Health inspection·July 3, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daily from 6/3/2024 through 7/1/2024 showed it was documented as Not Applicable on 6/7/2024 at 2:31 PM, 6/14/2024 at 2:54 PM, 6/17/2024 at 5:03 PM, 6/18/2024 at 6:59 PM, 6/21/2024 at 3:21 PM, 6/24/2024 at 3:05 PM, 6/29/2024 at 3:18 PM, 6/30/2024 at 3:12 PM, and 7/1/2024 at 3:57 PM. During an interview on 7/2/2024 at 10:30 AM, the DON stated, The staff should not be recording the splint application as not applicable. It should be either time applied or that the resident refused. Review of the facility policy and procedure titled Charting with the last review date of 2/15/2024, showed the policy read, Policy Interpretation and Implementation: 1. Medications given, services performed, etc. are recorded in the resident's chart. Review of the facility policy and procedure titled Administration of Drugs with the last review date of 2/15/2024, showed the policy read, Policy Interpretation and Implementation . 9. The nurse administering the drug must record such information on the resident's eMAR [electronic medication administration record] before administering the next resident's drug. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 2 of 4 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 07/03/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards during medication administration for 2 of 5 residents observed, Resident #35 and Resident #7, and during wound care for 1 of 2 residents observed, Resident #32, and failed to ensure staff disinfected the reusable medical equipment to prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: During an observation on 7/2/2024 at 7:57 AM, Staff A, Licensed Practical Nurse (LPN), was preparing medications for Resident #35. A dark colored capsule fell onto the top of the medication cart while popping the medication blister pack. Staff A picked up the capsule from the top of the medication cart with an ungloved hand and placed it into the medication cup. Staff A entered Resident #35's room and administered the medication. During an observation on 7/2/2024 at 8:05 AM, Staff A, LPN, poured medications into a medication cup for Resident #7. Staff A asked Resident #7 if she would like her potassium tablet to be cut in half and the resident replied Yes. Staff A, without donning gloves, removed the potassium tablet from the medication cup with her hands and cut the potassium tablet in half and placed the two halves of the medication back into the medication cup. Resident #7 asked Staff A to take her blood pressure one more time. Staff A placed a wrist blood pressure monitor on the resident's right wrist. Staff A read the blood pressure reading to the resident. Resident #7 asked Staff A if she could take her blood pressure manually. Staff A exited the room and walked towards the vital signs monitor covered with a plastic bag and removed the manual blood pressure cuff from the basket. Staff A returned to Resident #7's room and took Resident #7's blood pressure manually. Staff A read the blood pressure reading and Resident #7 accepted to take the medications. Staff A administered the medications to Resident #7. Staff A exited Resident #7's room and without sanitizing the manual blood pressure cuff, placed it back into the basket and covered the vital signs monitor with the plastic bag. During an interview on 7/2/2024 at 8:25 AM, Staff A, LPN, stated, I should have probably worn gloves when touching the medication and the one capsule that fell. I should have discarded and given another capsule. I should have sanitized the blood pressure cuff after using it with [Resident #7 name]. During an interview on 7/2/2024 at 9:28 AM, the Director of Nursing stated, If the staff drops the medication, they should dispose of it and get a new one. The staff should always wear gloves when handling medication and should clean the medical equipment in between patient use. If the patient vitals machines out in the hallway are covered with the plastic bag, it means they are clean and ready to be used on the next resident. Review of the facility policy and procedure titled Cleaning Blood Pressure Cuffs with the last review date of 2/15/2024 showed the policy read, Purpose: The purpose of this procedure is to prevent cross contamination when cleaning a blood pressure cuff. Procedure Guidelines . 2. Obtain alcohol prep pad or swab and use firm pressure to clean the blood pressure cuff before and after each resident use. Review of the facility policy and procedure titled Oral Medications with the last review date of 2/15/2024 showed the policy read, Protective Barriers That May Be Required: Handwashing, Gloves (as indicated) . Steps in the Procedure . 5. For unit dose tablets/capsules put packaged tablet/capsule (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 3 of 4 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 07/03/2024 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 0880 directly into medicine cup. Level of Harm - Minimal harm or potential for actual harm During an observation on 7/2/2024 at 9:40 AM, Staff B, LPN, Unit Manager, performed hand hygiene and entered Resident #32's room. Staff B donned gloves and removed a dressing dated 7/2/2024 from Resident #32's left heel. Staff B removed gloves and, without performing hand hygiene, donned a new set of gloves. Staff B cleansed the left heel wound area, pat the area dry, applied the ordered treatment and applied a new dressing without performing hand hygiene in between any of the wound care steps. Residents Affected - Few During an interview on 7/2/2024 at 9:48 AM, Staff B, LPN, Unit Manager, stated, I should have washed my hands when I took off my gloves after removing the dressing. I forgot. During an interview on 7/2/2024 at 10:00 AM, the Director of Nursing (DON) stated, The nursing staff should perform hand hygiene after removing gloves and when hands are considered contaminated. The nurse should have washed her hands in between the wound care steps. Review of the facility policy and procedure titled Dressing, Non-Sterile with the last review date of 2/15/2024 showed the policy read, Purpose: The purposes of this procedure are to provide guideline for non-sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria . Steps in the procedure . 10. Put on disposable exam gloves. 11. Loosen tape and remove soiled dressing. 12. Pull glove over dressing and discard into appropriate receptacle. 13. Wash hands or sanitize with ABHR [Alcohol Based Hand Rub] (if not visibly soiled). 14. Put on clean gloves. 16. Cleanse the wound. Use separate gauze for each cleansing stroke. Clean from the most contaminated area to the least contaminated area. 17. Use dry gauze to pat the wound dry. 18. Wash hands or sanitize hands with ABHR (if not visibly soiled) and apply new gloves. 19. Supply the ordered dressing and secure with tape. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 If continuation sheet Page 4 of 4