Inspection·October 12, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm Review of the Resident Council Minutes dated 7/5/2023 reads, Concern: Maintenance. Hot rooms shower room on west tiles falling off East shower. Number of residents who share the concern: All residents. Review of the facility's grievance log revealed no grievances related to the shower room for the months of June 2023, July 2023, August 2023, September 202, and October 2023. Residents Affected - Few Review of the facility policy and procedure titled Resident Council dated April 1, 2022 reads, Policy Interpretation and Implementation . 3. The facility will provide a designated staff person who is approved by the resident group and the facility who is responsible for providing assistance and responding to written requests that result from group meetings . 5. Responsibilities of the group council may include . b. Assisting in the development of resident grievance and complaint procedures. Review of the facility policy and procedure titled Grievance Program Policy- Suwannee dated April 1, 2022 reads, Process . 3. Grievances are formal written or verbal complaints made to the facility when prompt or bedside resolution to the satisfaction of the person making the objection was not possible. Grievances can also be made anonymously. Where there is a grievance, it will be: a. Documented on paper form. b. Routed to the Grievance Officer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 2 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in 3 of 3 shower rooms and 2 of 2 resident rooms, Residents #411 and #24 (Photographic evidence obtained). Findings include: 1. During the facility tour on 10/10/2023 at 12:20 PM with the Maintenance Director and the Regional Maintenance Director, the shower rooms were toured. The East Unit shower room had multiple personal items in the room. There was a black discoloration in the shower stall along the grout line of the floor tile and the wall tile and along the grout lines between the wall joints. There was a brown discoloration on the tiles of one shower stall and a gray discoloration on the floor tiles of the second shower stall. There was a Hoyer lift sling attachment apparatus with buildup residue on it. The tiles just above the baseboard in the dressing area were displaced and the baseboard and tile above it next to the toilet in the east shower room were also displaced. The [NAME] Unit shower room had unsecured disposable razors laying on the bar soap holder and next to the drain on the floor in the dressing area. There was a brown substance along the bottom edge of a laminated paper sign posted on the first shower stall wall near the faucet control, and a black substance along the grout line of the wall joints, on the wall to the floor joints, and on several tiles on the wall and floor of the stall. There were two used washcloths and paper product debris in the first stall. There was a black discoloration along the wall to the floor grout line of the second shower stall and a bottle of liquid bath product sitting on the grab bar. There were multiple personal items in the dressing area of the shower room. There was a shower chair with a brown substance on the seat. The south shower room's shower stall had brown discoloration on the floor tiles and a pair of shower shoes in the dressing area. During an interview on 10/10/2023 at 12:45 PM, the Maintenance Director confirmed the observations and stated, We have a concern with the shower rooms. During an interview on 10/11/2023 at 7:57 AM, the Administrator stated, My expectation is that all of the shower rooms are cleaned daily, and no personal items and unsecured razors are left in the shower rooms. Review of the facility policy and procedure titled Disinfecting: Bathtubs, Shower Chairs, Commode, Toilets dated October 24, 2022 reads, Purpose: Toilets, bathtubs, shower chairs, commodes and toilets have a high resident exposure (i.e., high-touch surfaces) and are frequently contaminated. Therefore, the facility will implement protocols to reduce the risk of pathogen transmission . Procedure . Shower Chair/Shower Bed . 1. Follow use of equipment, C.N.A. [Certified Nursing Assistant] will return equipment to shower room. 2. C.N.A. will clean chair/bed with disinfectant from supplies in shower room. 2. During an observation on 10/8/2023 at 10:22 AM, Resident #411 was lying in bed, visiting the family members in the room. To the right-hand corner of the ceiling, there was a tile with a large brown stain. During an interview on 10/8/2023 at 10:22 AM, Resident #411 stated, The stain on the ceiling bothers me. When I was admitted , the room's air conditioning had a black mildew on it from not being used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 3 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/8/2023 at 10:24 AM, Resident #411's Son stated, The ceiling should not have a stain for the price we pay here for her stay here. When she came in, the staff told us they were not using this room since COVID-19. The air conditioner had back mildew and maintenance came to clean it. I think it is starting to grow back again. During an observation on 10/9/2023 at 8:00 AM, Resident #411 was resting in bed with eyes closed. The ceiling tile to the right-hand corner had a large brown stain. 