Inspection·June 23, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of a resident's admission, for 1 of 3 newly admitted residents, Resident #518, in a total sample of 52 residents. Findings include: Review of Resident #518's medical record admission documentation read the resident was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood caused by organs not working as well as they should), dementia in other diseases classified elsewhere with behavioral disturbance, muscle weakness (generalized), history of falling, essential (primary) hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), pure hyperglyceridemia (high concentration of triglycerides in the blood), need for assistance with personal care. During an observation on 06/20/22 at 09:59 AM, Resident #518 was observed on the floor in the entry of the hallway in front of room [ROOM NUMBER]. During an observation on 06/21/2022 at 7:50 AM Resident #518 was observed on the floor in his room. Review of Resident #518's medical record revealed a baseline care plan was not in the medical record. During an interview on 6/22/2022 at 11:13, Staff D, Licensed Practical Nurse (LPN), stated, Normally we do a baseline care plan. Staff D reviewed the electronic record and confirmed Resident #518 did not have a baseline care plan. During an interview on 6/22/2022 at 3:40 PM the Director of Nursing (DON) reviewed the medical record for Resident #518 for a baseline care plan, she confirmed the resident did not have a baseline care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 2 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide services in accordance with professional standards of practice for gastrostomy tube medication administration for 2 of 6 residents, Residents #58 and #157 sampled for gastrostomy tubes, in a total sample of 52 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #58 documented the resident was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia without behavioral disturbances, generalized anxiety disorder, hypertensive retinopathy, Parkinson's disease, status post gastrostomy tube (a tube in the stomach that brings food directly to the stomach), iron deficiency, presence of left artificial hip joint, left ankle contracture, right ankle contracture, hypothyroidism, essential (primary) hypertension, cerebral infarction, (stroke) dysphagia (difficulty swallowing foods or liquids), and major depressive disorder. Review of the physician orders dated 12/18/2019 reads, Check tube feeding placement each shift and for residual [refers to the fluid/contents that remain in the stomach] before addition of feeding, flush, or medications. Record quantity. If residual is 100 cc (cubic centimeter) or more, hold feeding and notify MD (Medical Doctor) every shift record quantity of residual. During an observation of medication administration conducted on 6/21/22 at 10:13 AM for Resident #58, Staff E, Licensed Practical Nurse (LPN) crushed the medications docusate, hydrochlorothiazide, sertraline, simethicone 1 tablet, Vitamin C tablet, sennoside, acetaminophen, and gabapentin, and poured the medications into a 120 milliliter (ml) cup, added 50 ml of water and ferrous sulfate 300 mg liquid to the cup. Staff E placed the medications at the bedside, obtained 30 ml of water and flushed the gastrostomy tube, Staff E did not verify gastrostomy tube placement or residual. Staff E then administered all medication at one time and flushed the gastrotomy tube after administering the medications. During an interview conducted on 6/21/2022 at 2:00 PM Staff E, LPN stated, I did not verify the gastrostomy tube placement, I should have. I did not separate the medicines and give them separately and I should have. During an interview conducted on 6/22/2022 at 1:00 PM the Director of Nursing stated, All medications given by g [gastrostomy] tube should be done according to practice standards and administered separately, and the g tube should be verified by checking for a residual before administering meds. Review of the medical record for Resident #157 documented the resident was admitted on [DATE] with the following diagnoses: Parkinson's disease, unspecified Alzheimer disease, hypothyroidism, hyperlipidemia, unspecified mood disorder, hydronephrosis, adult failure to thrive, and unspecified protein-calorie malnutrition Record review of the physician orders on 03/30/2022 reads Check tube placement and for residual before addition of feeding, flush, or medications. Record quantity. If residual is 100 cc or more, hold feeding and notify MD. During an observation on 06/22/2022 at 1:30 PM Staff E, LPN, entered Resident #157's room with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 3 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 0658 Level of Harm - Minimal harm or potential for actual harm crushed medication and one carton of Jevity 1.2 for a bolus feeding (a type of feeding where a syringe is used to send formula through a feeding tube). Staff E, LPN placed the medication and administration supplies on the resident's bed side table. Staff E, LPN did not perform hand hygiene and donned gloves, did not check for residual and administered 30 ml of water into the gastrostomy tube and administered the medication and bolus