Health inspection·August 21, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dignity to one resident (#108) out of two sampled residents related to a catheter bag covering.Findings included:During an observation and interview on 08/18/2025 at 9:05 AM Resident #108's urinary catheter collection bag was hanging on the left side of the Resident's bed, uncovered, containing 300 milliliters (ML) of yellow fluid. There was a folded up white towel placed under the collection bag on the floor. Resident #108 stated, The urine bag has not been covered. Everyone can see it when they enter the room or even walk by, and it is embarrassing.Review of Resident #108's medical record revealed Resident #108 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, fracture of the right femur, subsequent encounter for closed fracture with routine healing, encounter for surgical aftercare following surgery on the digestive system, cholecystitis, and urinary retention.Review of Resident #108's physician order dated, 08/17/2025 revealed, indwelling urinary catheter: size 16 french (16fr) 30 milliliter (ml) for diagnosis of: urinary retention.An interview was conducted on 08/19/2025 at 2:00 PM with the DON who stated, All foley catheter bags should have a dignity cover over the bag.Review of facility's policy titled Catheter Care-Quality of Care, with an approval date of 01/28/2025 revealed, Procedure 3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is kept at an appropriate level to promote urine flow, and dignity is maintained. Catheter coverings are not required when drainage bags are out of sight from the public or per the resident's preference.Review of facility's policy titled Standards and Guidelines: Resident Rights, with a revision date of 1/2024 revealed, Procedure: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; Page 1 of 12 105599 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment and implement their policy on securing smoking materials in a secure location for one resident (#3) out of three residents reviewed for accidents.Findings included:Review of Resident #3 medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of, but not limited to, trimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing, asthma, chronic obstructive pulmonary disease (COPD), unspecified, type 2 diabetes mellitus with other oral complications, non-ST- elevation myocardial Infarction (heart attack), chronic diastolic (congestive) heart failure, and essential (primary) hypertension.Review of a list, provided by the Administrator titled, Residents who smoke revealed, the first and last name of Resident#3.An observation was conducted on 08/18/2025 at 09:00 AM, of Resident #3 reclining in bed. Attached to the bedside table, in a clear plastic bag, contained a light blue pack of cigarettes that was labeled 305's and two multicolored lighters. The bedside table is on the Resident #3's right side, perpendicular to the bed.An interview was conducted on 08/18/2025 at 09:01 AM with Resident #3 who stated I have kept my cigarettes and lighter in the room with me. They don't have a problem with that, and I don't want to give them one. I need assistance into the wheelchair but then I could go out when I want, no problems. An observation was conducted on 08/18/2025 at 11:00 AM of Resident #3 wheeling her wheelchair down the hall toward the main entrance doors asking staff who took cigarettes out of her room.An interview was conducted on 08/20/25 at 2:00 PM, the Nursing Home Administrator stated it is the facility's policy to have the cigarettes and the lighters locked up and removed during the scheduled smoking times. It is the responsibility of whoever takes them out to ensure they hand out and make sure they are returned after the smoking break is over.Review of the facility's policy and procedure titled Resident Smoking Supervised and Unsupervised-Use of Electronic Smoking/Vaping Devices with a revision date of 11/2022 revealed, Procedure: 11. Residents who have independent smoking privileges are not permitted to keep cigarettes, E cigarettes, pipes, tobacco, nicotine, and other smoking/vaping articles in their possession including all forms of lighters, matches, and electronic smoking/vaping device paraphernalia. 2. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including use of electronic smoking/vaping devices, designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences 12. Residents who have independent smoking privileges may request smoking/vaping materials from nursing personnel when desired, thus alerting nursing personnel of their intention to smoke at that time. Following use, lighters/matches, unused cigarettes, electronic cigarettes, vaping materials, etc. shall be returned to nursing personnel for safe storage. 