3. During an observation on 10/8/2023 at 11:16 AM, Resident #24 was sitting in bed. The wall adjacent to the bathroom had a large opening near the skirting board on the floor and pieces of dry wall were inside the opening. During an interview on 10/8/2023 at 11:17 AM, Resident #24 stated, My bathroom got flooded and the wall got damaged. That hole should be fixed, but they have not fixed it. I have told maintenance various times. During an observation on 10/10/2023 at 1:00 PM, Resident #24 was sitting in his wheelchair inside his room. There was a large opening noted near the skirting board on the wall adjacent to the bathroom. During an interview on 10/12/2023 at 10:54 AM, the Assistant Maintenance Director stated, [Resident #411's room] ceiling tile was stained due to the roof drain located there. It is connected to the roof, comes inside, and exits the wall. Due to the hurricane, it was clogged with pine needles. [Resident #24's room] wall had that damage because every time the resident goes to the bathroom, he clogs the toilet and it overfloods. It had been this way for maybe two weeks. We have not had time to get to it. We were busy. It has been reported to our reporting system as of 10/11/2023. Review of the facility policy and procedure titled, Resident Rights- Safe/Clean/Comfortable/ Homelike Environment, dated April 1, 2022 reads, Purpose: It is the policy of the facility to provide a safe, clean, comfortable homelike environment such a manner to acknowledge and respect resident rights . Procedure . 2. The facility must provide a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely . 3. Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 4 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure each resident received assistive devices to prevent accidents for 1 of 3 residents reviewed for accidents, Resident #128. Residents Affected - Few Findings include: During an interview on 10/8/2023 at 9:50 AM, Resident #128's Mother stated, I received a phone call at 8:30 AM telling me that my son had fallen. When I got here, he had a knot on his head. During an observation on 10/8/2023 at 10:58 AM, Resident #128 was lying in bed. There were no fall mats on either side of bed and nowhere in the resident's room. During a phone interview with Staff G, Licensed Practical Nurse (LPN), on 10/9/2023 at 10:10 AM, when asked if he had knowledge of any resident on 1 on 1 or increased supervision on the [NAME] Wing, he stated, I don't remember anyone being like that. During a phone interview with Staff D, Certified Nursing Assistant (CNA), on 10/9/2023 at 10:35 AM, when asked if she remembered fall mats being in place next to the Resident #128's bed, she stated that there were no fall mats next to the resident's bed when she assisted with getting the resident up on 10/8/2023. During a phone interview on 10/9/2023 at 12:19 PM and 12:56 PM, the Medical Director stated, The staffing is really bad. They are having a crisis. This patient needs real help. He has high needs. Mom is there all the time. They have a shortage and doing a lot of adjustments. If I order, they have to follow my instructions for patient care. [Staff G, LPN's Name] sent the patient to ER [Emergency Room]. No one knew what had happened. They did not call me after his return. He needs special nursing care. During an interview on 10/9/2023 at 12:25 PM, Resident #128 stated, Yes, I fell. I was in bed and fell to the floor. There were no mats on the floor. I got up and back into bed. During a phone interview on 10/9/2023 at 2:20 PM, Staff F, CNA, stated that she could not remember if there were two mats but believes that there was at least one. When asked if she would know where the mats were kept when not in use, she stated she did not know. Review of Resident #128's physician order dated 7/7/2023 reads, Resident is to have mats at bedside. Order Status: Active. Review of Resident #128's care plan dated 5/16/2023 reads, Focus- Resident is at risk of falls and fall related injuries related to decreased mobility, impaired mobility, and poor safety awareness. GoalsResident is at risk of falls and fall related injuries will be minimized during review. Interventions: Floor mats at bedside. Review of the facility policy and procedure titled Falls Management Guideline dated April 1, 2022 reads, Definition of a Fall . The nursing staff in conjunction with the interdisciplinary team will seek to identify residents at high risk for falls and implement interventions for safety. Fall Risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 5 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Evaluation . Residents who are identified as being Moderate to High Risk for Falls will have the appropriate, and least restrictive interventions, put in place immediately to mitigate the risk of the falls. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 6 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 1 of 10 residents receiving continuous oxygen services, Resident #104. Residents Affected - Few Findings include: During an observation on 10/8/2023 at 2:30 PM, Resident #104 was lying in bed, receiving oxygen via nasal cannula. Resident #104's oxygen concentrator was set to 2 liters per minute. During an observation on 10/9/2023 at 8:45 AM, Resident #104 was lying in bed, receiving oxygen via nasal cannula. The oxygen concentrator was set to 2 liters per minute. Review of Resident #104's physician's order dated 9/12/2023, read, O2 [Oxygen] @ [at] 3 L/M [liters per minute] via N/C [nasal cannula]. Verify tubing/humidification bottle are dated per facility protocol. Order Status: Active. Review of Resident #104's care plan dated 9/6/2023 reads, [Resident 104's name] has Oxygen Therapy r/t [related to] COPD [Chronic Obstructive Pulmonary Disease]. During an interview on 10/10/2023 at 3:10 PM, Staff C, Registered Nurse (RN), stated, [Resident #104's name] has an order to receive 3 liters of oxygen and his O2 concentrator setting is set at 2 liters per minute and is incorrect. During an interview on 10/10/2023 at 3:45 PM, the Director of Nursing stated, My expectation is that nurses follow physician orders for administering oxygen. Review of the facility policy and procedure titled Oxygen Therapy, dated April 1, 2022, reads, Policy . Oxygen therapy is administered per MD [Medical Doctor] order or as an emergency measure until an order can be obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 7 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the PRN [as needed] orders for psychotropic drugs were limited to 14 days for 2 of 9 residents reviewed for behavioral monitoring, Residents #152 and #37. Findings include: 1. Review of Resident #152's admission record showed the resident was admitted to the facility on [DATE] with the diagnoses including altered mental status, unspecified psychosis not due to substance or known physiological condition, and depression. Review of Resident #152's Physician order dated 7/24/2023 reads, Xanax Oral Tablet 0.5 mg [milligrams]. Give 0.5 mg via G-tube [Gastrostomy Tube] every 12 hours as needed for agitation/anxiety. Order Status: Active. Review of Resident #152's Medication Administration Record (MAR) showed the resident received Xanax 0.5 mg tablet on 8/3/23, 8/4/23, 8/5/23, 8/7/23, 8/8/23, 8/12/23, 8/13/23, 8/21/23, 8/24/23, 8/26/23, 8/28/23, 9/2/23, 9/7/23, 9/8/23, 9/11/23 (two doses), 9/13/23, 9/14/23, 9/23/23, 9/25/23, 10/3/23, 10/5/23, and 10/9/23. 2. Review of Resident #37's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dementia, bipolar disorder, and neuralgia and neuritis. Review of Resident #37's physician order dated 9/15/2023 reads, Ativan Oral Table 0.5 mg. Give 0.5 mg by mouth every 24 hours as needed for severe agitation. Order Status: Active. Review of Resident #37's MAR showed the resident received Ativan 0.5 mg on 9/15/23, 9/18/23, 9/21/23, 9/22/23, 9/25/23, 9/26/23, 10/4/23, 10/6/23, 10/8/23, and 10/9/23. During an interview on 10/10/2023 at 9:19 AM, the Director of Nursing confirmed that Resident #152 and Resident #37 both had PRN orders for psychotropic medications which had extended over 14 days without written documentation from the physician. Review of the facility policy and procedure titled Psychotropic Drug Use, last reviewed on July 26, 2023 reads, Policy . If psychotropic drug therapy is required, the physician, facility staff and Specialty Rx, Inc. pharmacist will assist each other in choosing the most effective medication for the customer that has the fewest possible side effects, adverse drug reactions, and in the smallest effective dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 8 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 10/8/2023 at 9:54 AM, Resident #313 was lying in bed. There were two medications on the resident's bedside table: a bottled medication labeled as Antifungal Powder with Miconazole Nitrate 2% and a tube labeled as Hydrocortisone Cream. During an observation on 10/9/2023 at 10:07 AM, there were three medications on Resident #313's nightstand. The medications were a bottled medication labeled as Antifungal Powder with Miconazole Nitrate 2%, a tube labeled as Hydrocortisone Cream, and a bottle labeled as Dyna Hex 4 Chlorhexidine Gluconate 4% Solution. Review of Resident #313's care plan showed no interventions for self administration of medications. During an interview on 10/10/2023 at 3:30 PM, Staff C, Registered Nurse (RN), stated, Those are medications at [Resident #313's name] bedside. She should not have those