feeding. Residents Affected - Few During an interview on 06/22/2022 at 1:40 PM Staff E, LPN stated, I should have performed hand hygiene and checked for residual. Review of the policy and procedure titled, Administering Medications Through an Enteral [by way of] Tube with an approval date of 1/24/2022, reads Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube. Standards: Medications shall be prepared and administered according to the following established guidelines: .Tube placement will be verified prior to administration of a medication. The enteral tube will usually be flushed with 30-50 ml of water before and after administration and 5-10 ml water between medications administered, unless otherwise ordered by physician. Guidelines: 2. Wash hands and prepare medications per physician order. 5. Verify feeding tube placement. 7. Pour medication into syringe attached to feeding tube. Flush with 5-10 ml of water between each medication administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 4 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 3 residents, Residents #130 and #46, in a total sample of 52 residents. Residents Affected - Few Findings include: During an observation on 6/20/2022 at 3:13 PM, Resident #130 has untrimmed long fingernails with a dark substance underneath the nail beds. During an observation on 6/21/2022 at 8:08 AM, Resident #130 has untrimmed long fingernails with a dark substance underneath the nail beds. During an observation on 6/22/2022 at 8:58 AM, Resident #130 has untrimmed long fingernails with a dark substance underneath the nail beds. Review of Resident #130's admission records showed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, dysphagia, oral phase, difficulty in walking, muscle weakness (generalized), need for assistance with personal care, cognitive communication deficit, hyperlipidemia, type 2 diabetes mellitus without complications. COVID-19. Review of Resident #130's care plan reads, Focus: [Resident #130's name] has a self-care deficit with dressing, grooming r/t [related to]: cognitive deficient r/t:, impaired mobility r/t dx [diagnosis] of: generalized weakness . Interventions: Assist with nail shaping, keep nails short and clean. Review of the Skin Monitoring: Comprehensive CNA [Certified Nursing Assistant] Shower Review for Resident #130 dated 6/10/2022, showed blanks for cutting fingernails for Monday through Saturday. During an interview on 6/22/2022 at 1:35 PM, Staff H, Licensed Practical Nurse (LPN), confirmed Resident #130's fingernails were long and needed to be cut. During an interview with the Director of Nursing (DON) on 6/22/2022 at 3:35 PM, when asked about the nail care for the residents, she stated, My expectation is that they do nail care and document if it was provided or refused. During an observation on 6/20/2022 at 3:23 PM, Resident #46 has long untrimmed fingernails. During an observation on 6/21/2022 at 8:15 AM, Resident #46 has long untrimmed fingernails. During an observation on 6/22/2022 at 9:18 AM, Resident #46 has long untrimmed fingernails. During an interview on 6/22/2022 at 1:35 PM, Staff H, LPN, confirmed Resident #46's fingernails were long and needed to be cut. During an interview on 6/23/2022 at 11:24 AM, Resident #46 stated, My nails are split. I need my nails cut. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 5 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #46's admission records showed the resident was initially admitted on [DATE] and readmitted on [DATE], with diagnoses to include pneumonia, type 2 diabetes mellitus with ketoacidosis without coma, personal history of other specified (corrected) congenital malformations of genitourinary system, major depressive disorder, unspecified dementia with behavioral disturbance, mood disorder due to known physiological condition with mixed features, essential (primary) hypertension, muscle weakness (generalized), difficulty in walking, pseudobulbar effect, hypo-osmolality and hyponatremia, unspecified psychosis not due to a substance or known physiological condition. Review of Resident #46's care plan reads, Focus: [Resident #46's name] has a self-care deficit with dressing, grooming, bathing, r/t: impaired mobility r/t dx of: generalized weakness, limited endurance r/t: visual limitations. Date Initiated: 03/20/2022. Revision on: 03/20/2022 . Interventions: . Provide hands on assistance with dressing, grooming, bathing as needed. Review of Skin Monitoring: Comprehensive CNA [Certified Nursing Assistant] Shower Review for Resident #46 dated 6/10/2022, showed blanks for cutting fingernails for Monday through Saturday. Review of the facility policy and procedure titled Activities of Daily Living (ADLs), Supporting, last reviewed on 1/24/2022, reads, Policy Statement: Residents will provided [Sic.] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Policy Interpretation and Implementation: . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 6 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for 4 of 13 residents who received respiratory care services, Resident #50, #58, #166 and #105. Residents Affected - Few Findings include: 1. An observation of Resident #50 was conducted on 6/20/2022 at 10:00 AM. Resident #50 was observed resting in bed with her eyes open. Oxygen was being administered at 2.5 liters per minute via nasal cannula. An observation of Resident #50 was conducted on 6/21/2022 at 9:52 AM. Resident #50 was observed lying in her bed. An oxygen concentrator was at the side of the bed. The oxygen concentrator was administering oxygen at 2.5 liters per minute via nasal cannula. An observation of Resident #50 was conducted on 6/22/2022 at 8:49 AM. Resident #50 was lying in her bed. An oxygen concentrator was beside her bed and was administering oxygen at 2.5 liters per minute via nasal cannula. The oxygen tubing was lying beside the resident on the bed. On 6/22/2022 at 8:49 AM an observation of Resident #50 was completed with Staff F, Registered Nurse. Staff F confirmed the oxygen concentrator beside Resident #50's bed was administering oxygen at 2.5 liters per minute. Staff F placed the nasal cannula prongs into Resident #50's nose. Review of Resident #50's Medical Certification for Medicare Long Term Care Services and Patient Transfer Form, dated 5/6/2022, showed a physician order for Resident #50 to receive oxygen continuously at 2 liters per minute. During an interview on 6/22/2022 at 8:51 AM, Staff F, Registered Nurse, confirmed the physician had ordered Resident #50 receive oxygen at 2 liters per minute. 2. During an observation on 6/20/2022 at 3:14 PM, Resident #166 was being administered oxygen at 2 L/min (liters/minute) via nasal cannula. The oxygen tubing was not labeled with a date. During an observation on 6/21/2022 at 8:00 AM, Resident #166 was in the hallway. The resident was being administered oxygen via nasal cannula at 2 L/min. The oxygen tubing was not labeled with a date. During an observation on 6/21/2022 at 1:01 AM, Resident #166 was in her room being administered oxygen at 2 L/min. The oxygen tubing was not labeled with a date. Review of Resident #166's admission records revealed the resident was admitted to the facility on [DATE] with the diagnoses to include metabolic encephalopathy, major depressive disorder, recurrent, mild, generalized anxiety disorder, moderate protein-calorie malfunction, pneumonia, unspecified organism, acute cystitis without hematuria, unspecified osteoarthritis, unspecified site, muscle weakness (generalized), and gastro-esophageal reflux diseases without esophagitis. Review the physician order for Resident #166 reads, Order: Check oxygen saturations Q [every] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 7 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 Level of Harm - Minimal harm or potential for actual harm shift. Directions: Every shift and as needed for being noncompliance [Sic.} with oxygen use. Status: Active. Order Date: 6/14/2022 10:15 [10:15 AM] Review of Resident #166's physician order showed no order for administration of oxygen at a specific rate or oxygen tubing change. Residents Affected - Few Review of the Minimum Data Set (MDS) dated [DATE] under Section O-Special Treatments, Procedures, and Programs read, the resident uses oxygen while not a resident and while is a resident. This section was checked yes. Review of Resident #166's care plan reads, Focus: [Resident #166's name] has a potential for complications of respiratory distress dx [diagnosis] of: COPD [Chronic Obstructive Respiratory Disease] recent dx [diagnosis] of pneumonia and CHF [Congestive Heart Failure] History O2 [oxygen] ordered continuous. Date Initiated: 06/14/2022. Revision on: 06/21/2022 . Interventions: O2 sats [saturations] as ordered. Administer O2 as ordered. Date initiated: 06/14/2022. During an interview on 6/22/2022 at 11:13 AM, Staff D, Licensed Practical Nurse (LPN), verified Resident #166 was being administered oxygen at 2 L/m and verified the oxygen tubing was not labeled with a date. Staff D reviewed the medical record for Resident #166's for oxygen therapy. After checking the electronic system Staff D confirmed Resident #166 does not have a physician's order for the administration of oxygen. 3. During an observation of Resident #105 on 6/20/22 at 1:48 PM the oxygen concentrator was administering oxygen at 2 liters via nasal cannula. Review of the medical record for Resident #105 documented the resident was admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease (COPD), pneumonia, essential hypertension, chronic kidney disease, unspecified, dependence on supplemental oxygen. Review of the physician's order dated 1/12/2022 reads, Continuous O2 [oxygen] at 4 l [liters]/min [minute] via nc [nasal cannula] q [every] shift. During an observation of Resident #105 conducted on 6/21/22 at 8:32 AM O2 was being administered at 2 liters via nasal cannula During an interview conducted on 6/21/2022 at 12:38 PM Staff E, LPN stated, I'm not sure what her oxygen is set at. I will check the orders. It is ordered for 4 liters. 