Inspection·April 27, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident received an accurate assessment of the resident's status for 1 of 3 residents, Resident #157. Residents Affected - Few Findings include: Review of Resident #157's electronic record showed Resident #157 was admitted to the facility on [DATE] and discharged on 1/29/23. Review of Resident #157's nursing progress note dated 1/29/23 read, Patient was D/C [discharged ] home with home health . Patient left with grandson. Review of Resident #157's Minimum Data Set Assessment Discharge Return Not Anticipated dated 1/29/23 documented the resident was discharged to an acute hospital. During an interview on 4/26/23 at 12:20 PM, Staff R, MDS (Minimum Data Set) Registered Nurse (RN), confirmed Resident #157's Discharge MDS documented him as being discharged to an acute hospital; he (the resident) was discharged home with family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 2 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 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** 3. Review of Resident #309's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential (primary) hypertension, dementia, chronic obstructive pulmonary disease, and adult failure to thrive. Residents Affected - Some Review of Resident #309's physician order dated 4/5/2023 reads. Oxygen @ [at] 2 L/Min [liters/minute] via NC [nasal cannula] CONT [continuous] every shift. During an observation on 4/24/2023 at 11:16 AM, Resident #309 was resting in bed and was being administered oxygen at 3 liters per minute via nasal cannula. During an observation on 4/25/2023 at 12:52 PM, Resident #309 was in bed and was being administered oxygen at 3 liters per minute via nasal cannula. During an interview on 4/25/2023 at 12:54 PM, Staff G, License Practical Nurse (LPN), verified the oxygen was being administered at 3 liters per minute via nasal cannula. Staff G stated, The orders are for 2 liters. I do not know why it is at 3. I normally check the oxygen rate when I give morning medications. I did not check it this morning. Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 6 of 6 residents reviewed for respiratory care, Residents #29, #30, #34, #76, #85, and #309. (Photographic evidence obtained) Findings include: 1. Review of Resident #85's admission record revealed the resident was admitted on [DATE] with diagnoses including unspecified atrial fibrillation, chronic obstructive pulmonary disease, interstitial pulmonary disease, and atherosclerotic heart disease of native coronary artery without angina pectoris. During an observation on 4/24/2023 at 10:05 AM, Resident #85 was lying in bed, and was being administered oxygen at 1 liter per minute via nasal cannula. During an interview on 4/24/2023 at 10:05 AM, Resident #85 stated, I should be on [oxygen] 2 liters per minute. During an observation on 4/25/2023 at 8:18 AM, Resident #85 was lying in his bed, and was being administered oxygen at 1 liter per minute via nasal cannula. On 4/25/2023 at 8:18 AM, Resident #85 was observed lying in his bed and was being administered oxygen at 1 liter per minute via nasal cannula. Review of the physician order dated 12/30/2022 for Resident #85 read, Oxygen 2 min [Sic.] via nasal cannula continuously every shift. During an interview on 4/25/2023 at 1:16 PM, Staff N, Licensed Practical Nurse (LPN), stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 3 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 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 [Resident #85's name] is supposed to be on 2 liters per minute. His concentrator is set to 1 liter per minute. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #34's admission record revealed the resident was admitted on [DATE] with diagnoses including heart failure, pleural effusion, acute respiratory failure with hypoxia, unspecified atrial fibrillation, acute pulmonary edema, and atelectasis (collapse of part or all of a lung). Residents Affected - Some During an observation on 4/24/2023 at 1:05 PM, Resident #34 was lying in bed, and was being administered oxygen at 2 liters per minute via nasal cannula. Review for Resident #34 medical records revealed no physician order for oxygen administration. Review of Resident #34's care plan dated 3/14/2023 read, [Resident #34's name] is at risk for altered respiratory status/difficulty breathing r/t [related to] Hx [history] of Respiratory Failure, Pleural Effusions, and Pulmonary Edema. During an interview on 4/25/2023 at 1:19 PM, Staff N, LPN, stated, [Resident #34's name] is currently receiving oxygen at 2 liters per minute. I cannot find an order for it in the medical record. 