13. Residents without independent smoking privileges may not have or keep any smoking/vaping materials, including cigarettes, E cigarettes, tobacco, nicotine, etc., except when they are under supervision. 14. Residents who require supervision with smoking privileges may be supervised by facility staff, volunteers, and family/legal representative during facility designated smoke times. 105599 Page 2 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure midline catheter dressing changes were completed according to professional standards of practice for one resident (#111) of one resident reviewed with a midline catheter.Findings include:During an observation on 08/18/2025 at 9:45 AM Resident #111 was observed in bed with a left upper arm single lumen midline catheter, with a dressing date of 08/11/2025 with gauze under the transparent semi-permeable dressing.During an observation on 08/18/2025 at12:15 PM Resident #111 was observed in bed with a left upper arm single lumen midline catheter with date of 08/11/2025 with gauze under the semi-permeable transparent dressing. Review of Resident #111's admission record revealed an admission date of 08/09/2025 and diagnoses of encounter for surgical aftercare following surgery on the genitourinary system, generalized anxiety disorder, adjustment disorder with depressed mood, adjustment insomnia, acute cystitis with hematuria, metabolic encephalopathy, and sarcopenia.Review of Resident #111's physician order dated 08/11/2025 revealed, Mid Line left arm: Change dressing within 24 hours of admission, insertion, or reinsertion and Q [every]7 Days and PRN [as needed] thereafter using sterile technique. Measure arm circumference and external length of catheter. every day shift every 7 day(s) and as needed and one time only for 1 Day Change dressing within 24 hours of admission/insertion/reinsertion using sterile technique.During an interview on 08/18/2025 Staff F, Licensed Practical Nurse (LPN) stated, I don't know about when the dressing should be changed, its every seven days, I think. No, I don't think there are any other reasons it should be changed.During an interview on 08/20/2025 at 7:15 AM the Director of Nursing (DON) stated, It is my expectation that all dressings get changed per policy and for midlines. Any dressing with gauze would be a two-day dressing.During a phone interview on 08/20/25 at 5:19 PM, Resident #111's Advanced Practical Registered Nurse (APRN) said all dressings should be placed for central and midline catheters per the orders. And if the dressing had gauze under it, it should be changed every two days.A request for a midline catheter policy and procedure was made to the DON on 08/20/2025 at 7:20 AM. One was not provided at the time of the survey exit.Review of the Centers for Disease Control and Prevention (CDC) Summary of Recommended Frequency of Replacements for Catheters, Dressings, Administration Sets, and Fluids with a publication date of August 9, 2002, revealed Replacement of catheter site dressing for midline catheters was to Replace dressing when the catheter is removed or replaced, or when the dressing becomes damp, loosened, or soiled. Replace dressings more frequently in diaphoretic patients. In patients who have large bulky dressings that prevent palpitation or direct visualization of the catheter insertion site, remove the dressing and visually inspect the catheter at least daily and apply new dressing. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5132a9.htm. Residents Affected - Few 105599 Page 3 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received respiratory services consistent with professional standards of practice related to oxygen administration and respiratory equipment storage for four residents (#99, #78, #42 and #83) out of four sampled residents. Findings included: Residents Affected - Some 1. Review of Resident #99’s admission record revealed an admission date of 02/08/2025 and diagnoses of chronic obstructive pulmonary disease unspecified (lung disease that blocks air flow in the lungs and makes it hard to breath), hyperlipidemia unspecified (high cholesterol), and essential primary hypertension (high blood pressure). Review of Resident #99's physician orders dated 07/23/2025 revealed, Respiratory-Oxygen: NC [nasal cannula]/Mask. Encourage and assist resident to use O2 [oxygen] @ 2 liters via NC as needed