Health inspection·December 7, 2023

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 Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received nail care for 1 of 3 reviewed residents, Resident #132. Residents Affected - Few Findings include: During an observation on 12/3/2023 at 9:40 AM, Resident #132 was sitting outside of his room in his wheelchair. Resident #132's fingernails on his right and left hands were long with dark brown and black substances underneath the nails. There was an injury on the resident's right cheek. Review of Resident #132's care plan, revised on 10/24/2023, revealed the resident had a self-care deficit related to generalized weakness and psychomotor deficit. Resident #132's care plan documented activities of daily living self-care interventions that included assist with nail shaping, keep nails short and clean. Review of Resident #132's personal hygiene task documentation dated 11/23/2023 through 12/3/2023, revealed no documentation indicating the resident had refused to participate in personal hygiene care. During an interview on 12/3/2023 at 9:44 AM, Staff A, Certified Nursing Assistant (CNA), stated that Resident #132's nails needed to be trimmed and cleaned and the resident liked to dig and suggested that he might have scratched his face. During an interview on 12/6/2023 at 8:40 AM, the Director of Nursing stated that the CNA staff should have taken care of Resident #132's fingernails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 2 of 15 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 12/07/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #62's admission record showed the was admitted with diagnoses including peripheral vascular disease and mild protein calorie malnutrition. Residents Affected - Few Review of Resident #62's physician order dated 10/30/2023 showed the order to cleanse the right arm with normal saline, pat dry, apply Xeroform and cover with pad two times a day for skin tear. During an observation on 12/4/2023 at 9:22 AM, Resident #62 was lying in bed with a dressing on the right upper arm dated 11/29/2023. During an observation on 12/4/2023 at 12:10 PM, Resident #62 had a dressing on the right upper arm dated 11/29/2023. During an interview on 12/4/2023 at 9:22 AM, Resident #62 stated, I don't know why that is there. During an interview on 12/5/2023 at 7:31 AM, Staff L, LPN, stated, I don't know why she has that dressing really, but I removed it and changed it yesterday. It has not been changed since last week. I changed it yesterday when I saw that the dressing had not been changed since November 29, 2023. During an interview on 12/5/2023 at 7:55 AM, the Director of nursing stated, The physician orders need to be followed and the dressing should be changed twice a day. Review of the facility policy and procedures titled Wound Care issued on 4/1/2022 reads, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure . 6. Wound care procedures and treatments should be performed according to physician orders. Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents receiving intravenous infusion via Peripherally Inserted Central Catheter (PICC) Line, Residents #18 and #62. Findings include: 1. During an observation on 12/5/2023 at 9:15 AM, Resident #18's PICC line dressing was not dated and there was no gauze or bio-patch under the dressing. There was dry residue under the dressing and there was no needleless connector at the end of the valve (Photographic evidence obtained). During an interview on 12/5/2023 at 9:15 AM, Resident #18 stated, I had this line in the hospital before I came. No one has changed it [dressing] here. Review of Resident #18's admission records showed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin-Resistant Staphylococcus Aureus (MRSA) bacterial infection of the right lower leg. Review of Resident #18's Catheter Insertion Procedure Note dated 11/27/2023 showed the PICC line was placed on the resident's right upper extremity on 11/27/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 3 of 15 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 12/07/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #18's physician order dated 11/29/2023 reads, Daptomycin Intravenous Solution Reconstituted 350 mg [milligrams]. Use 350 mg/ml [milliliters] intravenously every 24 hours for MRSA Infection for 10 days . Start Date: 11/30/2023. Review of Resident #18's physician order dated 12/4/2023 reads, Observe IV [intravenous] site at every shift, every shift for IV site integrity Transparent dressing- change Q [every] seven days and PRN [as needed] Securement device with each dressing change as needed. During an interview