Inspection·June 30, 2022

F 0583 Keep residents' personal and medical records private and confidential. 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 personal privacy during enteral gastrostomy tube feeding for 2 of 2 residents receiving ostomy care, Resident #92 and Resident #410. Residents Affected - Few Findings include: 1. Review of Resident #92's records revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, protein-calorie malnutrition, gastrostomy tube, hypertension, cardiovascular disease, anemia, hyperlipidemia, major depressive disorder, GERD (Gastroesophageal Reflux Disease). Review of the physician orders for Resident #29 reads, Order Summary: Enteral Feed Order every 4 hours Bolus with 8 oz (240 ml [milliliter]) Jevity 1.5 via g-tube q [every] 4 hours. Order Date: 12/01/2021. During an observation on 6/27/2022 at 2:00 PM, Staff A, Registered Nurse (RN), approached Resident #92 to administer his enteral feeding. Staff A pulled the privacy curtain halfway and left the door wide open. Staff A proceeded to expose the abdomen to visualize the G-tube. Staff A attached the feeding syringe to the distal end of the G-tube and poured 100 ml of water. Staff A proceeded to pour Jevity 1.5, 237 ml via gravity. Staff A exited the resident room at 2:10 PM. During an interview with Staff A, RN, on 6/27/2022 at 2:11 PM, when asked if he ensured privacy for Resident #92 during G-tube feeding, Staff A stated, I was about to pull the curtain around, but his roommate was leaving the room. 2. Review of Resident #410's records revealed the resident was admitted on [DATE] with the diagnoses to include gastrostomy tube and dysphagia. Review of the physician orders for Resident #410 reads, Order Summary: Jevity 1.5 Cal Liquid (Nutrition Supplements), Give 240 ml via G-tube every 4 hours related to Gastrostomy Status . Order Date: 06/29/2022. During an observation on 6/28/2022 at 1:25 PM, Staff B, Licensed Practical Nurse (LPN), entered Resident #410's room with Jevity solution and Amoxicillin 10 ml in a medicine cup. Staff B proceeded to expose Resident #410's abdomen to visualize the G-tube. Staff B did not pull the privacy curtain. Resident $401's roommate, Resident #409, was up on a chair approximately 3 feet within direct visual view to Resident #410. Resident # 409 was watching the G-tube feeding process. Staff B proceeded to connect the feeding syringe to the distal end of the G-tube. Staff B poured 30 ml of water to the tube, followed by the 10 ml of Amoxicillin, and then flushed the syringe with 30 ml of water. Staff B then poured the Jevity solution 237 ml to the G-tube, slowly infusing via gravity. During an interview with Staff B, LPN, on 6/28/2022 at 1:35 PM, she confirmed that she did not provide privacy to Resident #410. Staff B stated, I knew I am supposed to do those steps, but I was too nervous and shaky and not thinking right. During an interview with Resident #410 at 1:40 PM, when asked how he felt about his privacy during the tube feeding process, he stated, It happens all the time that I do not care anymore. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105606 If continuation sheet Page 2 of 9 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 105606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Center for Rehabilitation and Healing 575 Lamar Ave Brooksville, FL 34601 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedure titled Resident Rights with the review date of January 19, 2022 reads, (h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meeting with family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy. Event ID: Facility ID: 105606 If continuation sheet Page 3 of 9 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 105606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Center for Rehabilitation and Healing 575 Lamar Ave Brooksville, FL 34601 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set assessment was accurate for 1 of 5 residents reviewed for unnecessary medications, Resident #48. Residents Affected - Few Findings include: Review of Resident #48's quarterly Minimum Data Set, dated [DATE], revealed the resident received an anticoagulant medication for 7 days prior to the assessment. Review of Resident #48's medication administration record for the period from 4/1/2022 through 4/30/2022, did not show documentation that the resident had been administered an anticoagulant medication during April 2022. During an interview on 6/28/2022 at 12:53 PM, the Minimum Data Set Coordinator confirmed Resident #48 was not administered an anticoagulant medication during April 2022. She stated she must have clicked [anticoagulant] by accident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105606 If continuation sheet Page 4 of 9 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 105606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Center for Rehabilitation and Healing 575 Lamar Ave Brooksville, FL 34601 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to verify that the gastrostomy tube (G-tube) was functioning before beginning a feeding and before administering medications, which may include checking for gastric residual volume (GRV) according to professional standards of practice for 2 of 6 residents who received ostomy care, Resident #92 and #410. Findings include: 1. Review of Resident #92's records revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, protein-calorie malnutrition, gastrostomy tube, hypertension, cardiovascular disease, anemia, hyperlipidemia, major depressive disorder, GERD (Gastroesophageal Reflux Disease). Review of the physician orders for Resident #29 reads, Order Summary: Enteral Feed Order every 4 hours Bolus with 8 oz (240 ml [milliliter]) Jevity 1.5 via g-tube q [every] 4 hours. Order Date: 12/01/2021 . Enteral Feed Order every shift Enteral: Check residual prior to initiating a feeding. If greater than 100 CC's, hold