Health inspection·August 16, 2023

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few receiving steroid therapy to treat lung inflammation and for altered respiratory status/difficulty breathing related to episodes of shortness of breath. The interventions did not show the resident was assessed for self-administration of medications. On 8/16/23 at 10:35 a.m., the Director of Nursing (DON) reported not wanting to speak about a resident needing an assessment for self-administration (of medication). The Regional Nurse Consultant (RNC) reported reaching out to another RNC regarding a policy for self-administration. The RNC stated, on 8/16/23 at 10:43 a.m., the expectation was for the resident to be evaluated for self-administration (of medications). On 8/16/23 at 11:07 a.m., the RNC stated that an evaluation/assessment for self-administration should be done before being allowed for self-administration. The DON confirmed, on 8/16/23 at 11:47 a.m., that Resident #4 had no self-administration evaluation to be provided to this writer. The policy - Self-Administration of Medications, revised October 2010, identified that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The interpretation and implementation of the policy included the following: - As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. - The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. The interpretation indicated that in addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment for the resident which included the resident's ability to read and understand medication labels, comprehension of the purpose and proper dosage and administration time for his or her medications, ability, and ability to recognize risks and major adverse consequences of his or her medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 2 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents received medications in accordance with professional standards related to monitoring of blood pressure medications parameters and to ensure the physician was notified of held doses for one (#56) of six residents sampled for unnecessary medications. Residents Affected - Few Findings included: During a facility tour on 08/15/23 at 09:56 a.m., Resident #56 was observed lying on his bed. He stated he did not feel well because his blood pressure was too low. Resident #56 stated this had been going on for weeks and he had not seen the nurse practitioner or a physician. The resident said, I get dizzy, they said it's my ears, I don't think so. I am sweating all the time. The resident stated he had notified the nurses on multiple occasions, and they just held his blood pressure medication at that time. Resident #56 said, Last night my bed was soaked. I was sweating profusely. The CNA (Certified nursing Assistant) said I had spilled juice. It was not juice I was sweating badly. Review of an admission record dated 08/16/23 showed Resident #56 was admitted to the facility on [DATE] with diagnoses to include hypotension unspecified. Review of a Minimum Data Set (MDS) dated [DATE], showed Resident #56 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive response. Section G - Functional patterns showed the resident was totally dependent on staff for mobility and transfers. On 08/15/23 at 11:27 a.m., a follow up was conducted with Staff G, LPN (Licensed Practical Nurse) assigned to the resident. She stated she was aware the resident was having low blood pressure. She stated when this happens, they hold the medication. She stated they should notify the doctor whenever medications were held. During the interview, review of Resident #56's medication orders was conducted. Staff G noted the orders did not have parameters to hold the medication. When asked how she would know when to hold, Staff G said, when it is low. Review of a Medication Administration order with an effective date of 03/12/23, showed, Metoprolol Tartrate Tablet 25 Milligram (mg). Give 0.5 tablet by mouth every morning and at bedtime for HTN (Hypertension) for total of 12.5 mg each dose. Losartan Potassium oral tablet 25 mg. Give 0.5 mg tablet in the morning for HTN. On 08/15/23 at 12:34 p.m., Staff G, LPN confirmed the order did not have parameters to hold. She stated she had made the nurse practitioner aware of patient's concerns related to low blood pressures, and feeling like he was getting sick. She stated she had received new orders to discontinue Losartan and obtain labs. Staff G stated she had made the resident aware of all new orders. Review of MAR (Medication Administration Record) dated 8/01/23 to 8/31/23 showed Resident #56's Metoprolol documented with a number 5 indicating it was held on 8/1/23, 8/3/23, 8/8/23, 8/9/23 ,8/12/23 and 8/14/23. The MAR further showed Losartan Potassium was documented with a number 4 indicating it was outside of parameters on 8/02/23 , 8/03/23 and 8/08/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 3 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The MAR dated 7//01/23 to 7/31/23 showed Resident #56's Metoprolol was documented with a number 5 indicating it was held on 7/3/23 and 7/26/23. The Metoprolol was documented with a number 4 indicating it was outside of parameters on 7/2/23, 7/17/23, 7/28/23 and 7/30/23. The Losartan Potassium was held on 7/16/23 and it was outside of parameters on 7/2/23, 7/17/23, 7/28/23 and 7/30/23. Review of progress notes revealed the physician was not notified the medications were held, or they were outside parameters for 20 out of 60 encounters. On 08/15/23 at 10:19 a.m., an interview was conducted with the Director of Nursing (DON). He stated he should have expected there to be orders to hold. He reviewed the resident's orders with this surveyor. The resident did not have orders to hold and did not have parameters for blood pressure. Review of an undated facility policy titled, Physician Orders, showed orders for medications and treatments will be consistent with principles of safe and effective order writing. (1.) Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Medications should be given per the written order. (9.) Orders for medications should include: (e) Any interim follow-up requirements ( . therapeutic medication monitoring.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 4 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility did not ensure a resident with contractures received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to ensure restorative services were provided for one (Resident #56) of 14 residents. Findings included: On 08/13/23 at 10:01 a.m., an interview was conducted with Resident #56. The resident stated therapy was discontinued for him because of funding. The resident stated he was not receiving restorative services from the facility. Resident #56 was noted with a left arm contracture. He stated he was paralyzed on his left side and had some nerve ending damage. Resident #56 stated he used to receive exercises from nursing staff, but it had been a long time. He stated he was afraid of being contracted even more. Review of an admission record, dated 08/16/23 showed Resident #56 was admitted to the facility on [DATE] with diagnoses to include contracture, left shoulder, contracture on left elbow, contracture of muscle on left lower leg, Hemiplegia and Hemiparesis following infarction affecting left non-dominant side. Review of a Minimum Data Set (MDS) dated [DATE], showed Resident #56 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive response. Section G- Functional patterns showed the resident was totally dependent on staff for mobility and transfers. Review of a care plan dated 03/12/23 showed Resident #56 was at risk for loss of range of motion related to physical limitations. Interventions included assisted Range of Motion (ROM) of upper/lower extremities with ADL (Activities of Daily Living) care. On 08/15/23 at 3:00 p.m., an interview was conducted with the Director of Rehabilitation Services. He stated Resident #56 as a long-term resident who had received several episodes of therapy. He was discharged from Occupational Therapy (OT) and Physical therapy (PT) on 6/19/23 because his progress had plateaued, and he did not meet his goals. He stated Resident #56 wanted on-going therapy. He stated they would re-screen him because, We don't want him to decline. The DOR said, Right now there is no restorative program. We discharge residents to nursing staff and encourage nursing staff to do some ROM. We give them a therapy follow-up program. The DOR stated the follow-up program was specific to a resident's plan of care. He stated when Resident #56 was discharged from therapy, nursing received a therapy follow-up program for him. On 08/15/23 at 3:15 p.m., an interview was conducted with Staff G and Staff I, Licensed Practical Nurses (LPN). They confirmed they knew Resident #56 very well. They worked with him often. They both stated they did not know about the therapy follow-up program. Staff G said, I never heard of it. On 08/15/23 at 3:19 p.m., an interview was conducted with Staff J, CNA (Certified Nursing Assistant). She stated she had not seen any ROM tasks on the CNA assignments for Resident #56. Staff J stated she had seen the program in the past. She stated the restorative tasks would show in the CNA task log. She said, an example of a task log would be to complete passive ROM during care. It would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 5 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 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 0688 specific to each resident. I have not seen it in a while. Level of Harm - Minimal harm or potential for actual harm On 08/15/23 at 03:49 p.m., an interview was conducted with the Director of Nursing (DON). He said, We do not have a restorative program. It is a wish list right now. Staffing does not allow us to assign that program. The DON stated the nursing staff should be completing the restorative program, but they had not started. Residents Affected - Few On 08/16/23 at 10:02 a.m., an interview was conducted with the Regional Clinical Consultant (RCC). She stated she did not know about the facility's restorative program. She said, You should speak with the DON about that. A follow-up interview was conducted with the DON on 08/16/23 at 10:27 a.m. He stated they had been discussing the restorative program and identified they have a problem. The DON said, We have not been able to activate because the Unit Manager is new. we have not been able to do it. He confirmed a restorative program was to help maintain the level of function through assisting in ADLs and ROM. He stated the CNA's should be doing ROM during care. On 08/16/23 at 10:49 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She confirmed they did not have an established plan in place for their restorative program. A review of a facility policy titled, Restorative Nursing Services, dated 08/2022, showed a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Restorative nursing program refers to interventions that promote the resident's ability to adapt and adjust to living independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Under guideline, (2.) Residents may start on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. (6.) Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 6 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a pain assessment was conducted in a timely manner for one (Resident #13) of two residents reviewed for pain. Residents Affected - Few Findings included: On 08/13/23 at 10:00 a.m., an interview was attempted with Resident #13. The resident did not speak English. Staff F, CNA (Certified Nurse's Assistant) stated she would interpret for the surveyor. When asked if she had any concerns, Resident #13 motioned her hand over her peri area while grimacing and spoke in Spanish. The resident displayed frowning and clenching of her jaw as she spoke to Staff F. Staff F, CNA interpreted and stated the resident said she felt some irritation and pain in her peri area. Staff F stated the resident said the pain had started two days earlier. Resident #13 was observed wrinkling her nose and squeezing her eyes shut as she described how she was feeling. Resident #13 reported it hurts when she urinates. Staff F stated she would let the nurse know immediately. Staff F was observed leaving the room and heading to the nurse who was on her medication cart. Review of an admission Record for Resident #13 dated 08/16/23 revealed the resident was admitted to the facility on [DATE] with diagnoses to include, Unspecified severe protein calorie malnutrition, dementia, Parkinson's disease, anxiety disorder, and Alzheimer's disease among others. A review of a Minimum Data Set, dated , 08/02/23, section G- functional status, showed Resident #13 required extensive assistance for all ADLs (Activities of Daily Living). Review of a care plan dated 03/23/21 showed a focus, Resident #13 is at risk for pain related to complaints of generalized pain with a goal to reduce episodes of pain breakthrough. Interventions included reporting non-verbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. On 08/14/23 at 1:27 p.m., an interview was conducted with Staff F, CNA. She confirmed she had notified Staff G, LPN (Licensed Practical Nurse) of Resident #13's pain the day before. Staff F said, I told the nurse the resident had stated she had pain, burning and irritation in her vaginal area, and that it hurts when she urinates. Staff F stated she did not know what the nurse did about it. On 08/14/23 at 1:32 p.m., an interview was conducted with Staff H, LPN Agency. She stated she was assigned to Resident #13. She stated she did not know this resident had any pain concerns. She was not notified and there was no documentation related to new pain concerns. Staff H and this writer spoke to the resident. Resident #13 was observed grimacing and closing her eyes and her hands moving in circular motion as she pointed to her vaginal area. Staff H said, The resident confirmed she was still in pain. She described tingling and irritation to her vaginal area. Staff H stated she would let the doctor know. She stated she thought the resident might have an untreated infection. On 08/14/23 at 1:47 p.m., an interview was conducted with the Director of Nursing (DON). He stated the nurse who was initially notified of the pain should have completed a change in condition at the time the resident reported pain and irritation. The DON said, at the very least, the report would include a pain assessment and to notify the doctor. The DON stated there should be a note documenting the encounter. The DON confirmed there was no documentation related to the pain report. He stated he would assess the resident and notify the ARNP (Advanced Registered Nurse Practitioner). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 7 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm On 08/15/23 at 9:46 a.m., an interview was conducted with Staff G, LPN. She confirmed she had worked on Sunday 08/13/23 the 7:00 a.m. to 3:00 p.m. shift. Staff G said, The CNA told me [Resident #13] had some pain, she reported she had irritation and burning in her peri area. To be honest, it was my mistake. I forgot. Staff G stated what she should have done was notified the doctor and also fill out the Change in Condition. Residents Affected - Few On 08/15/23 at 01:51 p.m., a follow -up was conducted with the Regional Clinical Consultant (RCC). She stated she would expect the nurses to follow their policies. On 08/16/23 at 11:00 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated her expectation would have been to have the resident assessed for pain right away. The NHA stated she expected their residents would be receiving quality care. The NHA said, A resident should not wait to be assessed for pain. It is absolutely unacceptable. That nurse did not do what she was supposed to do. The NHA confirmed a timely response should have followed. Review of a facility policy titled, Pain Evaluation and Management, revised, February 2023, showed, acute pain (or significant worsening of chronic pain) should be evaluated 30 to 60 minutes after the onset and re-evaluated as indicated until relief is obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 8 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and seven errors were identified for three (#73, #11, and #446) of four residents observed. These errors constituted a 25.93% medication error rate. Residents Affected - Some Findings included: 1. On 8/13/23 at 11:11 a.m., an observation of medication administration with Staff A , Licensed Practical Nurse (LPN), was conducted with Resident #73. Staff A obtained a blood glucose level of 207 from the resident and dispensed the following medication: - Novolog FlexPen The staff member dialed the pen to 4 units, placed the pen and needle in a plastic cup, and entered the residents room. Staff A applied a needle to the pen and injected the insulin in the back of the residents' left arm. Staff A did not prime the insulin pen prior to the injection. The Director of Nursing (DON) stated, on 8/15/23 at 2:14 p.m., Novolog pens needed to be primed. The DON reported to prime insulin pens was to set it (dose selector) to 2 units, with needle pointed upwards, push it to zero, then dial to the units and administer. The DON provided documentation for instructions for use of Humalog KwikPen that showed staff were to Prime before each injection. The instructions showed Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. According to the manufacturer instructions, located at https://www.novo-pi.com/novolog.pdf, identified the following: - Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to select 2 units; - F. Hold your with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the NovoLog® FlexPen® needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog® FlexPen® and contact [manufacturer] A small air bubble may remain at the needle tip, but it will not be injected. 