Health inspection·February 4, 2026

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to coordinate assessments for the residents with newly evident or possible serious mental disorder for Level II PASRR (Pre-admission Screening and Resident Review) for 1 of 3 residents reviewed for PASRR, Resident #2.Findings include:Review of Resident #2's admission record documented the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (onset date of 1/12/2026), other specified anxiety disorders (onset date of 1/12/2026), and schizophrenia (onset date of 8/21/2024).Review of Resident #2's PASRR dated 7/22/2025 documented schizophrenia as the only mental illness or suspected mental illness under Section I. PASRR Screen Decision-Making.Review of Resident #2's psychiatry subsequent note dated 1/12/2026 read, Chief complaint: Depression, anxiety and insomnia. Diagnostic assessment and plan: Major depressive disorder recurrent moderate, other specified anxiety disorders, primary insomnia.During an interview on 2/4/2026 at 9:33 AM, the Director of Nursing stated, We should have rescreened the resident [Resident #2] to see if he required Level II services.During an interview on 2/4/2026 at 9:50 AM, the Assistant Director of Nursing stated, I should have gone in and updated the Level 1 PASSR to ensure he [Resident #2] did not require evaluation for Level II PASSR. Page 1 of 11 105717 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for residents who had language preferences for 1 of 3 residents reviewed for communication services, Resident #122.Findings include:During an interview (conducted in Spanish) on 2/2/2026 at 9:53 AM, Resident #122 stated she preferred to talk in Spanish and she had difficulty at times communicating with the staff and would prefer to speak in Spanish with the staff.During an observation on 2/3/2026 at 11:40 AM, Staff H, Certified Nursing Assistant (CNA), was assisting Resident #122, who was speaking in Spanish. Staff H was answering with a couple of words in Spanish.During an observation on 2/3/2026 at 1:12 PM, Staff E, CNA, was accommodating Resident #122 in her bed and speaking to resident in Spanish.Review of Resident #122's care plan did not document a focus for communication for Resident #122's Spanish speaking preference.During an interview on 2/3/2026 at 11:33 AM, Staff F, Registered Nurse (RN), stated, I can understand her [Resident #122] a little, but she is strictly a Spanish-speaking resident. I have had her [Resident #122] for some time now and gotten used to her and I can understand her, but she is [NAME] [Spanish] only. If I am not able to understand what she is saying, I will get a staff member to translate for me, so I can understand what she needs. During an interview on 2/3/2026 at 11:41 AM, Staff H, CNA, stated, I don't speak Spanish, but I can understand a little. I am learning with her [Resident #122]. If she gets very agitated, she only speaks in Spanish. I will get another staff member to translate for her to make sure we get anything she needs.During an interview on 2/3/2026 at 2:15 PM, the Minimum Data Set Coordinator stated, I was not aware that [Resident #122's name] preferred Spanish. Maybe, due to her age, she has reverted back to her native language. The care plan does not have a focus for Spanish language communication. It will need to be added.During an interview on 2/4/2026 at 10:11 AM, the Director of Nursing stated, Normally when I do my rounds, [Resident #122's name] is resting. Her [Resident #122] language preferences should be part of the care plan.Review of the facility policy and procedure titled Resident Assessment Instrument Comprehensive Care Plan Policy with the last review date of 1/22/2026 read, Purpose: To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI), and to comply with state and federal regulations. Policy Statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary team members and be revised to reflect resident condition changes. 