on 12/5/2023 at 11:26 AM, the Director of Nursing (DON) stated, My expectation is that there is a date/time on the dressing change. If there is no connector on the valve, then it is at risk for infection. During an interview on 12/5/2023 at 11:27 AM, Staff E, Registered Nurse (RN)/ Unit Manager, stated, It [the dressing] came like this from the hospital. I changed the dressing yesterday and I put the date and time on a sticker on the dressing. I put a valve on the line as well. Someone must have taken it off. During an interview on 12/5/2023 at 11:32 AM, Staff B, Licensed Practical Nurse (LPN), stated, I did not assess the valve/connector. I did look for redness and signs of infection this morning. I am not trained in IV [intravenous] therapy. During an interview on 12/6/2023 at 9:50 AM, Staff E, RN, stated, We don't check arm circumferences here, we just monitor for signs and symptoms of infection, if the IV is infusing correctly and monitor the line. Review of the facility policy and procedures titled P&P PICC/Midline IV Line issued on 4/1/2022 reads, Policy: It will be the policy of this facility to adhere to IV/PICC/Midline administration guidelines as set forth by infection control, state, and federal regulations. Licensed nurses shall provide care according to state and federal law. Considerations: Central Venous Catheters include Peripherally Inserted Central Catheters (PICC)/Midline, Non-tunneled Catheters (Subclavian, jugular, femoral) Tunneled Catheters, Implanted Venous Ports. Guidelines: 1. Medications shall be administered in accordance with physician orders. 2. Medication administration shall be documented in the clinical record. Dressing changes: 1. Sterile dressing change using transparent dressings is performed: 24 hours post-insertion or upon admission if not dated upon admission, at least weekly, if the integrity of the dressing has been compromised (wet, loose, or soiled). 2. Dressing changes will be documented in the clinical record. Review of PharmScript Infusion Intravenous (IV) Access Line Maintenance Protocol with an effective date of February 7, 2020 reads, Nurses must: 1. Follow individual therapy procedures for administration of infusion medications and line maintenance. 2) Assess the patient for conditions that may require concentration or volume changes. 3) Assess IV access patency (aspirate a blood return from the catheter. The blood return should be the color/consistency of whole blood. Note: Once a secondary set is detached from a primary set, the secondary set shall be considered a primary set for the instructions below. PICCFlush Protocols: Maintenance Flush Each Lumen: Non-valved Q12, 10 ml NS [normal saline], 5 ml 10 units/ml Heparin; Valved 10 ml NS Q week. Intermittent non-valved: 10 ml NS, Medication, 10 ml NS, 5 ml 10 units/ml Heparin. Intermittent valved: 10 ml NS, Medication, 10 ml NS . Site Management: Transparent Dressing Changes: On admission or 24' post insertion, then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change and PRN. Needless [Sic.] Connector Changes: On admission Q week & prn, Q 24'with TPN Post Blood Draw Post Blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 4 of 15 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 12/07/2023 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 0684 Transfusion. Administration Set Changes . Primary Intermittent: 24'. 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: 105649 If continuation sheet Page 5 of 15 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 12/07/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents maintained the nutritional status for 1 of 6 residents reviewed for nutrition, Resident #81. Residents Affected - Few Findings include: Review of Resident #81's physician order dated 10/27/2023 reads, NAS (No Added Salt) diet Finger Food texture, Thin consistency, Finger foods preferred. Review of Resident #81's care plan revised on 9/22/2023 revealed the resident was at risk for alteration in nutrition and/or hydration. Resident #81's care plan documented nutritional interventions that included Provide diet as ordered. Offer and provide alternate as needed and honor food preferences. Review of Resident #81's weight history showed a weight of 155 pounds on 10/25/2023 and a weight of 153.4 pounds on 11/21/2023, which was a 1.03% weight loss. Further review showed a weight of 169.6 pounds on 7/5/2023 and a weight of 153.4 pounds on 11/21/2023, which was a 9.55% weight loss. During an observation on 12/4/2023 at 1:09 PM, Resident #81 received ham, scalloped potatoes, beets in juice and fruit in juice as her midday meal. Resident #81 ate her meal using her hands. Resident #81 did not use utensils. During an observation on 12/5/2023 at 9:13 AM, Resident #81 received oatmeal, scrambled eggs, pancakes with syrup and bacon as her morning meal. Resident #81 ate her meal using her hands. Resident #81 did not use utensils. During an interview on 12/5/2023 at 9:15 AM, Staff I, Certified Nursing Assistant (CNA), stated, [Resident #81's name] ate with her hands and she was supposed to be on finger foods. On 12/5/2023 at 12:26 PM, Resident #81 received spaghetti and meatballs, green beans and apple crisps as her midday meal. Resident #81 ate her meal using her hands. Resident #81 did not use utensils. During an interview on 12/6/2023 at 7:47 AM, the Dietary Manager stated, We are to provide finger friendly foods. Typically, we take the main course entrée and serve it in a sandwich for finger friendly foods. I see the finger food order. Should have chosen the alternate meal and turned that into a sandwich. He confirmed that the meal items served to Resident #81 were not finger food friendly. He stated, It appears the diet was changed on 11/1/2023 and we did not get communication of it. Supposed to get notified by nursing. During an interview on 12/6/2023 at 8:50 AM, the Registered Dietician stated, We rely on nurses to let us know. [Resident #81's name] problem is not her appetite but more of function and [Resident #81's name] will benefit from being able to get food in her mouth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 6 of 15 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 12/07/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure medication error rate was below 5%. The facility's medication error rate was 7.14%. Residents Affected - Few Findings include: 1. During an observation on 12/5/2023 at 8:50 AM, Staff G, Licensed Practice Nurse (LPN), administered Brimonidine Tartrate 0.1% Ophthalmic Solution for Resident #65's eyes. Record review of Resident #65's medication order showed the order for Brimonidine Tartrate 0.2% Ophthalmic Solution to instill one drop both eyes two times a day for glaucoma. Review of the medication package label reads Brimonidine 0.1% Ophthalmic solution, instill one drop in both eyes two times a day for glaucoma. During an interview on 12/6/2023 at 9:41 AM, Staff G, LPN, stated, I didn't check the medicine against the order. I should have. During an interview on 12/6/2023 at 12:34 PM, the Director of Nursing (DON) stated, The nurse would call the family, doctor, supervisor, and fill out an incident form for a wrong medication dose or wrong medication given. 2. During an observation on 12/5/2023 at 9:03 AM, Staff G, LPN, administered Mucous Relief DM Guaifenesin and Dextromethorphan HBr ER tablets 600 mg (milligrams)/ 30 mg for Resident #98. Record review of Resident #98's medication order showed the order for Mucinex Oral Tablet Extended Relief 12-hour 600 mg to give one tablet by mouth two times a day for cough for 10 days, with the start date of 12/1/2023. Review of the medication package label reads, Mucous Relief DM Guaifenesin and Dextromethorphan HBr ER tablets 600 mg/ 30 mg, expectorant and cough suppressant. During an interview on 12/6/2023 at 12:08 PM, Staff G, LPN, stated, The order does not match the medication label. We get over-the-counter medicine from central supply. During an interview on 12/6/12023 at 12:34 PM, the DON stated, The nurse would call the family, doctor, supervisor, and fill out an incident form. I was not notified of this. Review of the Facility policy and procedures titled P&P Medication Administration issued on 4/1/2022, reads Procedure . 8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time, and right method of administration are verified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 7 of 15 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 12/07/2023 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 - 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** Based on observation, record review, and interview, the facility failed to ensure that opened blood glucose test strips were labeled in 3 of 6 medication carts observed. Findings include: During an observation of Medication Cart #1 in Hall 200- Spanish Village Unit on [DATE] at 9:10 AM, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 9:10 AM, Staff D, Licensed Practical Nurse (LPN), stated, I do not write the date on the bottle when I open them. I do not know what the policy for this facility is. During an observation of Medication Cart #2 on Hall 200- Spanish Village Unit on [DATE] at 9:30 AM, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 9:30 AM, Staff C, LPN, stated that the glucose strips were supposed to