and appearance of the residents, and morale of staff and to ensure residents' needs are being addressed in a proactive manner. Maintain a working knowledge and ensure compliance with all governmental regulations. Monitor medical records to assure the documentation reflects the skilled services provided and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 19 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0835 Level of Harm - Immediate jeopardy to resident health or safety complies with policies and regulations. Monitor associate relations practices key nursing staff to ensure compliance with employment laws and company policies and to ensure practices that maintain high morale and staff retention to include effective communication, prompt problem resolution, positive supervisory practices, and maintaining a positive work environment. Manage turnover and ensure current and future staffing through development of recruiting sources and through appropriate selection, orientation, training, and staff education. Residents Affected - Few Review of job description titled Assistant Director of Nursing [ADON], RN [Registered Nurse] read, Summary: To assist the Director of Nursing in leading and directing the overall nursing operation of the Center in accordance with residents' needs, government regulations, and company policies to maintain excellent care for the residents while achieving the Center's business objective. Essential Duties and Responsibilities: Assist the DON in working with management staff, Administrator, and Consultants in planning all aspects of the nursing operation, including setting priorities and job assignments. Conduct regular rounds to monitor delivery of nursing care, effective coordination with other support services, cleanliness and appearance of the residents, and morale of staff and to ensure residents' needs are being addressed in a proactive manner. Carry out, coordinate, and manage administrative functions in areas or programs related to nursing services, which may include departmental documentation or medical records; nursing supplies; ancillary supplies or services; center CQI [Continuous Quality Improvement]; care plan; MDSs [Minimum Data Sets]; Infection control programs; skin care program; Medicare; special programs; staff scheduling; selection, training, and orientation; and related functions. Maintain a working knowledge and ensure compliance with all governmental regulations. Monitor associate relations practices key nursing staff to ensure compliance with employment laws and company policies and to ensure practices that maintain high morale and staff retention to include effective communication, prompt problem resolution, positive supervisory practices, and maintaining a positive work environment. Manage turnover and ensure current and future staffing through development of recruiting sources and through appropriate selection, orientation, training, and staff education. Review of job description titled, Staff Developer-RN read, Summary: To plan and implement Center orientation, job skills training, and in-service education programs in accordance with Company policies and regulations. The primary function of this position is recruiting and training associates and to monitor and guide these positions throughout the course of employment. Work with the Administrator, Director of Nursing, and Center staff in assessing training needs and plan programs that meet priority needs and regulatory requirements. Review of Medical Director Agreement effective [DATE] reads, Section 1. Medical Director Duties . 13. Assuring that the medical standards of the facility comply with applicable laws, licensing, certification, and accreditation and professional standards. During an observation on [DATE] at 9:03 AM Resident #197 was in his room lying in bed. There is a double lumen peripherally inserted central catheter (PICC) covered with a transparent observed to the resident's upper right arm. The transparent dressing was dated [DATE] written with a black marker. During an interview on [DATE] at 9:04 AM Resident #197 stated, I have this IV [intravenous catheter] for antibiotics to treat the infection I have in my big toe. Review of the physician order report for [DATE] through [DATE] documented an order dated [DATE] for Resident #197 that read, Normal Saline Flush [sodium chloride 0.9% flush] syringe; amt [amount to administer]: 10 ml [milliliters]; injection. Special Instructions: Flush before and after each IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 20 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few medication administration. Every shift. [Dated] [DATE] Meropenem recon soln [reconstituted solution]; 1 gram; amt]: 1 gram; intravenous. Dx [diagnosis]: Other [osteomyelitis, ankle and foot]. Every 8 hours. [Dated] [DATE] Vancomycin recon soln; 1.25 gram; amt: 1.25 gram; intravenous. Dx Other [osteomyelitis, ankle and foot]. Once a day. Review of the Medication Administration History for Resident #197 documented Staff A, License Practical Nurse (LPN), administered 10 ml of sodium chloride 0.9% before and the administration of Meropenem 1 gram on [DATE] at 3:32 PM and on [DATE] at 2:00 PM. Review of the Medication Administration History for Resident #197 documented Staff G, LPN, administered 10 ml of sodium chloride 0.9% before and after the administration of the IV medication Meropenem 1 gram reconstituted solution on [DATE] at 11:56 PM, [DATE] at 10:00 PM, [DATE] at 6:00 AM, [DATE] at 10:00 PM