105717 Page 2 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure residents received oxygen therapy as ordered by the physician for 3 of 5 residents reviewed for respiratory care, Residents #22, #151, and #11.Findings include: Residents Affected - Few 1) During an observation on 2/2/2026 at 2:22 PM, Resident #22 was being administered oxygen at 4 liters per minute via nasal cannula. Review of Resident #22's physician order dated 6/7/2025 read, Oxygen @ [at] 3L [liters]/Min [minute] every shift related to chronic obstructive pulmonary disease. During an interview on 2/3/2026 at 11:55 AM, Staff N, Registered Nurse (RN), stated, We check on the amount of oxygen every time we have to take a resident on or off. I'm not sure why the oxygen was not at the right amount. We should follow the orders for what oxygen is running at. 2) During an observation on 2/2/2026 at 10:56 AM, Resident #151 was in bed with the head of bed elevated, with oxygen being administered at 3 liters per minute via nasal cannula. Review of Resident #151's physician order dated 2/2/2026 read, Oxygen @ 2 liters/min via N/C [nasal cannula] PRN [as needed]. During an interview on 2/2/2026 at 10:56 AM, Resident #151 stated, I do not change my oxygen level at all. During an interview on 2/3/2026 at 9:08 AM, Staff N, Registered Nurse (RN), stated, She [Resident #151] has oxygen and CPAP [Continuous Positive Airway Pressure] at night for her sleep apnea. We should be checking every shift to make sure it is correct. We should follow doctor's order for the rate. 3) Review of Resident #11's physician order dated 12/31/25 read, Oxygen @ 2 liters/minute continuous inhalation via nasal cannula every shift related to chronic obstructive pulmonary disease. During an observation on 02/02/2026 at 1:08 PM, Resident #11 was observed with oxygen being administered via nasal cannula through an oxygen concentrator at 3 liters per minute. During an interview on 02/01/2026 at 11:58 AM, Staff O, LPN stated, Nursing staff are responsible for setting and adjusting oxygen flow rates and that oxygen must be administered strictly according to physician orders. The nursing staff monitor the resident's oxygen use every shift and are required to communicate any changes in respiratory condition or oxygen needs to the physician. The facility has protocols in place for monitoring oxygen equipment and ensuring alarms are functioning. Review of the facility policy and procedures titled Oxygen Administration with the last review date of 1/22/2026 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure. 4. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 105717 Page 3 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician ordered parameters were followed for 6 of 8 residents, Residents #15, #88, #23, #6, #94 and #179, reviewed for unnecessary medications. Findings include: Residents Affected - Some 1. Review of Resident #15's admission record documented diagnosis that include unspecified sequala of cerebral infarction (a stroke), major depressive disorder, recurrent moderate, depression unspecified, and essential (primary) hypertension. Review of Resident #15's physician orders dated 7/22/2025 read, Losartan Potassium Oral Tablet 25 MG [milligrams] (Losartan Potassium) Give 1 tablet by mouth two times a day for HTN [hypertension] HOLD FOR SBP [systolic blood pressure] BELOW 130. Review of Resident #15's medication administration record (MAR) for January 2026 documented Losartan was administered outside of physician ordered parameters at 0900 (9:00 AM) on 1/9/2026 for a blood pressure (B/P) of 116/53, on 1/10/2026 with a B/P of 123/49, on 1/11/2026 with a B/P of 116/64, on 1/18/2026 with a B/P of 116/71, on 1/23/2026 with a B/P of 118/66, on 1/24/2026 with a B/P of 127/54, on 1/25/2026 with a B/P of 95/55, and at 1700 (5:00 PM) on 1/3/2026 with a B/P of 124/71, on 1/4/2026 with a B/P of 114/71, on 1/10/2026 with a B/P of 101/72, on 1/11/2026 with a B/P of 121/60, on 1/16/2026 with a B/P of 110/65, on 1/18/2026 with a B/P of 124/68, on 1/24/2026 with a B/P of 124/75, on 1/25/2026 with a B/P of 102/71 and on 1/30/2026 with a B/P of 116/71. Review of Resident #15's MAR for February 2026 documented Losartan was administered outside of physician ordered parameters on 2/1/2026 at 1700 (5:00 PM) with a B/P of 92/54. During an interview on 2/4/2026 at 10:23 AM Staff L, Licensed Practical Nurse (LPN) stated If there is a check mark, I probably administered this medication. We should follow the orders to hold if there are parameters. 