feeding and recheck in 1 hour(s) . Order Date: 11/24/2021 . Enteral Feed Order every shift Enteral: Check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding, when there is an interruption of feeding, or at least every shift for continuous feeding. Order Date: 11/24/2021. During an observation on 6/27/2022 at 2:00 PM, Staff A, Registered Nurse (RN), approached Resident #92 to administer his enteral feeding. Staff A raised the head of the bed. The resident was in semi-Fowlers position. Staff A proceeded to expose the abdomen/ G-tube. Staff A attached the feeding syringe to the distal end of the G-tube and poured 100 ml of water. Staff A did not check for gastric residual and or check for G-tube placement. Staff A proceeded to pour Jevity 1.5, 237 ml via gravity. During an interview on 6/27/2022 at 2:11 PM, Staff A, RN, confirmed that he did not check G-tube placement, did not check for residual, and did not rinse the feeding syringes after using it. Staff A stated, I checked the residual early today and was 5 ml. I will remember to rinse syringes. Review of Resident #92's Minimum Data Set (MDS) with assessment reference date of 11/30/2021 showed the resident was coded for tube feeding under Section K. Review of Resident #92's care plan initiated on 12/4/2021 reads, Focus: [Resident #92's name] requires tube feeding r/t [related to] Depression, Dysphagia, Swallowing problem, and CVD . Interventions: Check for tube placement and gastric contents/ residual volume per facility protocol and record . Monitor/ document/ report PRN [as needed] any s/sx [signs/ symptoms] of: Aspiration- fever, SOB [Shortness of Breath], tube dislodged, infection at tube site. 2. Review of Resident #410's records revealed the resident was admitted on [DATE] with the diagnoses to include gastrostomy tube and dysphagia. Review of the physician orders for Resident #410 reads, Order Summary: Jevity 1.5 Cal Liquid (Nutrition Supplements), Give 240 ml via G-tube every 4 hours related to Gastrostomy Status . Order Date: 06/29/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105606 If continuation sheet Page 5 of 9 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 105606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Center for Rehabilitation and Healing 575 Lamar Ave Brooksville, FL 34601 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 0693 Level of Harm - Minimal harm or potential for actual harm Review of Resident #410's care plan initiated on 6/27/2022 reads, Focus: [Resident #410's name] requires tube feeding r/t [related to] Dysphagia . Interventions: Administer Jevity 1.5 240 ml [milliliter] via G-Tube Q4 [every 4] 4 hours . Check for tube placement and gastric contents/ residual volume per facility protocol and record . Flush GT (gastrostomy tube) with 50 ml of water Q4 hours for total of 300 ml/24 hours . Provide local care to G-Tube site as ordered and monitor for s/sx [signs and symptoms] of infection. Residents Affected - Few During an observation on 6/28/2022 at 1:25 PM, Staff B, Licensed Practical Nurse (LPN), entered Resident #410's room with Jevity solution and Amoxicillin 10 ml in a medicine cup. Staff B donned personal protective equipment (PPE). The resident was seated upright on a wheelchair. Staff B proceeded to expose the resident's abdomen to visualize the G-tube. Staff B proceeded to connect the feeding syringe to the distal end of the G-tube. Staff B poured 30 ml of water to the tube, followed by the 10 ml of Amoxicillin, and then flushed the syringe with 30 ml of water. Staff B then poured the Jevity solution 237 ml to the G-tube, slowly infusing via gravity. Staff B did not check for gastric residual and did not check the G-tube placement. Staff B flushed the G-tube with 100 ml of water. Staff B immediately placed the feeding syringe with the plunger in a plastic container bag without rinsing them. Staff B doffed off the gloves and exited the room. During an interview on 6/28/2022 at 1:35 PM, Staff B, LPN, confirmed that she did not check for residual and G-tube placement, and did not rinse the feeding syringe after use. Staff B stated, I knew I am supposed to do those steps, but I was too nervous, shaky, and not thinking right. During an interview on 6/28/2022 at 1:06 PM, Unit B Manager stated, Nurse is to check for residual, and tube placement before giving the feeding. The nurse uses a stethoscope to auscultate the abdomen for placement. They give the feeding by gravity. Unit B Manager acknowledged that the feeding syringe must be rinsed after use and placed separating the syringe and the plunger in the plastic bag. Review of the policy and procedure titled Feeding Tubes reviewed on January 19, 2022 reads, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of tube feedings . Procedure: Feeding Administration. 1- Bolus Gravity Feedings: d. Verify tube placement using both of the following 2 methods: * Auscultation: Instill 10-20 cc [cubic centimeter] of air using 30 cc syringe into gastric tube and listen for sound of air rushing or gurgling by placing stethoscope over upper left quadrant of abdomen. * Aspiration: Using a 30 cc syringe, clear tube with 20 cc of air. Withdraw gastric contents and evaluate color of aspirate. e. Check for residual, as indicated . h. Allow feeding prescribed solution to drain in by gravity, refilling the syringe as necessary (note: To avoid instilling more air into the stomach, do not allow syringe to empty before adding more solution) . Miscellaneous: . 