there. They should be kept with the nursing staff. During an interview on 10/10/2023 at 3:40 PM, the Director of Nursing stated, My expectation is that the nurses should not leave medications at the residents' bedside. Review of the facility policy and procedure titled Medication Storage with last review date of July 26, 2023 reads, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL [Florida] Department of Health guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 5 of 6 medication carts and failed to ensure the medications were secured in 1 of 3 wings (Photographic evidence obtained). Findings include: During an observation of Medication Cart [NAME] Run 1 on 10/8/2023 at 9:43 AM with Staff K, License Practical Nurse (LPN), there were one medication cup with 3 circular pills and 18 loose pills inside the medication drawer, one opened Levemir vial with no opened or expiration dates, one opened Basaglar Kwikpen with no legible opened date, one opened bottle of Loteprednol [NAME] 0.5% eye drops with no opened or expiration dates, one opened Breo Ellipta Inhaler with no opened or expiration dates, one opened Fluoromethol [NAME] 0.1% with no opened or expiration dates, one opened Timolol Mal Sol 0.5% with no opened and expiration dates, two opened Latanoprost Sol 0.005% with no opened or expiration dates, one opened Combigan Sol 0.2/0.5% with no opened or expiration dates, and one opened and expired Azelastine Dro 0.05% dated 8/21/2023. During an interview on 10/8/2023 at 9:55 AM, Staff K, LPN, stated, I am agency, so I was going down the list figuring out who the residents were and I pulled her medications, but she was not next, so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 9 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some I left it in the cart until it's her turn. Medications should be dated when opened with open and expiration. If not dated or expired, we should discard. Eye drops are good for 28 to 30 days. No loose medication should be in the medication cart. During an observation of Medication Cart East Wing Run 2 on 10/8/2023 at 9:59 AM with Staff L, LPN, there was one opened artificial tears container with no opened or expiration dates. There was also a total of 23 loose pills in the medication drawers. During an interview on 10/8/2023 at 10:06 AM, Staff L, LPN, stated, All medications should be dated with opened and expiration dates. Unless I physically drop a medication, I will not know if there is loose medication. It is all the way to the back, which makes it hard to see. The loose medication should not be in the medication cart. It should be wasted. During an observation of Medication Cart East Run 1 on 10/8/2023 at 10:12 AM with Staff M, LPN, there were one opened lubricant eye drop bottle in the original pharmacy packaging with no resident identifier, one opened NovoLog Flexpen with no opened or expiration dates, one opened Insulin Glargine not stored in the original pharmacy packaging with no opened or expiration dates, one expired Humulin 70/30 vial with an opened date of 9/2/2023, one expired Admelog Solo Flexpen with an opened date of 8/29/2023, one expired Novolog vial dated 8/17/2023, one opened Prednisolone [NAME] 1% with no opened or expiration dates, one opened Timolol Mal 0.5% eye drops with no opened or expiration dates, one expired Latanoprost eye drops with opened date of 8/24/2023, and one expired Prednisolone 1% eye drops with an opened date 8/30/2023. During an interview on 10/8/2023 at 10:19 AM, Staff M, LPN, stated, Medication should have opened and expiration dates. Expired medication should be discarded. If the medication has no open date, it should be discarded. During an observation of Medication Cart [NAME] Run 2 on 10/8/2023 at 10:21 AM with Staff H, LPN, there were one unopened Lantus vial with the label reading refrigerate until open, one opened Lantus vial with no opened or expiration dates, two opened Travoprost Dro 0.004% eye drops with no opened or expiration dates, one opened Prednisolone [NAME] 1% eye drops with no opened or expiration dates, one opened Timolol Mal Sol 0.5% eye drops with no opened or expiration dates, and one opened Brimonidine Sol 0.2% eye drops with no opened or expiration dates. During an interview on 10/8/2023 at 10:29 AM, Staff H, LPN, stated, Insulin should be stored in the refrigerator until ready to use. Insulin should be dated with opened and expiration dates. Eye drops are good for 28 days and should be dated when opened with opened and expiration dates. During an observation of Medication Cat South Wing Run 2 on 10/8/2023 at 10:39 AM with Staff N, LPN, there were one unopened vial of Levemir with label reading refrigerate until open, two opened Novolog Flexpens with no opened or expiration dates, one opened Insulin Glar pen with no opened or expiration dates, one opened Novolog vial with no opened or expiration dates, and one opened Lispro vial with no opened or expiration