2. Review of Resident #179's admission record documented diagnosis to include encounter for orthopedic aftercare following surgical amputation, difficulty in walking not elsewhere classified, muscle weakness generalized, type 2 diabetes mellitus with hyperglycemia, essential primary hypertension, hyperlipidemia unspecified, polyneuropathy unspecified, depression unspecified, gastroesophageal reflux disease without esophagitis, radiculopathy, lumbar region, peripheral vascular angioplasty, gangrene not elsewhere classified, peripheral vascular disease unspecified, acquired absence of right great toe, atherosclerosis of arteries of extremities with gangrene right leg, and anemia unspecified. Review of Resident #179's physician order dated 12/26/2025 read, Oxycodone-Acetaminophen Tablet 10-325 MG Give 1 tablet by mouth every 4 hours as needed for Non acute Moderate Pain 6-10. Review of Resident #179's MAR for January 2026 document Oxycodone-Acetaminophen was administered on 1/5/2026 at 0205 (2:05 AM) with a documented pain assessment of 5 out of 10, on 1/7/2026 at 0600 (6:00 AM) with a documented pain scale of 5, at 2038 with a documented pain scale of 5, on 1/25/2026 with a documented pain scale of 4, and on 1/31/2026 at 0501(5:01 AM) with a documented pain scale of 5. During an interview on 2/4/2026 at 8:44 AM Staff M, LPN stated, I did give the pain medication. I 105717 Page 4 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some guess I should have followed the doctor's orders for the parameter. I should have called the doctor if it was not in the parameters. 3. Review of Resident #6's admission record documented an admission date of 12/21/2021 with diagnosis that include cerebral infarction unspecified, major depressive disorder, schizoaffective disorder bipolar type, type 2 diabetes mellitus with unspecified complications, essential hypertension, and generalized anxiety disorder. Review of Resident #6's physician orders dated 8/13/2025 read, Enalapril Maleate Oral Tablet 20 MG (Enalapril Maleate) Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP less than 110. Review of Resident #6's MAR for December 2025 read, Enalapril Maleate Oral Tablet 20 mg Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP less than 110. On 12/28/2025, Resident #6's blood pressure was documented as 108/50 and signed as administered with a code 13 = WNL (within normal limits). Review of Resident #6's MAR for January 2026 read, Enalapril Maleate Oral Tablet 20 mg (milligrams) Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP less than 110. On 1/18/2026, Resident #6's blood pressure was documented as 101/55 and signed as administered with a code 13 = WNL. On 1/21/2026, Resident #6's blood pressure was documented as 102/44 and signed as administered. During an interview on 02/04/2026 at 1:08 PM, Staff B, LPN stated that the check mark on the MAR on 12/21/2025 meant she administered the medication. The medication was administered outside of the physician's ordered parameters. 4. Review of Resident #23's admission record documented the resident was first admitted on [DATE] with diagnosis not limited to essential hypertension, chronic diastolic heart failure and hypertensive heart disease with heart failure. Review of Resident #23's physician order dated 5/20/2023 read, Midodrine HCI [Hydrochloride] Oral Tablet 10 MG (Midodrine HCI) give 1 tablet by mouth three times a day for hypotension HOLD FOR SBP > [greater than] 110. Review of Resident #23's MAR for the month of January 2026 documented Midodrine 10 mg was administered given on 1/2/2026 at 0900 [9:00 AM] blood pressure was 124/59, on 1/2/2026 at 1300 [1:00 PM] blood pressure was 124/59, on 1/4/2026 at 1700 [5:00 PM] blood pressure was 144/82, on 1/5/2026 at 0900 blood pressure was 138/75, on 1/6/2026 at 0900 blood pressure was 122/51, at 1300 blood pressure was 122/51, on 1/17/2026 at 1700 blood pressure was 115/67, on 1/18/2026 at 0900 blood pressure was 120/56, on 1/19/2026 at 1300 blood pressure was 112/59, on 1/30/2026 at 0900 blood pressure was 120/72, and at 1300 blood pressure was 117/59. Review of Resident #23's Medication Administration Record for the month of December 2025 documented Midodrine 10 mg was administered on12/1/2025 at 0900 blood pressure was 131/73, on 12/11/2025 at 0900 blood pressure was 122/58, on 12/19/2025 at 0900 blood pressure was 113/70, on 12/22/2025 at 1300 blood pressure was 115/63, on 12/29/2025 at 0900 blood pressure was 120/78, and on 12/31/2025 at 0900 blood pressure was 121/59. During an interview on 2/03/2026 at 3:46 PM Staff A, LPN, stated, I don't recall those dated for [Resident #23's name] but if there is a check mark that means I have given the medication. 