4. Review of the medical record for Resident #58 documented the resident was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia without behavioral disturbances, pleural effusion (a fluid build-up between the tissue that lines the lungs), generalized anxiety disorder, hypertensive retinopathy, Parkinson's disease, status post gastrostomy tube (a tube in the stomach that brings food directly to the stomach), iron deficiency, presence of left artificial hip joint, left ankle contracture, right ankle contracture, hypothyroidism, essential (primary) hypertension, cerebral infarction, (stroke) dysphagia (difficulty swallowing foods or liquids), and major depressive disorder. Review of the Physician's order dated 6/21/2021 reads, Ipratropium-Albuterol Solution 0.5-2.5 (3) mg [milligram]/3 ml [milliliter], 3 ml inhale orally four times a day for wheezing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 8 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation conducted on 6/21/22 at 10:32 AM, Staff E, LPN administered Ipratropium-Albuterol Solution 0.5-2.5(3) mg/3 ml. Staff E placed 3 ml into the passive nebulizer medication chamber, placed the face mask on the resident and started the machine. Staff E did not assess the lung sounds or vital signs of the resident. After turning on the nebulizer machine Staff E left the room and returned to the medication cart. After 15 minutes Staff E returned to Resident #58's room, did not assess breath sounds or vital signs for the resident, removed the mask and placed it back on the nightstand. During an interview conducted on 6/21/22 at 11:11 AM Staff E, LPN stated, All the passive nebulizers should be cleaned after they get used and they should be placed in a plastic bag until they are used again. I should have washed my hands and put on gloves. I should have checked the resident's lung sounds before I administered the breathing treatment and after to see if it helped. During an interview conducted on 6/22/22 at 1:17 PM the DON (Director of Nursing) stated, I do expect all staff to wash their hands, assess a residents lung sounds before and after administering any respiratory treatments. Review of the policy and procedure titled, Oxygen Administration reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 4. Vital signs: 5. Lung sounds. Steps in procedure: 12. Change oxygen tubing per physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 9 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 - Many 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. 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 6 of 8 medication carts. Findings include: During an observation of medication cart #1 conducted on 6/20/2022 at 8:57 AM with Staff A, Licensed Practical Nurse(LPN), there was one opened Levemir insulin with no date opened, no resident identifier, and not in the original pharmacy packaging, one opened Lantus insulin pen with no date opened or expiration date, one opened Latanoprost Ophthalmic Solution with no date opened or expiration date, and one medication cup with eleven medications with no resident identifier or list of what the medication were. During an interview conducted on 6/20/2022 at 9:05 AM Staff A, LPN, stated, All insulin should be labeled with the resident who they are for and when they are opened or expire. I know who the medications are for, but I shouldn't have left them in the cart. During an observation of medication cart #2 conducted on 6/20/2022 at 9:10 AM with Staff B, LPN, there was one opened Novolog insulin pen with no date opened or expiration date, one unopened Novolog insulin with pharmacy instructions to refrigerate until opened, one opened Humalog insulin with no date opened or expiration date, and one opened bottle of Novolog insulin with no date opened, resident identifier or original pharmacy packaging. During an observation of medication cart #3 conducted on 6/20/2022 at 9:17 AM with Staff B, LPN, there was one unopened Novolog insulin with pharmacy instructions to refrigerate until opened and one opened Novolog insulin with no date opened or expiration date. During an interview conducted on 6/20/2022 Staff B, LPN stated, All insulin should stay in the refrigerator until we are ready to use it and it should be labeled when we open it with the date we opened it or when it expires. During an observation of medication #4 conducted on 6/20/2022 at 9:25 AM with Staff C, LPN, there was one unopened Novolog insulin with pharmacy instructions to refrigerate until opened and one opened bottle of artificial tears with no date opened or expiration date. During an observation of medication cart #5 on 6/20/2022 at 9:35 AM with Staff C, LPN, there was on opened Humalog Insulin with no resident identifier and no date opened or expiration date and not in original pharmacy packaging, one opened Levemir insulin with no date opened or expiration date, one bottle of Humalog 75/25 insulin with no resident identifier, no date opened or expiration date and not in the original pharmacy packaging and one unopened vial of Promethazine 25 mg/ml (milligram/milliliter) with no resident identifier and not in original pharmacy packaging. During an interview conducted on 6/20/2022 at 9:40 AM Staff C, LPN stated, All medications should stay in the pharmacy package. If they are opened, they need to be labeled when they were opened or when they expire. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 10 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 - Many During an observation of medication cart #6 on 6/20/2022 at 9:50 AM with Staff D, LPN, there were two medications one white circular pill and one orange circular pill in the top drawer, not in a medication cup and two bags of M&M candy, one bag was opened. During an interview conducted on 6/20/2022 at 9:53 AM Staff D, LPN stated, I have no idea what those two pills are, and we should not have food on the medication carts. During an interview conducted on 6/23/2022 at 8:00AM the Director of Nursing stated, Nurses are to label medication with open dates and label expiration dates. Medication should have resident identifiers. Nurses are supposed to store medication as pharmacy instructed. Unopened medication should be refrigerated if that is the instructions provided. Medications must be secure in the medication cart at all times. Review of the policy and procedure titled, Administering Medication revised January 2022, read: 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Review of the policy and procedure titled, Storage of Medications revised January 2022, read: 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing system in which they are received. 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secure location. Review of the policy and procedure titled, Labeling of Medication Containers revised January 2022, read: 3. Labels for individual resident medication include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number (if applicable); f. The date that the medication was dispensed; g. Appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Directions of use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 11 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to ensure garbage and refuse was properly disposed of. Residents Affected - Few Findings include: During an observation on 06/20/22 at 09:19 AM with the Certified Dietary Manager in the back of the facility building outside in the dumpster area there is debris consisting of soiled briefs in plastic bags, soiled gloves, plastic cups, paper, straws and milk cartons near garbage receptacles, not in the garbage receptacles. (Photographic evidence obtained) During an interview on 06/20/22 at 09:20 AM the Certified Dietary Manager confirmed the observation, and stated, That trash is not supposed to be there. A request was made for the policy and procedure for garbage disposal. The Certified Dietary Manager stated, No policy exist, we are to put the garbage in the dumpsters and the area should be clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 12 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure infection control procedures were followed to prevent the possible spread of infection. Residents Affected - Many Findings include: 1. During an observation on 6/21/2022 at 9:33 AM of the laundry room it showed the door between the soiled laundry hold and the clean laundry area was propped open with a bucket. In the clean utility room near the dryers there was a pink bottle of water/ice on the table that contained folded linen and curtains. A Styrofoam cup containing ice and water was on the metal frame four tier laundry cart that contained clean linen. During an interview on 6/21/22 at 9:42 AM the Director of Environmental Services stated, In the staff's defense the air conditioner was broken, and the staff had the liquids to stay hydrated. The staff has been in-survived on not having drinks in the laundry or having drinks in the linen areas. The doors should not be propped open. I don't know why the door is propped open. 2. During an observation on 6/22/2022 at 2:33 PM it showed Resident #40 rolled himself up to the red and white ice chest located on the 300 hallway near the nurses' station and lifted the white lid to the ice chest. He used a blue ice scoop that was on the side of the ice chest and scooped ice into a stainless-steel cup. The resident was not observed to cleanse/sanitize his hands before scooping the ice. During an Interview on 6/22/2022 at 2:36 PM Staff C, Licensed Practical Nurse (LPN) stated, Resident #40 is very impatient and doesn't want to wait for ice. The residents will scoop their own ice. The ice chest supplies all of the residents' ice from rooms 301-330. Review of the policy and procedure titled, Environmental Services last reviewed in January 2022 read, Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. Review of the policy and procedure titled, Ice Machines and Ice Storage Chest read, Ice-making machines, ice storage chest/containers and ice can all become contaminated by: unsanitary manipulation by employees, residents, and visitors. Limit access to ice machines or ice storage chests/containers to employees only. 3. During an observation on 6/21/2022 at 10:13 AM of Staff E, LPN during medication administration showed Staff E exiting a resident's room after administering medications without performing hand hygiene. Staff E returned to the medication cart, unlocked the cart, did not perform hand hygiene, and began pouring medications for Resident #58. Staff E crushed all the medications, placed them in a cup and added water. Staff E locked the medication cart, enter the resident's room, did not perform hand hygiene, and donned gloves. Staff E administered the medications, removed her gloves, did not perform hand hygiene, returned to the medication cart, unlocked the cart and began to prepare medications for Resident #93. Staff E entered Resident #93's room, did not perform hand hygiene, and administered the medications. Staff E returned to the medication cart, did not perform hand hygiene, and prepared medications for Resident #79. Staff E entered Resident #79's room, did not perform hand hygiene, administered medications to Resident #79, exited the room, returning to the medication cart, did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 13 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 not perform hand hygiene, and began to prepare medications for another resident. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 6/21/2022 at 10:59 AM Staff E, LPN stated, I should have washed my hands when I went into the rooms and after I left. I just got nervous. Residents Affected - Many 4. During an observation on 6/22/2022 at 1:58 PM of Staff C, LPN of IV (intravenous) medication administration it showed Staff C prepared the medication for Resident #161, entered the room, did not perform hand hygiene, and donned gloves. Staff C uncapped the 10 milliliters (ml) syringe of normal saline, removed the air and placed the syringe down on the overbed table, uncapped. Staff cleaned the needleless connector with alcohol and administered the 10 milliliters of normal saline without checking for blood return to verify placement of the line. Staff C prepared the medication and connected the medication to the IV tubing, inserted the tubing into the IV pump and connected the IV tubing to the PICC (peripherally inserted central catheter which provides access to the large central veins near the hear) line needleless connector without cleaning the needless connector. During an interview on 6/22/2022 at 2:12 PM Staff C, LPN stated, I shouldn't have put the saline on the table uncapped. I should have checked for blood return, and I should have cleaned the connector again before I placed the medication into the line. I was just so nervous. Review of the policy and procedure titled, Handwashing/hand hygiene with a revision date of January 2022, reads, Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy interpretation and implementation. 7. Use an alcohol based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations; before preparing or handling medications; e. Before and after handling any invasive device (e.g., urinary catheters, IV access sites); g. before handling clean or soiled dressings, gauze pads, etc.; k. after handling used dressings, contaminated equipment, m. after removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare - associated infections. 5. Review of the medical record for Resident #58 documented the resident was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia without behavioral disturbances, pleural effusion (a fluid build-up between the tissue that lines the lungs), generalized anxiety disorder, hypertensive retinopathy, Parkinson's disease, status post gastrostomy tube (a tube in the stomach that brings food directly to the stomach), iron deficiency, presence of left artificial hip joint, left ankle contracture, right ankle contracture, hypothyroidism, essential (primary) hypertension, cerebral infarction, (stroke) dysphagia (difficulty swallowing foods or liquids), and major depressive disorder. Review of the Physician's order dated 6/21/2021 reads, Ipratropium-Albuterol Solution 0.5-2.5 3 mg/3 ml [milligram/milliliter], inhale orally four times a day for wheezing. During an observation conducted on 6/21/22 at 10:32 AM, Staff E, LPN administered Ipratropium-Albuterol Solution 0.5-2.5 3 mg/3 ml. Staff E placed 3 ml into the passive nebulizer medication chamber, placed the face mask on the resident and started the machine. Staff E did not assess the lung sounds or vital signs of the resident. After turning on the nebulizer machine Staff E left the room and returned to the medication cart. After 15 minutes Staff E returned to Resident #58's room, did not assess breath sounds or vital signs for the resident, removed the mask and placed it back on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 14 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 nightstand. Staff E did not clean the passive nebulizer mask. Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 6/21/22 at 11:11 AM Staff E, LPN stated, All the passive nebulizers should be cleaned after they get used and they should be placed in a plastic bag until they are used again. I should have washed my hands and put on gloves. I should have checked the resident's lung sounds before I administered the breathing treatment and after to see if it helped. Residents Affected - Many During an interview conducted on 6/22/22 at 1:17 PM the DON (Director of Nursing) stated, I do expect all staff to wash their hands, assess a residents lung sounds before and after administering any respiratory treatments. Review of the policy and procedure titled, Oxygen Administration reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 4. Vital signs: 5. Lung sounds. Steps in procedure: 12. Change oxygen tubing per physician orders. 