for SOB [shortness of breath]/DOE [dyspnea on exertion] as needed for O2 less than 93%. Review of Resident #99's comprehensive care plan revealed a focus of the resident is at risk for altered respiratory status/difficulty breathing r/t (related to) COPD (chronic obstructive pulmonary disease)/emphysema with an intervention of administer oxygen as ordered. During an interview on 08/18/2025 at 2:26 PM Resident #99 stated, I don't touch the oxygen, I need it, I have COPD. During an interview on 08/18/2025 at 2:30 PM Staff E, Licensed Practical Nurse (LPN) stated, I was not aware that the oxygen was wrong, maybe it got bumped when the aides were giving her care. During an interview on 08/20/2025 at 9:30 AM the Director of Nursing (DON) stated, I do expect all staff to have the oxygen running at the correct amount and to follow the orders. We do not have a specific policy for oxygen administration. 2. Review of Resident #78's admission record documented diagnosis that include Parkinson's disease without dyskinesia without mention of fluctuations, unspecified diastolic congestive heart failure, unspecified atrial fibrillation (an irregular heartbeat), and peripheral vascular disease unspecified. During an observation on 08/18/2025 Resident #78 was observed sitting at bedside in a wheelchair. Resident #78 was sitting on the left side of the bed, and the oxygen concentrator was on the right side of the bed out of the residents’ reach. The oxygen concentrator was set at four liters per minute. Review of Resident #78's physician orders dated 06/11/2025 revealed, “Respiratory-Oxygen: NC [nasal cannula] Continuous. Encourage and assist resident to use O2 @ 2 Liters via NC continuously CHF [congestive heart failure] Patient may apply/remove device adlib every shift for SOB [shortness of breath] related to UNSPECIFIED DIASTOLIC (CONGESTIVE) FAILURE.” During an interview on 08/18/2025 at 2:38 PM, Staff E, LPN stated, That oxygen should be at two liters. I usually check it when I give meds and make sure it’s correct then. I do need to follow the doctors’ orders. 105599 Page 4 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. An observation was conducted on 08/18/2025 at 9:40 AM of Resident #42 ambulating in the room from the bathroom to sit on the edge of the bed. A nebulizer mask is located on the bedside table to the right of the Resident’s bed unbagged and not labeled. Review of Resident #42’s medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of, but not limited to, chronic obstructive pulmonary disease (COPD), chronic systolic (congestive) heart failure, pre-excitation syndrome, and paroxysmal atrial fibrillation. Review of Resident #42’s physician order dated 07/06/2025, revealed, Arformoterol Tartrate 15 Micrograms (MCG)/2 milliliters (ML) Nebulization solution, 1 vial inhale orally via nebulizer two times a day for COPD. And a physician order dated 07/08/2025, revealed, Budesonide Suspension 0.5 MG (milligrams)/2ML, 2 ml inhale orally via nebulizer two times a day for COPD. Review of Resident #42’s medication administration record (MAR) documentation revealed Arformoterol Tartrate was delivered via nebulizer at 0900 (09:00 AM) and 1700 (5:00 PM) daily, beginning on 07/06/2025. Budesonide Suspension was delivered via nebulizer at 0900 (09:00 AM) and 1700 (5:00 PM) daily, beginning on 07/08/2025. 4. An observation was conducted on 08/18/2025 at 09:50 AM, Resident #83 was lying in bed with his eyes closed. The nebulizer mask attached to the nebulizer machine was laying on top of a blanket rolled up on the chair to the right side of Resident #83. Review of Resident #83’s medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses of, but not limited to, chronic diastolic (congestive) heart failure, other malformations of cerebral vessels, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), unspecified, and unspecified asthma, uncomplicated. Review for Resident #83’s physician order, dated 07/28/2025, revealed, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB). Review of Resident #83’s medication administration record (MAR) for Resident #83 revealed the medication was administered on 08/19/25 at 09:00 AM. An interview was conducted on 08/19/2025 at 11:25 AM, with the DON, who stated, “Once the nebulizer is complete the mask should be bagged and labeled”. Review of the facility’s policy and procedure titled “Standards and Guidelines: Nebulizers” with a revision date of 12/2023 revealed, “General Guidelines 4. Store nebulizer in [sic] tubing in a hygienic manner when not in use (i.e. labeling bag with date tubing was changed”. Review of the policy and procedure titled, Oxygen Administration, revised 12/2023, revealed, Standard: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 1. Review the physician's order for oxygen administration. General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device, per physicians’ orders. 