105717 Page 5 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Review of Resident #88's admission record documented the resident was first admitted on [DATE] with diagnosis including but not limited to essential hypertension, paroxysmal atrial fibrillation, chronic combined systolic and diastolic heart failure, and type 2 diabetes mellitus without complications. Review of Resident #88's physician order dated 10/11/2025 read, Sacubitril-Valsartan Oral Tablet 24-28 MG (Sacubitril Valsartan) Give 1 tablet by mouth two times a day for HTN Hold for SBP less than 110. Review of Resident #88's MAR for the month of January 2026 documented Sacubitril-Valsartan Oral Tablet 24-26 MG was administered on 1/4/2026 at 1700 blood pressure was 101/61, on 1/10/2026 at 0900 blood pressure was 105/69, at 1700 blood pressure was 103/67, on 1/14/2026 at 1700 blood pressure was 106/66, on 1/17/2026 at 1700 blood pressure was 100/73, on 1/19/2026 at 0900 blood pressure was 102/64, on 1/21/2026 at 1700 blood pressure was 106/64, on 1/24/2026 at 0900 blood pressure was 100/60 and on 1/30/2026 at 1700 blood pressure was 106/60. Review of Resident #88's MAR for the month of December 2025 documented Sacubitril-Valsartan Oral Tablet 24-26 MG was administered on 12/12/2025 at 1700 blood pressure was 101/64, on 12/16/2025 at 1700 blood pressure was 102/73, on 12/18/2025 at 1700 blood pressure was 101/64, on 12/23/2025 at 1700 blood pressure was 104/57, on 12/26/2025 at 1700 blood pressure was 108/71, and on 12/28/2025 at 1700 blood pressure was 108/75. During an interview on 2/03/2026 at 3:46 PM Staff A, LPN, stated, I don't recall those dates for [Resident #88's name] but if there is a check mark that means I have given the medication. During an interview on 2/04/2026 at 1:40 PM Staff J, LPN, stated, If the medication has a check mark in the medication administration record it means that the medication was given. I am always supposed to follow the parameters. I really don't recall those residents [Resident #23 and Resident #88's names]. I see over 30 residents. During an interview on 2/04/2026 at 10:04 AM the Director of Nursing stated, Nurses should follow the parameters that are ordered by the provider. During an interview on 2/04/2026 at 11:29 AM Medical Doctor #1 stated, I expect staff to follow parameters strictly as ordered. 6. Review of #94's medical record documented diagnoses to include essential hypertension and atrial flutter. Review of Resident #94's physician order dated 5/30/2023 read, Carvedilol Tablet 3.125 MG, Give 1 tablet by mouth two times a day for HTN, Hold if SBP < [less than] 110. Review of Resident #94's physician order dated 10/31/2022 read, Diltiazem HCl [hydrochloric acid] 120 MG, Give 1 capsule by mouth two times a day for a fib [atrial fibrillation] Hold if SBP < 110. During review of Resident #94's MAR for December 2025 documented Carvedilol was administered on 12/14/2025 at 9:00 AM with the blood pressure documented as 105/60, 12/18/2025 at 9:00 AM with the blood pressure documented as 102/59, and on 12/21/2025 at 9:00 AM with the blood pressure documented as 102/70. 105717 Page 6 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #94's MAR for January 2026 documented Carvedilol was administered on 01/02/2026 at 9:00 AM with the blood pressure documented as 109/68 and on 01/09/2026 at 9:00 with a blood pressure documented as 100/60. Review of Resident #94's MAR for December 2025 documented Diltiazem was administered on 12/14/2025 at 5:00 PM with the blood pressure documented as 105/60 and on 12/21/2025 at 9:00 AM with the blood pressure documented as 102/70. Review of Resident #94's MAR for January 2026 documented Diltiazem was administered on 01/02/2026 at 9:00 AM with a blood pressure documented as 109/68 and on 01/09/2026 at 9:00 AM with a blood pressure documented as 100/60. Review of the facility policy and procedure titled Medication Administration General Guidelines with a last review date of 1/22/2026 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedure: B. Administration: 2) Medications are administered in accordance with written orders of the prescriber. 105717 Page 7 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and staff interview, the facility failed to maintain complete and accurate medical records for 1 of 8 residents, Resident #11, reviewed for documentation. Findings Include: Residents Affected - Few Review of Resident #11's Medication Administration Record (MAR) for January 2026, on 01/27/2026 for the scheduled 9:00 AM medication pass, the MAR was blank, no entries, for the physician ordered medications: Citalopram 0.5 tablet (10 mg) by mouth daily for depression, Fluticasone-Salmeterol one inhalation daily for COPD (chronic obstructive pulmonary disease), Tamsulosin HCl 0.4 mg one capsule by mouth daily, Thiamine HCl 100 mg one tablet by mouth daily, Doxycycline Hyclate 