be dated when the bottle was opened and were good for 90 days after they were opened. During an interview on [DATE] at 10:54 AM, Staff F, LPN, stated that the glucose strips were opened, and the date opened should be written on the bottle. Staff F confirmed the strips would expire 30 days after the bottle was opened. During an interview on [DATE] at 11:20 AM, Staff G, LPN, stated that glucose strips should be dated with the open date when the bottle of strip were opened and would be good for 90 days after they were opened. During an observation of Medication Cart #1 on French Quarter Hall on [DATE] at 12:10 PM, with Staff J, LPN, Nursing Manager, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 12:10 PM, Staff K, LPN, stated, The dates should be written on the strips when it is opened. I do not know how long they are good for after they have been opened. I thought we went by the expiration date on the bottle from the manufacturer. During an interview on [DATE] at 12:18 PM, Staff J, LPN, Nursing Manager for French Quarter, stated, Blood sugar strips are to be dated when the bottle of strips are opened. The date the bottle is opened should be written on the top of the strips. I do not know for sure how long the strips are good after they are opened. I will have to check. There is an expiration on the bottle of strips by the manufacturer. During an interview on [DATE] at 12:41 PM, the Director of Nursing (DON) stated, My expectation is for the nurses to write the open date on top of the glucose strips. We go by the expiration date written on the bottle by the manufacturer. Review of Assure Prism Multi Blood Glucose Monitoring System Quality Assurance/Quality Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 8 of 15 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 12/07/2023 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 Reference Manual reads, Storage and Handling . Use all of the test strips within the expiration date printed on the test strips bottle/box label. Do not use the expired strips and dispose the expired test strips immediately because using test strips past the expiration dates can produce incorrect test results . Warnings and Precautions . Do not use beyond 3 months (90 days) after opening the bottle. Record the discard date (3 months from the day the bottle was opened) on the bottle label. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 9 of 15 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 12/07/2023 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure adaptive eating equipment or devices were provided to 1 of 6 residents reviewed for nutrition, Resident #469. Residents Affected - Few Findings include: During an observation on 12/4/2023 at 9:17 AM, Resident #469 was using plastic disposable utensils to eat his breakfast. During an observation on 12/5/2023 at 12:40 PM, Resident #469 was using plastic disposable utensils to eat his meal. Review of Resident #469's physician order dated 9/15/2023 showed the order reads, Pt [Patient] to utilize built-up utensils for all meals. During an interview on 12/4/2023 at 12:43 PM, the Speech Therapist stated that she was aware Resident #469 was supposed to be using built-up utensils. During an interview on 12/6/2023 at 8:00 AM, the Certified Dietary Manager (CDM) stated, The dishwasher is not functioning currently and residents are being given disposable dishware. The specialized utensils should have been going out to residents but the new staff is in need of further training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 10 of 15 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 12/07/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 12/4/2023 at 9:22 AM, Resident #62 was lying in bed with a dressing on the right upper arm dated 11/29/2023. During an observation on 12/4/2023 at 12:10 PM, Resident #62 had a dressing on the right upper arm dated 11/29/2023. Review of Resident #62's physician order dated 10/30/2023 showed the order to cleanse the right arm with normal saline, pat dry, apply Xeroform and cover with pad two times a day for skin tear. Review of Resident #62's Treatment Administration Record for November 2023 and December 2023 revealed the wound care and dressing change was completed on 11/30/2023, 12/1/2023, 12/2/2023, 12/3/2023. During an interview on 12/6/2023 at 1:53 PM, the Director of Nursing stated that the dressing had not been changed since November 29, 2023, and that the nurses documented that the skin care on the upper right arm was completed. The Director of Nursing stated that the nurses documented the dressing changes in error when the dressing was not completed. She confirmed the dressing changes were not completed on 11/30/2023, 12/1/2023, 12/2/2023, 12/3/2023. 