4. Review of Resident #29's admission record revealed the resident was admitted to the facility on [DATE] with the diagnoses including chronic obstructive pulmonary disease, unspecified systolic (congestive) heart failure, acute and chronic respiratory failure with hypoxia, and anemia. During an observation on 4/24/2023 at 10:12 AM, Resident #29 was lying in bed. There was a nebulizer machine on the bedside table with a hand-held nebulizer mouthpiece attached to the nebulizer machine. The tubing to the nebulizer machine was dated 4/2/2023. During an interview on 4/24/2023 at 10:12 AM, Resident #29 stated, The staff do not change my treatment mouthpiece or the tubing. It has been over two weeks since they have changed them and put a new set. Review of Resident #29's physician order dated 1/23/2023 read, Nebulizer tubing, cannula/mask change weekly on Thursdays and PRN [as needed] and every day shift every Thu [Thursday] for infection control. Review of Resident #29's physician order dated 1/25/2023 read, Nebulizer equipment change: change nebulizer HHN [Hand Held Nebulizer] and tubing weekly every day shift every Thu for infection control. During an interview on 4/25/2023 at 1:27 PM, the Assistant Director of Nursing (ADON) stated, Staff should be changing nebulizer tubing weekly. 5. Review of Resident #30's admission record revealed the resident was admitted to the facility on [DATE] with the diagnoses including acute on chronic diastolic (congestive) heart failure, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, adjustment disorder, other specified interstitial pulmonary disease, muscle weakness, repeated falls, dizziness and giddiness, essential hypertension, hyperlipidemia, tachycardia, and hypothyroidism. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 4 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 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 During an observation on 4/24/2023 at 10:02 AM, Resident #30 was lying in bed, with oxygen being administered at 3 liters per minute via nasal cannula. During an observation on 4/25/2023 at 8:00 AM, Resident #30 was lying in bed, with oxygen being administered at 3 liters per minute via nasal cannula. Residents Affected - Some Review of Resident #30's physician order dated 4/5/2023 reads, Oxygen @ 2 L/Min via NC, CONT every shift for supplemental. During an interview on 4/25/2023 at 1:13 PM, the Assistant Director of Nursing (ADON) stated, [Resident #30's name] oxygen should be running at 2 liters per minute not at 3 liters per minute. I do not know if she has had any recent changes. Her orders are for two liters. 6. Review of Resident #76's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis, chronic obstructive pulmonary disease, and personal history of pulmonary embolism. During an observation on 4/24/2023 at 10:12 AM, Resident #76 was sitting in his wheelchair facing the bedside table. There was an oxygen tank behind the resident's wheelchair with oxygen tubing dated 3/28/2023 and a nasal cannula wrapped on the oxygen tank that was stored in a bag. Review of Resident #76's physician order dated 3/10/2023 read, Oxygen tubing, cannula/mask change weekly and PRN and every day shift Thu for Maint Care [Maintenance Care]. During an interview on 4/25/2023 at 1:15 PM, the Assistant Director of Nursing (ADON) confirmed that Resident #76's oxygen tubing was dated 3/28/2023. The ADON stated, As far as I understand, oxygen tubing should be changed once a week and nasal cannulas should be stored in a bag when not in use. During an interview on 4/25/2023 at 1:46 PM, the Director of Nursing (DON) stated, My expectation is that we are to follow physician orders for oxygen administration and that all tubing should be changed out every 7 days. Review of the policy and procedure titled Nursing-Oxygen Administration with an annual review date of 12/20/22 reads, Procedure . 8. Turn on the oxygen. Start the flow of oxygen at the prescribed rate . Care of Tubing and Supplies . 3. Store oxygen and respiratory supplies in a bad [Sic.] labeled with resident's name when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 5 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on record review and interview, the facility failed to ensure nurse staffing information was posted daily. (Photographic evidence obtained) Residents Affected - Many Findings include: During an observation on 4/24/2023 at 9:04 AM, the posted nurse staffing information readily accessible to residents and visitors was dated 4/13/2023. During an observation on 4/25/2023 at 1:38 PM, the posted nurse staffing information readily accessible to residents and visitors was dated 4/24/2023. During an interview on 4/26/2023 at 3:18 PM, the Director of Nursing stated, My expectation is that staffing hours are to be posted daily. Review of the facility policy and procedure titled Nursing - Nurse Staffing Information last reviewed on 12/20/2022 read, Policy: (1) Data Requirements. The facility must post the following information on a daily basis: (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified Nursing Assistants, Nursing Assistants, Personal Care Assistants and other Direct Care staff. (2) Posting requirements. the facility must post the nurse staffing data specified above on a daily basis at the beginning of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 6 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on [DATE] at 10:16 