105599 Page 5 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to administer insulin according to physician orders for one resident (#65) out of two residents reviewed for insulin administration.Findings included:Review of Resident #65's admission record revealed a diagnosis of type 2 diabetes mellitus without complications.Review of Resident #65's physician order dated 04/17/2025 revealed, Insulin Glargine-yfgn 100 UNIT/ML(milliliter) Solution pen-injector. Inject 50 unit subcutaneously at bedtime for diabetes and inject 5 unit subcutaneously in the morning for DM [diabetes mellitus].Review of Resident #65's August medication administration record revealed documentation on 08/02/2025 at 6:00 AM of a chart code of 4. Review of the Chart Codes/ Follow Up Codes revealed 4=Pulse below 60/min [minute] Ineffective.Review of Resident #65's July medication administration record revealed documentation on 07/16/2025 at 6:00 AM, on 07/25/2025 at 6:00 AM, on 07/28/2025 at 6:00 AM and on 07/30/2025 at 6:00 AM a chart code of 4.During an interview on 08/20/2025 at 6:30 AM Staff G, Licensed Practical Nurse (LPN) stated, I did hold the insulin in the morning, it [blood sugar] was low and her parameters on the other insulin so I held it. I guess I should have let the doctor know.During an interview on 08/20/2025 at 6:54 AM the Director of Nursing (DON) stated, I would expect all staff to follow the orders for insulin.During a phone interview on 08/20/25 at 5:19 PM, Resident #111's Advanced Practical Registered Nurse (APRN) stated I expect to be notified if nurses are holding insulin . I expect parameters to be followed. I am usually on call. I don't think holding the long acting five units would have caused any concerns for harm, she was also getting 50 units at night and [sliding scale insulin]. 105599 Page 6 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure pharmacy reviews were conducted monthly and the facility failed to ensure a physician provided a clinical rational for two residents (#11 and #51) out of five residents reviewed for medication regimen review (MRR). Findings included: 1. Review of Resident #11’s Consultant Pharmacist MRR’s for the months of August 2024 through July 2025 revealed the following: · There was no documentation a pharmacist performed an MRR for the month of September 2024 for Resident #11. · There was no documentation a pharmacist performed an MRR for the month of October 2024 for Resident #11. · There was no documentation a pharmacist performed an MRR for the month of April 2025 for Resident #11. · A pharmacy review for the month of June 2025 had a pharmacist recommendation for Resident #11 that revealed, the Resident received Eliquis 5mg (milligram) twice daily for “anticoagulation” and Phenytoin ER (extended release) 200mg every 12 hours for seizures. A recommendation was made to re-evaluate the continued use of the combination of Eliquis and Phenytoin because it may decrease the serum concentrations of Apixaban [Eliquis]. Per the manufacture, this combination should be avoided because of the interacting drugs effect of decreasing exposure to apixaban. There was a signature and a response from the physician dated 07/07/2025 to disagree, but there was no clinical rationale noted. A review of the “Census” for Resident #11 showed the date of admission was on 05/29/2024 with no in-active dates or discharges since the date of admission. An interview was conducted with the Director of Nursing (DON) on 08/21/25 at 7:45AM related to the pharmacy review for Resident #11. The DON confirmed that a rationale had not been provided by the physician for disagreeing with the recommendations by the pharmacy consultant for the month of June 2025. The DON also confirmed Resident #11 was not on the list of residents who had a medication regiment review but had no recommendations for September 2024, October 2024, and April 2025. The DON confirmed Resident #11 did not have a medication regimen review for September 2024, October 2024, and April 2025. 