and [DATE] at 6:00 AM. Dated [DATE] Staff G, LPN administered 1.25 grams of Vancomycin reconstituted solution IV on [DATE] at 5:31 AM. During an interview on [DATE] at 10:09 AM the Director of Nursing (DON) stated, We have no IV certification records for Staff A, LPN. He was contacted and cannot produce a certification. If the MAR [Medication Administration Record/Medication Administration History] is initialed by a nurse, it means the medication was given by that nurse unless if there is parenthesis which means they made a note. The Staff Developer and Human Resources are responsible for verification of staff certification. During the interview a request was made for the IV Certification for Staff G. During an interview on [DATE] at 10:30 AM Staff C, Unit Manager LPN, stated, LPNs need to have IV certification. The Human Resource staff and Staff Development is responsible for making sure staff have all certifications upon hire. During an interview on [DATE] at 10:41 AM Staff A, LPN, stated, Yesterday I helped administer medication. The Assistant Director of Nursing was in the room with me. I hung medication, flushed, and cleaned the port. I was supervised. I am always supervised by an RN [Registered Nurse]. The facility did not request IV certification from me upon hire. I did not know I needed IV certification. I have done IV medication administration before. I do not know how to place an IV in an arm [to insert an IV] but I know how to hang medication. When I was hired, I was trained and shown how to administer medication via IV. The first time the nurse showed me [how to administer IV medications]. After that, she has always supervised me doing the administration and flushes. The RN is always with me at all times. Normally I will do it and chart under my name since he is my resident. During an interview on [DATE] at 12:55 PM the Human Resource/ABOM (Assistant Business Office Manager) stated, The IV certification would be kept in the employee file only if provided, it is not requested. During an interview on [DATE] at 12:55 PM the Staffing Coordinator stated, Staff is assigned to halls. I leave it up to the nursing staff to tell me if they are capable or not of treating the resident. I hold a CNA [Certified Nursing Assistant] license. I am aware that the RN is the only one who is able to do PICC lines. I do not have copies of all the nurses' certifications. I am the only one who schedules. The head nursing department is responsible to verify certifications. I assume that all the credentials have been verified by the head of nursing. We do not have a 24-hour RN on the schedule. From 7 PM to 7 AM that we do not have an RN. During an interview on [DATE] at 1:21 PM the Staff Developer stated, Upon hire, I will request the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 21 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0835 Level of Harm - Immediate jeopardy to resident health or safety license, CPR [cardiopulmonary resuscitation], and any certifications. Prior to me, it was [name of the previous owner company] who was in charge of all the onboarding. Upon hire, I request the IV certification and give them up to 30 days. If the staff does not provide the certification, I have to readdress. During orientation, I asked [Staff A's name] for his certification. [Staff A's name] stated he had it. When [Staff A's name] did not provide it in the 30-day time frame, I readdressed, and we were in the process of a teachable moment. Residents Affected - Few Review of the personnel record for Staff A, LPN documented the LPN's hire date as [DATE]. During an interview on [DATE] at 1:21 PM the DON stated, Newly hired staff are told upon hire if there is something that they are not able to do or do not feel comfortable there is a 24-hour RN that is on call that is able to assist. We stress constantly that if a task is not in their scope of practice or they are unable to complete ask for assistance. Upon hire, the Staff Development will do the competency and skills fair. My expectation for [Staff A's name] would be to get an RN that was on duty and assist and perform the task for him. It is not the practice of the facility to allow a non-IV Certified LPN to administer IV medications supervised. That was not the case there was no RN in the building that approved of [Staff A's name] to administer IV medications. It would be falsification of documentation to only initial; an LPN will not be allowed to initial the task if they had not performed the task themselves. During an interview on [DATE] at 1:40 PM the ADON stated, I have not been in the room with an LPN to supervise or walk through IV medication administration for [Resident #197's name]. Onboarding is done by Staff Development and Human Resources goes behind with a checklist. I don't get an official notification of who is certified. I understand that someone will learn in school what their scope is that would be my expectation. The Staff Developer is the one who should be checking the paperwork and verifying that all LPNs have all certifications. I don't know if the Staff Developer reports to the DON since everything in the building falls under her. I will find out who is responsible for verifying agency [LPNs]. I have provided emergency cover for 7 PM-7 AM. During an interview on [DATE] at 2:05 PM the Medical Director stated, If nursing staff is non-IV certified, they should not be doing medication administration via IV. I was not aware that LPNs were administering medications via IV and