6. Review of the medical record for Resident #157 documented the resident was admitted on [DATE] with the following diagnoses: Parkinson's disease, unspecified Alzheimer disease, hypothyroidism, hyperlipidemia, unspecified mood disorder, hydronephrosis, adult failure to thrive, and unspecified protein-calorie malnutrition Record review of the physician orders on 03/30/2022 reads Check tube placement and for residual before addition of feeding, flush, or medications. Record quantity. If residual is 100 cc or more, hold feeding and notify MD. During an observation on 06/22/2022 at 1:30 PM Staff E, LPN, entered Resident #157's room with the crushed medication and one carton of Jevity 1.2 for a bolus feeding (a type of feeding where a syringe is used to send formula through a feeding tube). Staff E, LPN placed the medication and administration supplies on the resident's bed side table. Staff E, LPN did not perform hand hygiene and donned gloves, did not check for residual and administered 30 ml of water into the gastrostomy tube and administered the medication and bolus feeding. During an interview on 06/22/2022 at 1:40 PM Staff E, LPN stated, I should have performed hand hygiene and checked for residual. Review of the policy and procedure titled, Administering Medications Through an Enteral [by way of] Tube with an approval date of 1/24/2022, reads Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube. Standards: Medications shall be prepared and administered according to the following established guidelines: .Tube placement will be verified prior to administration of a medication. The enteral tube will usually be flushed with 30-50 ml of water before and after administration and 5-10 ml water between medications administered, unless otherwise ordered by physician. Guidelines: 2. Wash hands and prepare medications per physician order. 5. Verify feeding tube placement. 7. Pour medication into syringe attached to feeding tube. Flush with 5-10 ml of water between each medication administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 15 of 16 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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 Level of Harm - Minimal harm or potential for actual harm 7. Review of the medical record documented Resident #13 was admitted on [DATE] with the following diagnoses: Type 1 Diabetes Mellitus with diabetic neuropathy, non-pressure chronic ulcer of other part of unspecified foot with unspecified severity, pain in unspecified joint, morbid (severe) obesity due to excess calories, obstructive sleep apnea, generalized muscle weakness, unspecified peripheral vascular disease, acquired absence of other right toes. Residents Affected - Many Review of the physician's order on 2/18/2022 reads, Betamethasone Dipropionate Cream 0.05%, apply to back topically every shift for rash. Review of the physician's order on 05/17/2022 reads, Silvadene Cream 1%, apply to testicles topically every 7 days for irritation. Review of the physician's order on 06/22/2022 reads, Apply house barrier cream to buttocks as needed for prevention each brief change and/or incontinence episode. During an observation on 06/22/2022 at 1:40 PM with Staff I, LPN of wound care it showed Staff I entered Resident #13's room with the treatment cart, placed a barrier without disinfecting the top of the treatment cart. Staff I, did not perform hand hygiene and placed Bamethasone Dipropionate Cream 0.05%, Silvadene Cream 1%, and Barrier Ointment on the upper left corner of the barrier. Staff I, assembled the remaining needed supplies of normal saline, 4x4 gauze, and a border foam dressing on the barrier. Staff I did not perform hand hygiene, donned gloves, and assisted the resident to turn to his right side. Staff I did not doff the gloves or perform hand hygiene and removed the Bamethasone Dipropionate Cream 0.05% from the barrier and applied the cream on the resident's back. Staff I doff the gloves, did not perform hand hygiene, and donned a new pair of gloves. Staff I cleaned the wound to the resident's left buttock with normal saline. Staff I used the same gauze multiple times to clean the left buttock wound and surrounding area, wiping from front to back. Staff I discarded the used gauze on the barrier. Staff I, patted the buttock dry and placed the gauze on the clean barrier and doff the gloves, placing them on top of barrier. Staff I did not perform hand hygiene, donned a new set of gloves and applied Barrier Ointment to the wound area. Staff I doff the gloves, placed the used gloves on the clean barrier. Staff I did not perform hand hygiene, donned new gloves and applied the foam dressing. During an interview on 6/22/2022 at 2:05 P.M. Staff I, LPN stated, I should have performed hand hygiene before and after putting on gloves during the resident's wound care. I should have discarded all dirty gloves and gauze in the trash can instead of contaminating the barrier. I was nervous. During an interview on 06/23/2022 at 8:05AM the Director of Nursing stated, Nurses are expected to wash their hands before and wear gloves. When they are finished, they are supposed to wash hands. Review of the policy and procedure titled, Wound Care with an approval date of 1/24/2022 reads, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the procedure: 2. Wash and dry hands thoroughly. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 16. Discard disposable items into the designated container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 16 of 16