2. On 8/14/23 at 8:24 a.m., an observation of medication administration with Staff B, Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 9 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Practical Nurse (LPN), was conducted with Resident #11. Staff B dispensed the following medications: Level of Harm - Minimal harm or potential for actual harm - Iron 325 milligram (mg) tablet - Wellbutrin 150 mg Extended Release (XL) tablet Residents Affected - Some - Eliquis 5 mg tablet - Furosemide 40 mg tablet - Lactulose 10 gram/15 milliliter (gm/mL) - 30 mL's - Diltiazem Extended Release (ER) 240 mg capsule - Potassium Chloride 20 milliequivalent's (meq) tablet - Multi Vitamin with mineral tablet - Senna 8.6 mg - 2 tablets - Sodium chloride 1 gm tablet - Acidophilus tablet - Vitamin C 500 mg tablet - Zenpep 5000 unit capsule - Aranesp injectable 25 microgram (mcg) syringe - Metoprolol Tartrate 25 mg - 2 tablets A review of Resident #11's August Medication Administration Record (MAR) showed the resident was to receive the following physician ordered medications and not the ones observed as administered: - Multi Vitamin oral Tablet (did not include minerals) - 2 tablets of Senna Plus 8.6-50 mg The website: medline.gov described Senna as Senna is used on a short-term basis to treat constipation. It also is used to empty the bowels before surgery and certain medical procedures. Senna is in a class of medications called stimulant laxatives. It works by increasing activity of the intestines to cause a bowel movement. The website: webmd.com described Senna Plus as This product is used to treat constipation. It contains 2 medications: Sennosides and Docusate. Sennosides are known as stimulant laxatives. They work by keeping water in the intestines, which helps to cause movement of the intestines. Docusate is known as a stool softener. It helps increase the amount of water in the stool, making it softer and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 10 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 easier to pass. Level of Harm - Minimal harm or potential for actual harm 3. On 8/14/23 at 9:17 a.m., an observation of medication administration with Staff C, Registered Nurse (RN), was conducted with Resident #446. Staff C dispensed the following medications: Residents Affected - Some - Tamsulosin 0.4 mg capsule - Thiamin B1 100 mg capsule - Pantoprazole Delayed Release (DR) 40 mg tablet - Nifedipine 30 mg ER tablet - Clopidogrel 75 mg tablet The staff member confirmed dispensing 5 tablets prior to entering Resident #446's room and assisting the resident with the administering. After returning to the medication cart Staff C reported the medication pass was complete and moved the medication cart to the nursing station then sat down behind the station. A review of Resident #446's August Medication Administration Record (MAR) showed the resident was to receive one tablet of Thiamine 250 mg instead of the one 100 mg tablet observed as given. The MAR showed Staff C documented the following medications had been administered: - Polyethylene Glycol 3350 powder - 17 gm's by mouth one time a day for constipation; - Carvedilol 6.25 mg tablet two times a day for hypertension; - Docusate Sodium 100 mg capsule two times a day for constipation. An interview was conducted on 8/15/23 at 11:18 a.m., with Staff D, LPN/Unit Manager (UM) regarding the administration of medication for Resident #446. Staff D reviewed Resident #446's MAR and said Staff C had confirmed 5 tablets had been dispensed for Resident #446. Staff D confirmed Staff C had documented on 8/14/23 at 9:25 a.m. the resident had received Polyethylene Glycol, Carvedilol, and Docusate sodium. The Director of Nursing (DON) stated on 8/15/23 at 2:14 p.m. the expectations were for staff to follow physician orders and follow the 5 rights of medication administration that included: Right patient, right dose, right medication, and right time. On 8/14/23 at 1:24 p.m., the Regional Nurse Consultant (RNC) stated the Medication Administration policy was generic, the facility followed physician orders, and said an insulin administration policy would be a general policy. The facility policy - Medication Administration, undated, showed Orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy instructed staff on the documentation required for obtaining a physician order and not staff responsibilities for the dispensing and administration of medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 11 of 12 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 105599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm The policy - Documentation of Medication Administration, revised April 2007, indicated that The facility shall maintain a medication administration record to document all medication administered. The interpretation and implementation portion of the policy indicated that Administration of medication must be documented immediately after it is given. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105599 If continuation sheet Page 12 of 12