2. Review of Resident #51’s medical record revealed an admission date of 03/29/2023 with diagnoses including, but not limited to polyneuropathy, dementia, depression, anxiety and muscle weakness. Review of Resident #51's physician orders revealed an order dated 06/25/2024 for “Mirtazapine oral tablet 7.5 mg [milligram] -give 1 tablet by mouth at bedtime for depression with no end date.” 105599 Page 7 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0756 Level of Harm - Minimal harm or potential for actual harm Review of Resident #51’s Consultant Pharmacist MRR documents revealed a recommendation made on 05/31/2025 which read, Psychiatry recommendation: RE (regarding): Mirtazapine 7.5 mg at bedtime for depression started 11/21/24. Please consider a gradual dose reduction to Mirtazapine 7.5 mg every other night at bedtime x (for) 30 days, then discontinue. The Physician disagreed but did not provide a clinical rationale on the form or in a progress note. Residents Affected - Few During an interview on 08/21/2025 at 12:06 PM, the DON confirmed the physician did not write a rationale for the disagreement with the recommendation made for Resident #51’s medication on 05/31/2025. Review of facility’s policy Medications Utilization and Prescribing- Clinical Protocol, with a revision date of 01/2024, revealed Guideline: The facility will comply with the requirements specified in accordance with State and Federal regulations as they pertain to Medications Utilization and Prescribing. Procedure: 2. The Physician and staff will identify situations in which a resident is taking medications associated with potentially significant medication- related problems such as allergies, drug- drug interactions, drug-food interactions and adverse drug reactions .4. The consultant pharmacist may help by reviewing facility medications usage patterns and trends and by medication reviews of individuals taking medications that present clinically significant risks .6. The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms. 105599 Page 8 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure physician ordered parameters were followed related to hypertensive medications resulting in the administration of unnecessary medications for one resident (#106) out of five residents reviewed for unnecessary medications.Review of Resident #106 admission record documented diagnosis of unspecified atrial fibrillation, heart failure unspecified, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, unspecified osteoarthritis unspecified malignant neoplasm of esophagus unspecified, and atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain).Review of Resident #106 physician order dated 3/22/2025 read, Metoprolol Succinate ER (extended release), extended release 24 hour 25 mg (milligrams) give 0.5 tablet every 12 hours for hypertension, hold for SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60.Review of Resident #106's Medication administration record for April 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 0900 ( 9:00 AM) on 4/11/2025 with a Blood pressure (B/P) of 114/57, on 4/12/2025 with a B/P of 104/51, on 4/22/2025 with a B/P of 99/57, and on 4/27/2025 with a blood pressure of 74/36.Review of Resident #106's Medication administration record for April 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 2100 (9:00 PM) on 4/1/2025 with a B/P of 111/59, on 4/2/2025 with a B/P of 96/65, on 4/3/2025 with a B/P of 103/58, on 4/7/2025 with a B/P of 86/57, on 4/11/2025 with a B/P of 104/51, on 4/14/2025 with a B/P of 79/50, on 4/18/2025 with a B/P of 90/54, on 4/22/2025 with a B/P of 119/41 and on 4/25/2025 with a B/P of 88/63.Review of Resident #106's Medication administration record for May 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 0900 (9:00 AM)on 5/2/2025 with a blood pressure (BP) of 116/52, on 5/5/2025 with a B/P of 103/55, on 5/12/2025 with a B/P of 102/53, on 5/14/2025 with a B/P of 100/57, on 5/22/2025 with a B/P of109/54, on 5/29/2025 with a B/P of 118/59 and on 5/30/3035 with a B/P of 110/58. Review of Resident #106's Medication administration record for May 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 2100 (9:00 PM) on 5/6/2025 with a B/P of 118/54, on 5/10/2025 with a B/P of 105/57, on 5/18/2025 with a B/P of 98/58, on 5/20/2025 with a B/P of 106/52 and on 5/23/2025 with a B/P of 96/49.Review of Resident #106's Medication administration record for June 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 0900 on 6/15/2025 with a B/P of 119/59, on 6/16/2025 with a B/P of 107/58, on 6/23/2025 with a B/P of 119/54, and on 6/27/2025 with a B/P of 113/53, Review of Resident #106's Medication administration record for June 2025 documents that Metoprolol Succinate ER 25 mg give 0.5 tablet was administered at 2100 on 6/1/2025 with a B/P of 