100 mg one tablet by mouth twice daily, Gabapentin 100 mg one tablet by mouth twice daily, Metoprolol Succinate ER (extended release) 25 mg one tablet by mouth twice daily with parameters to hold if heart rate less than 60, and Sennosides 8.6 mg one capsule by mouth twice daily. The MAR did not include staff initials, documentation codes, or narrative notes to indicate whether these medications were administered, refused, held, or unavailable on 01/27/2026. Review of the MAR for Resident #11 was not documented for Antidepressant side effect monitoring for the shift on 01/27/2026 from 7:00 AM through 3:00 PM, Behavioral monitoring on 01/01/2026 at 3:00 PM, Nursing care documentation related to respiratory support, including encouragement to elevate the head of the bed to assist breathing for 01/01/2026 at 3:00 PM and for 01/27/2026 during the 7:00 AM through 3:00 PM shift, Dietary documentation for fortified foods ordered three times daily there was no documentation for 01/23/2026, 01/24/2026, 01/25/2026, 01/27/2026, and 01/29/2026 at the scheduled 3:00 PM administration times, and there was no supporting nursing documentation corresponding to a nursing note time-stamped 01/27/2026 at 2:30 PM. During an interview on 02/04/2026 at 9:10 AM, Staff S, Registered Nurse (RN), stated that blank MAR entries are not acceptable and must include documentation explaining why the medication was not administered. She further stated that if medication administration is passed to another nurse, this should be documented in the progress notes and that staff are expected to follow facility documentation codes. During an interview on 2/03/2026 at 10:02 AM the Director of Nursing stated, The documentation in the resident record should be accurate and reflect the actual administration of the medication. Review of the facility policy and procedure titled Documentation with a last review date of 1/22/2026 read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. Review of the policy and procedure titled, Medication Administration General Guidelines last approval date of 1/22/2026 read, Procedure: D. Documentation (including electronic): 1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the documentation. 7) If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding 105717 Page 8 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0842 of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105717 Page 9 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

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 prevent the possible spread of infection when failing to perform hand hygiene during medication administration and dining observations and failing to follow transmission-based precautions. Residents Affected - Few Findings include: 1. During an observation of medication administration on 2/3/2026 beginning at 8:43 AM with Staff F, Registered Nurse (RN) for Resident #120, Staff F did not perform hand hygiene, unlocked the medication cart, activated the computer and prepared the medications for the resident. Staff F, RN, entered the resident's room, did not perform hand hygiene, administered the medications, did not perform hand hygiene, and exited the resident's room. Staff F returned to the medication cart, did not perform hand hygiene, unlocked the medication cart, activated the computer and began preparing medications for Resident #141. Staff F entered the resident's room, did not perform hand hygiene, administered the medications, did not perform hand hygiene, and exited the resident's room. Staff F returned to the medication cart, did not perform hand hygiene, unlocked the medication cart, activated the computer, and began to prepare medications for Resident #14. Staff F entered the resident's room, did not perform hand hygiene, administered the medications, did not perform hand hygiene, and exited the resident's room. Staff F returned to the medication cart, did not perform hand hygiene and began preparing medications for another resident. During an interview on 2/3/2026 at 1:13 PM Staff F, RN stated, I should have done that [hand hygiene] each time I left the room. Review of the policy and procedure titled, Medication Administration General Guidelines last approval date of 1/22/2026 read, Procedure: A, Preparation: 2). Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident. b. Hand sanitization is done with an approved sanitizer between hand washings when returning to the medication cart or preparation are, at regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. These procedures should be followed. 