4. Review of Resident #1's admission record revealed the resident was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included fracture of unspecified part of neck of left femur. Review of Resident #1's physician order dated 1/2/2013 reads, Send to ER [Emergency Room] to eval [evaluate] and treat as indicated. Review of Resident #1's nursing home to hospital transfer form dated 1/2/2023 revealed the resident was transferred to hospital on 8/26/2022 for abnormal white blood cell count (High). During an interview on 12/5/2023 at 3:00 PM, the Director of Nursing stated, Nursing home to hospital transfer form has the wrong date and reason for transfer written on the transfer form. It is dated correctly on the bottom. The patient was transferred after a fall on 1/2/2023 with complaint of leg pain after a fall. During an interview on 12/6/2023 at 3:14 PM, the Corporate Regional Registered Nurse stated, Nursing home to hospital transfer form had the wrong date and reason, but is time stamped on the bottom of the form with the correct date. During an interview on 12/6/2023 at 3:40 PM, the Assistant Director of Nursing stated, I do not know why wrong date or diagnosis is written on the nursing home to hospital transfer form. It must automatically fill in from the computer. He was transferred out because he fell and broke his hip on 1/2/2023. Review of the facility's policy and procedures titled Transfer and Discharge reviewed on 1/18/2023 reads 3. Appropriate documentation and forms will be sent to the receiving facility/accompany the resident during transport and attempt to have them singed by the resident/resident representative should be made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 11 of 15 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 12/07/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure medical records were accurate for 1 of 4 residents reviewed for PASRR, Resident #141, for 3 of 6 residents reviewed for nutrition, Residents #81, #141 and #156, for 1 of 5 residents reviewed for wound care, Resident #62, and for 1 resident transferred to the hospital, Resident #1. Residents Affected - Some Findings include: 1. Review of Resident #141's admission record showed the resident was originally admitted on [DATE] and was diagnosed with brief psychotic disorder on 4/3/2023. Review of Resident #141's PASRR dated 11/1/2023 showed no diagnosis of psychotic disorder. During an interview on 12/6/2023 at 8:38 AM, the Director of Nursing confirmed Resident #141's PASRRs was inaccurate. 2. Review of Resident #141's weight summary showed the resident weighed 85.6 pounds on 11/3/2023 and 82.1 pounds on 12/4/2023. Resident #141's historical weight record showed the resident had a body mass index of 12.9 (underweight). Review of Resident #141's care plan revised on 11/3/2023 revealed the resident was at risk for an alteration in nutrition and/or hydration related to a fracture of unspecified part of neck, moderate protein-calorie malnutrition, dementia, chronic obstructive pulmonary disease, dysphagia, low body mass index and the need of a therapeutic diet. Review of Resident #141's percentage of meal eaten data from 11/23/2023 through 12/5/2023 showed the percentage of meal intake was not recorded for all meals on 10 of 14 days reviewed. Review of Resident #156's weight summary showed the resident weighed 128.8 pounds on 9/28/2023 and 124.4 pounds on 12/4/2023. Resident #156's historical weight record showed the resident had a body mass index of 17.8 (underweight). Review of Resident #156's care plan revised on 10/3/2023 revealed the resident was at risk for an alteration in nutrition and/or hydration related to unspecified dementia, Alzheimer's disease, major depressive disorder and hypertension. Review of Resident #156's percentage of meal eaten data from 11/23/2023 through 12/5/2023 showed the percentage of meal intake was not recorded for all meals on 3 of 12 days reviewed. Review of Resident #81's weight summary showed the resident weighed 169.6 pounds on 7/5/2023 and 153.4 pounds on 11/21/2023, which was a 9.55% weight loss. Review of Resident #81's care plan revised on 9/22/2023 revealed the resident was at risk for an alteration in nutrition and/or hydration related to mood disorder, hyperlipidemia, hypothyroidism, hypertension, dementia, depression, obese and planned weight loss program unrealistic based on diagnosis of dementia. Review of Resident #81's percentage of meal eaten data from 11/23/2023 through 12/5/2023 showed the percentage of meal intake was not recorded for all meals on 11 of 13 days reviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 12 of 15 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 12/07/2023 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 0842 During an interview on 12/6/2023 at 1:45 PM, the Director of Nursing confirmed meal percentage intakes should have been consistently recorded daily for Resident #141, Resident #156 and Resident #81. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 13 of 15 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 12/07/2023 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** 2. During an observation on 12/4/2023 at 9:23 AM, Resident #470's catheter bag was on the floor. Residents Affected - Few During an interview on 12/4/2023 at 9:23 AM, Staff B, Licensed Practical Nurse (LPN), stated, I usually check cath [catheter] bags each morning, but I was not able to get into his room this morning because I was busy and running, but it should have been checked. During an interview on 11/6/2023 at 9:33 AM, the Director of Nursing stated that it was her expectation for the nurses on the floor to check the catheter bags while passing medication. Review of the facility policy and procedure titled, P&P Prevention of Catheter Associated Urinary Tract Infections (CAUTIs) reads, Guidelines . 11. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Based on observation, record review, and interview, the facility failed to ensure staff performed assessment and proper dressing changes for Peripherally Inserted Central Catheter (PICC) Line and attach a needleless connector to the PICC line valve to help prevent the development and transmission of infection for 1 of 3 residents, Resident #18, and failed to ensure infection control standards were followed for 1 of 3 residents reviewed for indwelling urinary catheter, Resident #470. Findings include: 1. During an observation on 12/5/2023 at 9:15 AM, Resident #18's peripherally inserted central catheter (PICC) line dressing was not dated and there was no gauze or bio-patch under the dressing. There was dry residue under the dressing and there was no needleless connector at the end of the valve (Photographic evidence obtained). During an interview on 12/5/2023 at 9:15 AM, Resident #18 stated, I had this line in the hospital before I came. No one has changed it [dressing] here. Review of Resident #18's admission records showed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin-Resistant Staphylococcus Aureus (MRSA) bacterial infection of the right lower leg. Review of Resident #18's Catheter Insertion Procedure Note dated 11/27/2023 showed the PICC line was placed on the resident's right upper extremity on 11/27/2023. Review of Resident #18's physician order dated 11/29/2023 reads, Daptomycin Intravenous Solution Reconstituted 350 mg [milligrams]. Use 350 mg/ml [milliliters] intravenously every 24 hours for MRSA Infection for 10 days . Start Date: 11/30/2023. During an interview on 12/5/2023 at 11:32 AM, Staff B, Licensed Practical Nurse (LPN), stated, I did not assess the valve/connector. I did look for redness and signs of infection this morning. I am not trained in IV [intravenous] therapy. During an interview on 12/6/2023 at 9:50 AM, Staff E, RN, stated, We don't check arm circumferences here, we just monitor for signs and symptoms of infection, if the IV is infusing correctly and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 14 of 15 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 12/07/2023 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 monitor the line. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedures titled P&P PICC/Midline IV Line issued on 4/1/2022 reads, Policy: It will be the policy of this facility to adhere to IV/PICC/Midline administration guidelines as set forth by infection control, state, and federal regulations. Licensed nurses shall provide care according to state and federal law. Considerations: Central Venous Catheters include Peripherally Inserted Central Catheters (PICC)/Midline, Non-tunneled Catheters (Subclavian, jugular, femoral) Tunneled Catheters, Implanted Venous Ports. Guidelines: 1. Medications shall be administered in accordance with physician orders. 2. Medication administration shall be documented in the clinical record. Dressing changes: 1. Sterile dressing change using transparent dressings is performed: 24 hours post-insertion or upon admission if not dated upon admission, at least weekly, if the integrity of the dressing has been compromised (wet, loose, or soiled). 2. Dressing changes will be documented in the clinical record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105649 If continuation sheet Page 15 of 15