AM, there were medications on Resident #54's bedside table including two bottles of Equate Eye Drops with no opened date and the manufacturer's expiration date of [DATE], and two containers of Dermasil Dry Skin Treatment. During an observation on [DATE] at 8:03 AM, there were medications on Resident #54's bedside table including two bottles of Equate Eye Drops, and two containers of Dermasil Dry Skin Treatment. During an interview on [DATE] at 1:11 PM, Staff O, LPN, stated, A resident would need to have an order to self-administer medications to be able to keep them at their bed side. All medications are supposed to be in a locked box per facility policy. Review of Resident #54's physician orders revealed no order for self-administration of medications.3. During an observation on [DATE] at 9:53 AM, there was Opti-nail fungal nail repair ointment, icy hot pain relieving cream, Aspercreme lidocaine pain relief cream and two bottles of lubricant eye drops in Resident #87's room. During an interview on [DATE] at 9:53AM, Resident #87 stated, My son has bought me those medications so that I can put them on my feet and the eye drops I apply them every day. During an interview on [DATE] at 1:21 PM, the Assistant Director of Nursing (ADON) stated, I do not see an order for medication self-administration. [Resident #87's name] should not have those medications in her room. 4. During an observation on [DATE] at 10:12 AM, there was a bottle of lubricant eye drops on top of the dresser labeled with Resident #81's name in Resident #81's room. During an observation on [DATE] at 10:12 AM, there was a bottle of lubricant eye drops on top of the dresser labeled with Resident #76's name in Resident #76's room. During an interview on [DATE] at 10:14 AM, Resident #81 stated, I apply those drops myself and I also help [Resident #76's name] apply them as well. During an interview on [DATE] at 1:17 PM, the ADON stated, I do not see any order for self-administering for [Resident #81's name] and [Resident #76's name]. Family often bring medications. 5. During an observation on [DATE] at 1:30 PM, there was a restless leg medication, Mucinex, a Debrox earwax removal kit, and Vitamin A and D skin protectant ointment in Resident #89's room. During an interview on [DATE] at 1:24 PM, the ADON stated, [Resident #89's name] does not have orders to self-administer medication. In order for the resident to self-administer, we would need a doctor's order, do a self-administering assessment and provide the resident with a lock box and key. Review of the facility policy and procedure titled, Storage of Medications issued in [DATE] and last reviewed on [DATE] reads, Policy: Medications and biologicals are stored safely, securely, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 7 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 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 properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Expiration Dating (Beyond-use Dating) D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be (30) days unless the manufacturer recommends another date or regulations/ guidelines require different dating. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles. (Photographic evidence obtained). Findings include: 1. During an observation of Medication Cart #1-200 Hall on [DATE] at 7:40 AM with Staff A, Registered Nurse (RN), there was one Basaglar Inj. (injectable) open insulin pen for Resident #90, that was not labeled with an open date or date of expiration and one Lantus Solostar 100 unit/ml (milliliters) insulin pen for Resident #119, that was open and was not labeled with an open date or date of expiration. During an observation of Medication Cart #2-200 Hall on [DATE] at 7:50 AM with Staff B, License Practical Nurse (LPN), there was one open Novolin R Flex pen 100 unit/ml for Resident #11 that was opened and was not labeled with an open date or expiration date, one Basaglar Inj. 100 unit pen for Resident #5 that was opened and was not labeled with an open date or expiration date, one Lantus Solostar 100/unit ml insulin pen for Resident #66 that was opened and was not labeled with an opened date or date of expiration, one Basaglar Inj. insulin pen for Resident #6 that was opened and was not labeled with an opened date or date of expiration, one Lantus Solostar insulin pen for Resident #14 that was opened and was not labeled with an open date or date of expiration, and Novolin R Flex pen 100 unit/ml that was opened and was not labeled with a resident's name, the open date, or the expiration date on the pen or the clear bag the pen from the pharmacy. During an observation of Medication Cart #4-400 Hall on [DATE] at 8:10 AM with Staff C, LPN, there was one Humulin 70/30 Kwik Pen Susp Pen Inj. for Resident #467 that was opened and was not labeled with an opened date or expiration date. During an observation of Medication Cart #5-500 Hall on [DATE] at 8:40 AM with Staff E, RN, there was one Basaglar Inj. 100 u/ml (units) insulin pen for Resident #127 that was opened and was