101/59, on 6/15/2025 with a B/P of 101/59, on 6/16/2025 with a B/P of 100/56, on 6/18/2025 with a B/P of 98/53, on 6/24/2025 with a B/P of 103/54 and on 6/29/2025 with a B/P of 98/66.expect to be notified if nurses are holding insulin or blood pressure medications. I expect parameters to be followed. I am usually on call.During an interview on 8/21/2025 at 5:05 AM Staff H, Licensed Practical Nurse (LPN) stated, I didn't realize that I had given them with the blood pressure low or outside of the parameters. I always check my own blood pressure every day. I should not have administered them outside the parameters. During an interview on 8/21/2025 at 6:54 AM the DON stated, All medications should be administered or held per any parameters that are written. Residents Affected - Some 105599 Page 9 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

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 policy review, the facility failed to ensure food in the refrigerator was discarded upon the expiration date and the facility failed to ensure the facility had and followed a cleaning schedule for food service equipment for one of one kitchen.Findings included: A kitchen tour was conducted on 08/18/2025 at 9:07 AM with the Dietary Manager (DM). The walk-in refrigerator revealed two containers of cottage cheese that had an expiration date of 08/16/2025. The tour of the kitchen also revealed a covered piece of equipment identified as a meat slicer. The DM uncovered the meat slicer stating it was supposed to be clean when covered. An observation was made of food particle debris on the base and blade of the meat slicer.An interview with the Dietary Manager (DM) was conducted on 08/18/2025 at 9:17 AM. The DM confirmed the two expired cottage cheese containers and the food particle debris on the meat slicer. The DM verified expired foods should be disposed of prior or on the expiration date. The DM stated the meat slicer should not have been covered until it was properly cleaned.A review of the facility's policy titled Food Storage, with a revision date of 12/2024 revealed, foods shall be received and stored in a manner that complies with safe food handling practices.A review of the facility's policy titled Sanitation, with a revision date of July 2023, revealed, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, except during tray line and production use/time. 105599 Page 10 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review and policy and procedure review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases for three residents (#1, #14, #44 and #27) out of seven residents sampled for infection control. Findings included: 1. On 08/18/2025 at 1:17 PM Resident #1's room was observed without isolation signage or personal protective equipment (PPE) available outside or in Resident #1's room, Staff E, Certified Nursing Assistant (CNA) was observed entering Resident #1's room with incontinence care supplies, closed the door, and Staff E, CNA did not don a gown prior to entering Resident #1's room. Staff E, CNA was observed assisting Resident #1 with gloves on but no gown. Staff E, CNA removed a soiled brief and provided incontinence care. Staff E, CNA stated, Oh I'm just changing [Resident #1]. Staff E, CNA confirmed Resident #1 should be on enhanced barrier precautions because she has a catheter and confirmed she should be wearing a gown because she was performing care.On 08/18/2025 at 1:45 PM the facility staff was observed in the 300 and 400 hallways placing enhanced barrier precaution signage on doorways and placing PPE of gowns and gloves outside in the hallways.Review of Resident #1's admission record document revealed diagnoses of pneumonia, unspecified Organism, type 2 diabetes mellitus without complications, chronic kidney disease stage 4 severe, paroxysmal atrial fibrillation, depression unspecified, essential primary hypertension, sarcopenia, cognitive communication deficit, obstructive and reflux uropathy comma and chronic pain syndrome. Review of Resident #1's physician order dated 08/18/2025 revealed, Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precautions for sacral wound. every shift.Review of Resident #1's physician order dated 8/6/2025 revealed, Treatment as follows: Sacrum - Cleanse with NS, pat dry. Apply skin prep to peri wound area. Apply Santyl to wound bed; then calcium alginate AG (Silver) cover with bordered gauze. every day shift for open area AND as needed Change dressing if becomes soiled or dislodged.Review of Resident #1's care plan revealed, Focus: Resident requires enhanced