3. Proper placement of the tube must be assessed by auscultation and gastric aspiration before the instillation of any liquid into it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105606 If continuation sheet Page 6 of 9 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 105606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Center for Rehabilitation and Healing 575 Lamar Ave Brooksville, FL 34601 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 observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered, labeled, and discarded in the areas of the kitchen coolers and freezers, failed to ensure food was properly served on the tray line, and failed to ensure the equipment were cleaned as per the policy guidelines. Findings include: A walk-through tour of the kitchen on 6/27/2022 at 9:16 AM with the Certified Dietary Manager (CDM) showed an opened large container of macaroni salad with no open date in the walk-in cooler. The tour also revealed a food container labeled as Lasagna and a pan of chicken noodle soup placed on the steam table at 9:13 AM that was designated as lunch by the CDM. During an interview on 6/27/2022 at 10:28 AM, the Certified Dietary Manager (CDM) confirmed that the observed products did not have a label and identified them as macaroni salad, potato salad, and cottage cheese. The CDM stated, The products should be labeled according to the policy. All products should be closed or covered when stored. The CDM confirmed that Lasagna and soup were on the tray line at 9:30 AM and should be placed on the line 30 minutes or less before serving the meal. A follow-up tour of the kitchen on 6/28/2022 at 7:33 AM with the CDM showed a pink slimy buildup on the interior door of the ice machine, a 2-cup measuring cup left in a large bulk container of flour, five containers of what appeared to be cottage-cheese on a tray in the walk-in cooler without a label, numerous dirty pots and pans and utensils in the prep-sink, numerous dirty rags, which were not in a sanitation solution bucket, and numerous food particles inside the microwave oven on the sides, top and base. The CDM was observed taking temperatures of the pan of scrambled eggs on the tray line and the pan of prepared oatmeal without sanitizing the thermometer between the two foods. During an interview on 6/28/2022 at 8:28 AM, the CDM confirmed that no dipping or measuring devises should be stored in the bulk food containers, and the thermometer should be cleaned and sanitized with an alcohol pad after temping each food to prevent cross-contamination. The CDM verified the presence of a pink slimy substance on the interior door of the ice machine and confirmed that the microwave was dirty with numerous food particles on the top and base of the equipment. Review of the policy and procedure titled Sanitation/Infection Control reads, 5. All equipment is cleaned as needed. The following suggestions indicate the frequency of cleaning of major equipment, but the list is not all inclusive . c. Once weekly, storage shelves are cleaned thoroughly, as are tables, chairs, dish machines, knife guard, counter, janitor's closets, all drawers, refrigerators, freezers and flatware containers. Dishes & cups are soaked for stain removal. Graters, spice racks, work tales, baseboards, hoods & filter, range, all stainless steel equipment, ice machines, the storeroom (including the shelves), carts, oven, & racks are cleaned & sanitized. Review of the policy and procedure titled Food Serving Temperatures reads, Holding Temperatures . 3. The temperature will be taken and recorded for all hot and cold food items at each meal prior to starting tray service. Sanitize thermometer prior to taking temperature of each item . 7. Heating food in the steam table is prohibited. Heating food to the proper temperature is accomplished by direct heat (stove, oven, steamer, etc.) and food is then transferred to the steam table not more than 30 minutes before meal service. 8. Foods temperatures shall maintain minimum temperatures through tray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105606 If continuation sheet Page 7 of 9 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 105606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Center for Rehabilitation and Healing 575 Lamar Ave Brooksville, FL 34601 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 line or no greater than 2 hours on tray line. Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure titled Food Storage reads, Procedures . 6. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are not to be stored in the food containers but are kept covered in a protected area near the containers . 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105606 If continuation sheet Page 8 of 9 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 105606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Center for Rehabilitation and Healing 575 Lamar Ave Brooksville, FL 34601 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to inform residents, their representatives, and families by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection. Residents Affected - Few Findings include: Review of the facility records revealed Residents #98, #14, and #93 were COVID-19 positive on 6/2/2022, and Resident #47 was COVID-19 positive on 6/20/2022. Further review of the records did not reveal any notifications sent to the residents, resident representatives, and families. During an interview on 6/29/2022 at 2:00 PM, the Infection Control Nurse stated that notifications were not sent out when those residents were COVID-19 positive. Review of the policy and procedure titled COVID-19 Dedicated Unit: Responding to COVID-19 in the facility reviewed on January 19, 2022 reads, Policy: The facility will adhere to current CDC [Centers for Disease Control and Prevention] guidance and the direction of the Florida Department of Health and/or the Agency for Health Care Administration for infection prevention and control of COVID-19 . Procedure for COVID Positive Unit: . Communication: * Develop a system of notification and communication: 1. Promptly (by 5 pm the next calendar day) notify staff, residents and families about identification of COVID-19 in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105606 If continuation sheet Page 9 of 9