were not certified. If the staff is not certified they might not know what they are doing and there is a risk for infection, mishandling of the IV port, bleeding, pain, the list can go on, but it is only a potential. During an interview on [DATE] at 10:35 AM, the DON stated, The facility does not have IV Certification for [Staff A's name] and [Staff G's name]. During an interview on [DATE] at 2:56 PM, Staff G stated, I became a nurse in the 1990s and while working at [Name of facility], I took a [Name of pharmacy] IV certification course in [Name of City], but I have not been able to locate the paperwork. During an interview on [DATE] at 2:58 PM, the DON, stated, There was an IV certified LPN, but I don't know why [Staff G's name] didn't ask for assistance. Ultimately, as far as the nursing department, I oversee nursing staff qualifications and the Staff Developer. [Staff G's name] verbally told us that she is IV certified. IV certification was requested. No documentation was provided of IV certifications for Staff A or Staff G. During an interview on [DATE] at 7:20 AM the Administrator stated, I understand there is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 22 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0835 Level of Harm - Immediate jeopardy to resident health or safety certification LPNs need to obtain that certifies them for IVs. The hiring process is new with all the corporate buy outs. Now we have a Human Resource Manager. Upon hire employees are ask for any and all certificates they have; if they do not produce the certifications, we assume they do not have them. During an interview on [DATE] at 9:30 AM with DON stated, It is not up to me to determine what neglect is. I would have to refer to my neglect policy. Residents Affected - Few During an interview on [DATE] at 9:30 AM with Administrator stated, It would be neglect if we were aware and condoned it. Our policy does not condone. This was a [NAME] employee. We expect the staff to work within their scope of practice. As the facility Administrator I oversee the facility. My responsibilities are listed in my job description. During an interview on [DATE] at 9:34 AM the Director of Clinical Services, stated, I would consider it neglect if the staff worked outside their scope. We did not have a system in place to check for qualifications. We expect staff to work within their scope of practice, we trusted them. During an interview on [DATE] at 12:57 PM with the Administrator stated, We didn't have a process in place for verification of staff qualifications. The previous company took care of the onboarding and now the new company has HR [Human Resource] in house. We have weekly meetings and daily staff meetings. During an interview on [DATE] at 12:57 PM the Staffing Coordinator stated, I depend on higher nursing staff for qualifications. I am responsible for the hours per resident care and PBJ [Payroll Based Journal, a system for facilities to submit staffing information]. I rely on the head of nursing to verify staff certifications and qualifications. I was trained on hours per resident care and PBJ. Review of the facility policy and procedure titled, Abuse, Neglect and Misappropriation of Property with a last review date of [DATE], read, Definitions of Types of Abuse: Neglect - Is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Policy Components . C. Prevention: Ensuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Responsibilities with a last reviewed date of [DATE], read, Policy . 6. Maintain records of personnel qualified by education and experience who may provide infusion therapy in the facility. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Policies and Procedures with a last review date of [DATE], read, The policies and procedures of a facility may be more stringent, and duties may be more restrictive than what is permitted by state regulations but may never be more lenient. For example: The State Board of Nursing may indicate that it is within the scope of practice for LPNs to flush Central Venous Catheters in long term care facilities, but it is the individual facility's decision to allow or not allow LPNs to perform the procedure. On the other hand, if the State Board of Nursing prohibits LPNs from flushing Central Venous Catheter in long term care facilities, then a facility may NEVER allow an LPN to perform that procedure. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 23 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Legal Issues with a last review date of [DATE], read, Legal Issues . Rule of Personal Liability: No Nurse, LVN [Licensed Vocational Nurse]/LPN or RN, should perform any procedure that he or she has not been specifically trained to do. Review of the facility policy and procedure titled, Nursing Services with a last review of [DATE], read, Policy . 5. The facility will ensure that licensed nurse have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Board of Nursing Rule Chapter 64B9-12 titled Administration of Intravenous Therapy by Licensed Practical Nurse reads, Section 64B9-12.005 - Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy .(2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. [Florida Administrative Code] Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL [central venous catheters] site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnessed by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. (3) Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the Board pursuant to Rule 64B9-5.005, F.A.C. To be qualified to teach any such course, the instructor must be a currently licensed registered nurse in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying completion of the requisite number of hours and course content. (4) Educational Alternatives. The cognitive training shall include one or more of the following: (a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S. [Florida Statutes], for practical nursing programs are extensive and that every licensed practical nurse will not administer IV therapy. The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B9-12.005(1), F.A.C.(b) Credit for Previous Education. The continuing education provider may credit the licensed practical nurse or graduate practical nurse for previous IV therapy education on a post-graduate level, providing each component of the course content of subsection 64B9-12.005(1), F.A.C., is tested by and competency demonstrated to the provider. (c) Nontraditional Education. Continuing education providers may select nontraditional education alternatives for acquisition of cognitive content outlined in Rule 64B9-12.005, F.A.C. Such alternatives include: 1. Interactive videos; 2. Self-study; 3. Other nontraditional education that may be submitted to the Board for consideration and possible approval. Any continuing education providers using nontraditional education must make provisions for demonstration of and verification of knowledge. (5) Clinical Competence. The course must be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 24 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed registered nurse. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the likelihood of harm and/or possible death as evidenced by the following: On [DATE] during interviews, 6 RNs, 4 LPNs and 5 CNAs confirmed education for abuse/neglect, scope of practice and the 30 hour IV certification requirement for LPN's, the Director of Nursing, Assistant Director of Nursing, Staff Development, Human Resources and the Scheduler confirmed education for abuse/neglect, scope of practice, the 30 hour IV certification requirement for LPN's, and the new system for scheduling per residents needs according to staff qualifications. Review of staff training documented 100% of staff were educated on abuse/neglect and 100% of RNs and LPNs were educated on scope of practice. On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and/or receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On [DATE] all LPN personnel records were audited to verify training credentials. On 3/1 - [DATE], the facility educated all nursing staff related to neglect, scope of practice, and the 30-hour IV certification requirement for LPNs prior to IV medication administration. On [DATE], the Director of Clinical Services provided training to the facility administration on verification of staff competency, working within their scope of practice and abuse/neglect policy. On [DATE], the Director of Clinical Services provided training to the Staff Developer and Staff Scheduler on neglect, scope of practice and supervision of staff. On [DATE], a new system for scheduling per residents needs according to staff qualifications was developed and implemented. On [DATE] the Director of Clinical Services educated the nursing managers on the new scheduling system. Event ID: Facility ID: 105597 If continuation sheet Page 25 of 26 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to maintain equipment to be in a safe and clean operating manner. Residents Affected - Many Findings include: An observation of the meat slicer equipment was conducted on 02/28/23 at 6:45 AM when the Certified Dietary Manager (CDM) removed the covering for observation. The meat slicer had a rust-colored debris and food particles on a center connector of the blade. During an interview with the CDM on 2/28/23 at 6:53 AM the CDM confirmed that the meat slicer had a rust-colored debris and food particles on a center connector of the blade. The CDM stated that a covered piece of equipment should designate that the equipment is clean and ready for use. During a follow-up tour conducted on 02/28/23 at 6:45 AM with the Certified Dietary Manager, an observation was made of 24 trays with sharp and broken edges being used for room trays. An observation was made of heated metal insert being used in dome bases that were not designed to need a heated metal insert therefore was sitting above the base exposing the heated metal. An observation was made of a knife holder on the wall that had a clear plexiglass covering that had food crumbs in the base. An observation was made of the convection oven with a buildup of food and debris on the external and internal part of the oven. An interview was conducted with the CDM on 3/01/23 at 1:45 PM related to the observation made during the follow up visit to the dietary department. The CDM confirmed that the trays with broken and sharp edges should not be used. The CDM verified that the convection oven should be cleaned and not have a buildup of food and debris inside or outside. The CDM confirmed that the heated metal inserts should only be used in designated bases to prevent the potential of burns to the staff and residents. The CDM stated that there should not have been breadcrumbs in the knife container. A policy titled Equipment dated September 2017 read, policy statement, all foodservice equipment will be clean, sanitary, and in proper working order. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 26 of 26