barrier precautions during high contact resident care activities r/t (related to) sacral wound.Goal: enhanced barrier precautions will remain in effect for limited periods (i.e. while the risk of transmission of the infectious agent persists or for the duration of the illness) Interventions: enhanced barrier precautions: sacral wound during high contact care activities, dressing, bathing showering transferring providing hygiene changing linens changing briefs or assisting with toileting.2. On 08/21/2025 at 5:11AM observed Staff K, CNA enter Resident #14's room with supplies to provide incontinence care, there was an enhanced barrier precaution sign and PPE supplies in the hallway and in the resident's room. Staff K, CNA did not perform hand hygiene, donned gloves, removed Resident #14's brief and provided care without donning a gown. Staff K, CNA got assistance from Staff A, CNA, retrieved a mechanical lift machine and without donning PPE, both staff assisted the resident out of bed into a wheelchair.On 08/21/2025 at 5:35 AM Staff K, CNA confirmed Resident #14 was on enhanced barrier precautions and said, I should have had a gown on, I'm sorry I forgot.On 08/21/2025 at 5:43 AM Staff A, CNA stated, Oh that's right we should have had on gowns when we got [Resident #14] up.3. During an observation of Resident #44 on 8/19/2025 at 12:21 PM , Staff C, CNA entered Resident #44's room with a mechanical lift. Staff C did not perform hand hygiene and did not don a gown. Staff C, CNA assisted Resident #44 back to bed, repositioned the resident and exited the room without performing hand hygiene.During an interview on 08/19/2025 at 12:50 PM Staff C, CNA stated, He does have a G [gastrostomy] tube and I should have had a gown on.Review of Resident #44's admission record revealed an admission date of 8/6/2025 and diagnoses of metabolic encephalopathy, unspecified Residents Affected - Some 105599 Page 11 of 12 105599 08/21/2025 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asthma uncomplicated, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance anxiety, unspecified depression, chronic kidney disease unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, presence of cardiac pacemaker, venous insufficiency chronic peripheral, status gastrostomy, sarcopenia, dysphasia oropharyngeal phase, cognitive communication deficit.Review of Resident #44 physician orders dated 08/7/2025 revealed, Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precautions r/t PEG-tube. every shift for infection control. Review of Resident #44's comprehensive care plan revealed, Focus: Resident requires Enhanced Barrier Precautions during High contact Resident care activities r/t [related to] tube feed . Goal: Enhanced Barrier Precautions will remain in effect for limited periods (i.e. while the risk of transmission of the infectious agent persists or for the duration of the illness). Interventions: Enhanced Barrier Precautions: tube feed during high contact care activities, dressing, bathing showering, transferring providing hygiene, changing linens, changing briefs or assisting with toileting.4. On 08/21/2025 at 9:18 AM observed Staff L, CNA entered Resident #27's room with incontinence care supplies, there was an enhanced barrier precaution sign at the doorway, no PPE in the room but PPE was available in the hallway. Staff L, CNA explained to Resident #27 that she was cleaning her up. Staff L, CNA did not perform hand hygiene, donned gloves, and began to provide incontinence care by removing Resident #27's brief. Staff L, CNA completed the care and exited Resident #27's room after doffing gloves. Staff L, CNA did not perform hand hygiene and went to another resident's room to provide care.On 08/21/2025 at 9:27 AM Staff L, CNA stated, [Resident #27] is on enhanced barrier precautions I should have put a gown on, I had gloves on I thought that was enough. Oh, I should have washed my hands before and after I took off my gloves.Review of the Policy and Procedure titled, Handwashing/Hand Hygiene Level I, with an approval date of 01/28/2025 revealed, Purpose: The purpose of this procedure is to provide for effective guidelines for effective hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. General Guidelines: 1. Appropriate twenty (20) second handwashing with antimicrobial or antimicrobial soap and water must be performed under the following conditions: a. Before and after direct contact with residents: .c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions. 2. The use of gloves does not replace handwashing. 105599 Page 12 of 12