dates. During an interview on 10/8/2023 at 10:45 AM, Staff N, LPN, stated, Insulin should be dated when opened with open and expiration dates. If not open, it should be kept in the refrigerator. This is ongoing. During an interview on 10/10/2023 at 4:05 PM, the Director of Nursing stated, Nursing staff should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 10 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some keep medication carts clean at all times. The staff should label open medication with opened and expiration dates. No medication should be prepared ahead of time. Expired medications should be pulled off the medication carts and medication should be stored accordingly. Review of the facility policy and procedure titled Medical [Sic.] Labeling Policy with last review date of July 26, 2023, reads, Purpose: To ensure that all medications within the facility are labeled and are labeled [Sic.] in a consistent manner. Review of the facility policy and procedure titled Medications with Shortened Expiration Dates with last review date of July 26, 2023, reads, Many healthcare providers are not aware that the expiration dating of many products change once the items are removed from their primary packaging and are in use. Once these products are opened, they must be used within a specific timeframe to avoid reduced potency and, potentially, reduced efficacy . Product Name: Humulin R . Novolog . Expiration Notes: Good for 28 days after opening or removing from refrigerator . Product Name: Levemir. Expiration Notes: Prior to use refrigerate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 11 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 stored in a safe and sanitary manner in 3 of 3 nourishment rooms. Residents Affected - Some Findings include: During a tour of the facility nourishment rooms on 10/8/2023 at 9:55 AM with Staff A, Dietary Aide, During an observation on 10/8/2023 at 9:57 AM in the [NAME] Unit nourishment room with Staff A, Dietary Aide, there were three grocery store food bags containing an unlabeled and undated fruit bowl, an unlabeled and undated sub sandwich, and one container of unidentifiable food substance on the middle shelf of the refrigerator. There was a red sticky substance splattered on the interior base of the freezer. During an interview on 10/8/2023 at 9:57 AM, Staff A, Dietary Aide, stated, Those should be labeled with the residents' name, room number, and when it was brought in. Staff A acknowledged the red substance on the interior base of the freezer and stated she did not know whose responsibility it was to clean the freezer. During an observation on 10/8/2023 at 10:05 AM in the East Unit nourishment room Staff A, Dietary Aide, there were three sandwiches with an expiration date of 10/7/2023 in the bottom left drawer of the refrigerator. During an interview on 10/8/2023 at 10:05 AM, Staff A, Dietary Aide, acknowledged the unlabeled expired sandwiches. During an observation on 10/8/2023 at 10:15 AM in the South nourishment room with Staff A, Dietary Aide, there was an unlabeled and undated opened box of Crunchy Raisin Bran on the top shelf of the refrigerator, and four unlabeled and undated sandwiches in the bottom drawer of the refrigerator. During an interview on 10/8/2023 at 10:15 AM, Staff A, Dietary Aide, stated she did not know who the box of Crunchy Raisin Bran belonged to, or when it was brought in. During an interview on 10/8/2023 at 11:15 AM, the Director of Nutrition Services stated it was her expectation that nourishment rooms were cleaned and stocked each day by the dietary staff, and any and all unlabeled, undated, or expired foods would be thrown out. Review of the facility policy and procedure titled Dietary Manual Infection Control: Use and Storage of Food and Beverage Brought in for Residents dated April 1, 2022, reads Policy: It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors . Procedure . c. Monitor: i. Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment, and quality, and disposal of items when necessary. d. Foods requiring refrigeration will be received by the facility designee. The staff will examine food for quality (smell, packaging, appearance) to identify potential concerns. They will ensure proper storage including labeling and dating. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 12 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and maintained infection control standards during enteral medication administration for 1 of 3 residents reviewed for gastrostomies, Resident #21, and during direct care for 1 of 3 residents reviewed for tracheostomies, Resident #72. Residents Affected - Few Findings include: 1. During an observation on 10/10/2023 at 12:39 PM, Staff J, License Practical Nurse (LPN), performed hand hygiene with hand sanitizer and prepared Resident #21's medication. Staff J entered Resident #21's room. Staff J entered the shared bathroom and prepared water administration. Staff J washed her hands and donned gloves. Staff J placed a barrier on top of the bedside table and placed four medication cups that contained water on the barrier. Staff J stated she needed an enteral syringe in order to administer Resident #21's medication. Staff J removed her gloves and took the medication with her and walked down the hall to the nursing station. While holding the medication cup in her left hand, Staff J rested her right hand on the door of the nursing station. Staff J walked to the central supply area where another staff member handed her an enteral syringe. Staff J returned to Resident #21's room. Resident #21's Roommate was in the shared bathroom. Staff J did not perform hand hygiene, donned gloves, checked the gastric tube placement, flushed the tube with water and administered the medication. Staff J stated she needed some more water since she had used all the water due to medication viscosity. Staff J did not remove her gloves, opened the bathroom door and poured more water into the medication cup. Staff J closed the bathroom door and returned to Resident #21's side and finished flushing the gastric tube. Staff J did not perform hand hygiene. During an interview on 10/10/2023 at 1:07 PM, Staff J, LPN, stated, I figured I had washed my hands when I went in originally and did not notice I had touched anything. I should have washed my hands after going into the bathroom before returning to administer the remaining water. During an interview on 10/10/2023 at 4:11 PM, the Director of Nursing (DON) stated, The staff should wash their hands upon returning to the room. Donning new gloves does not replace hand hygiene. The staff should have removed her gloves and should have preformed had hygiene. Review of the facility policy and procedure titled Enteral Feeding with last review date of July 26, 2023, reads, Purpose: To provide nourishment and medications via enteral tubes. To ensure the safe and effective administration of enteral formulas and medications. 2. During an observation on 10/10/2023 at 1:13 PM, Staff O, LPN, entered Resident #72' room and washed her hand and donned gloves. Staff O placed a towel on top of the bedside table and put a 4x4 gauze and normal saline on the bedside table. Staff O split the 4x4 sponge gauze and a sealed sterile inner cannula for tracheostomy care. Resident #72 had mucus and secretions. Staff O removed Resident #72's tracheostomy oxygen mask and removed the inner cannula from tracheostomy. Staff O applied normal saline to the 4x4 gauze and removed mucus from the tracheostomy outer cannula opening and plate. Staff O used 4x4 gauze to pat dry outer plate and under the outer plate. Staff O opened the sterile inner cannula. By using the same gloved hand that had been used to clean mucus and secretions, Staff O inserted the inner cannula. Staff O applied the split 4x4 sponge gauze and placed the tracheostomy oxygen mask back in place. During an interview on 10/10/2023 at 1:54 PM, Staff O, LPN, stated, I should have removed my gloves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 13 of 14 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 and washed my hands after cleaning the resident's secretions before changing the inner cannula. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/10/2023 at 4:09 PM, the Director of Nursing stated, The nurse should have removed her gloves after cleaning the mucous from the tracheostomy and washed her hands, donning new gloves before placing the new inner cannula. Residents Affected - Few Review of the facility policy and procedure titled Tracheostomy Care with last review date of July 26, 2023, reads, Policy Statement: It is the policy of Bedrock Care to establish standards for the care and maintenance of tracheostomy tubes. Following these standards will assist in maintaining a patent airway, reduce the risk for nosocomial infection, and help prevent excoriation, breakdown, and infection of surrounding skin. Review of the facility policy and procedure titled Hand Hygiene: Why, How and When with last review date of July 26, 2023, reads, When? 1. Before touching a patient . 2. Before clean/aseptic procedure . c) Before inserting an invasive medical device (nasal cannula, nasogastric tube, endotracheal tube, urinary probe, percutaneous catheter, drainage), disrupting/opening any circuit of an invasive medical device (for food, medication, draining, suctioning, monitoring purposes). d) Before preparing food, medications, pharmaceutical products, sterile material . 3. After body fluid exposure risk . a) when the contact with a mucous membrane and with non-skin ends . 5. After touching patient surroundings . Hand Hygiene and Medical Glove Use: The use of gloves does not replace the need for cleaning your hands . Discard gloves after each task and clean your hands-gloves may carry germs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105613 If continuation sheet Page 14 of 14