2. Review of Resident #68's physician order dated 2/02/2026 read, Contact isolation precautions for ESBL [Extended-spectrum beta lactamase] in urine until 2/13/2026. During an observation on 2/02/2026 at 12:25 PM with Staff E, Certified Nursing Assistant (CNA), the CNA entered Resident #68's room without donning a gown or gloves and delivered the lunch tray to Resident #68. Resident #68's room had a Contact Precaution sign and a bin with personal protective equipment outside of the resident's room. Staff E adjusted Resident #68's bed touching the bed linen and bed controller. Staff E assisted Resident #68 with setting up her lunch meal. Staff E exited Resident #68's room without performing hand hygiene and returned to the meal cart. Staff E removed another meal tray from the meal cart and entered Resident #145's room to deliver the lunch tray. During an observation on 2/02/2026 at 1:01 PM Staff E, CNA, entered Resident #68's room without donning a gown or gloves removed the meal tray. Staff E returned the meal tray to the meal cart, did not perform hand hygiene, and entered Resident #5's room. 105717 Page 10 of 11 105717 02/04/2026 Timberridge Nursing & Rehabilitation Center 9848 SW 110th St Ocala, FL 34481

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 2/03/2026 at 10:55 AM Staff F, Registered Nurse (RN), entered Resident #68's room to administer medications to the resident without donning a gown or gloves. Staff F exited the room and began to pour medications for Resident #67 without performing hand hygiene. Resident #68 called Staff F to help her. Staff F entered Resident #68's room and opened a bottle of soda that Resident #68 had in her hand. Staff F without performing hand hygiene exited the room and continued to pour Resident #67's medications. Staff F entered the resident's room without performing hand hygiene and administered the medications to Resident #67. During an observation on 2/03/2026 at 11:31 AM Staff G, Licensed Practical Nurse Unit Manager, entered Resident #68's room without donning a gown or gloves and delivered a bowl of soup to Resident #68. During an interview on 2/03/2026 at 1:43 PM Staff F, RN, stated, When a patient is on contact you should always wear the ppe [personal protective equipment] when going into the room. I should have worn the ppe and washed my hand's when I was done with her [Resident #68]. During an interview on 2/03/2026 at 1:50 PM Staff G, LPN Unit Manager, stated, I should have worn a gown and gloves before entering the room [Resident #68's room]. During an interview on 2/03/2026 at 3:00 PM Staff E, CNA, stated, We were not trained to put on a gown and gloves to go into the room. Only when we are having physical contact with the resident. They spoke to me about it and when it is contact precautions you should always were the gown and gloves to go into the room. I forgot to perform hand hygiene I should have hand sanitized between each resident. During an interview on 2/03/2026 at 4:28 PM the Assistant Director of Nursing stated, Staff should follow the signage posted on the door and don personal protective equipment as listed on the sign. The staff should perform hand hygiene before exiting the room, upon meal delivery, and in between each resident. If a resident is on contact precautions personal protective equipment should be donned before entering the room at all times. During an interview on 2/4/2026 at 10:04 AM the Director of Nursing stated, The staff should utilize the sign posted outside of the room and don and doff ppe as instructed. For a contact precaution room, the staff should don before entering the resident's room with gown and gloves. Hand hygiene should be performed in between each resident and after each meal tray delivery. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with a last review date of 1/22/2026 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation. Administrative Practices to Promote Hand Hygiene: 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene. 1. Hand hygiene is indicated: a. immediately before touching a resident; d. after touching a resident; e. after touching the resident's environment; Review of the facility policy and procedure titled Isolation-Categories of Transmission-Based Precautions with a last review date 1/22/2026 read, Contact Precautions: 7. Staff and visitors wear gloves (clean, non-sterile) when entering room.8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 105717 Page 11 of 11