not labeled with an opened date or date of expiration. During an observation of Medication Cart #6-600 Hall on [DATE] at 8:54 AM with Staff F, RN, there was one Novolog Flex insulin pen for Resident #117 that was opened and was not labeled with an open date or date of expiration. During an observation of Medication Cart #7-700 Hall on [DATE] at 8:59 AM with Staff G, LPN, there were one Basaglar Inj. insulin Pen for Resident #91 that was opened and was not labeled with an opened date or date of expiration, and one Basaglar Inj. insulin pen for Resident #38 that was opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 8 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 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 and was not labeled with the open date or expiration date. Level of Harm - Minimal harm or potential for actual harm During an observation of medication Cart #8-800 Hall on [DATE] at 9:10 AM, with Staff H, LPN, there were one Humalog Kwik insulin pen for Resident #16 that was opened and was not labeled with an opened date or date of expiration, one Lantus Solostar 100 unit/ml insulin pen for Resident #5 that was opened and was not labeled with an open date or date of expiration. Residents Affected - Some During an observation of Medication Cart #3-300 Hall on [DATE] at 9:30 AM with Staff D, LPN, there were one Lispro Kwik Inj. insulin pen for Resident #310 that was opened and was not labeled with an opened date or expiration date and one vial of Humulin R 100 unit/ml for Resident #459 that was opened and was not labeled with an open date or expiration date. During an interview on [DATE] at 9:20 AM, Staff I, LPN, [NAME] Wing Manager, stated, An open date and expiration date should be written on the insulin and insulin pens when the medication is removed from the refrigerator. During an interview on [DATE] at 9:45 AM, the Director of Nursing (DON) stated, I told the night crew to go through everything last night and make sure that nothing was expired and clean all the carts and the medication rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 9 of 10 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 105717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during wound care to prevent the possible spread of infection for 1 of 2 residents observed for wound care, Resident #16. Residents Affected - Few Findings include: During an observation on 4/26/2023 at 8:00 AM, Resident #16 was lying in bed and had gauze wraps dated 4/25/2023 to the lower extremities with dried red colored stains on the gauze. Review of Resident #19's physician order dated 4/26/2023 reads, Cleanse bilateral lower extremities with normal saline, pat dry, apply Xeroform to abrasions on bilateral lower extremities, cover with ABD [abdominal] pads & secure with kerlix cling wrap once daily and as needed for soiling everyday shift. During an observation on 4/26/2023 at 10:08 AM, Staff G, License Practical Nurse (LPN), entered Resident #16's room, performed hand hygiene and donned gloves. The bedside table had wound care supplies on a barrier. Staff G placed the resident's legs on a barrier on the bed. Staff G cleansed the left lower extremity with gauze and normal saline and placed the left leg back down on the contaminated barrier next to the right leg. Staff G did not perform hand hygiene and did not change her gloves. Staff G pat dried the left lower extremity, dressed the left lower extremity, and placed the left leg back down on the contaminated barrier. Staff G performed hand hygiene, and donned gloves. Staff G cleansed the right lower extremity. Staff G did not perform hand hygiene or change her gloves. Staff G pat dried the right lower extremity and placed the resident's right leg back down on the contaminated barrier. The Kerlex wrap had fallen on the floor. Staff G removed her gloves, performed hand hygiene, and left the room. Staff G returned to the room performed hand hygiene, donned gloves, and wrapped the right lower extremity with Kerlex wrap. During an interview on 4/26/2023 at 10:25 AM, Staff G, LPN, stated, I should have washed my hands in between wound care and placed [Resident #16's name] legs on a clean barrier after cleaning the wounds. During an interview on 4/26/2023 at 10:44 AM, the Director of Nursing stated, Staff should be doing wound care by policy per infection control. Dirty, Dirty and Clean, Clean. The staff should be washing hands in between the wound care procedure. Review of the policy and procedure titled Handwashing/Hand Hygiene last reviewed on 12/20/2022 reads, 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, g. before handling clean or soiled dressings, gauze pads, etc k. After handling used dressings, contaminated equipment, etc. Review of the policy and procedure titled Nursing-Wound Care last reviewed on 12/20/2022 reads, Policy: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Procedure: 23. Be certain all clean items are on a clean field. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105717 If continuation sheet Page 10 of 10