Inspection·August 14, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to report an allegation of misappropriation of residents' property, medications. Findings include:During an interview on 08/12/2025 at 8:30 AM the Interim Administrator (ADM) stated, The former supervisor was terminated for improper disposition of medications. When asked if the allegation was reported to the Agency For Health Care Administration (AHCA) the ADM stated, I felt a report should have been filed but one had not been. I contacted the previous Administrator related to the incident and was told that she did not feel it rose to the level of any type of reportable offense as the medications were all discontinued medications. Two employees were termed for the offense as one was the alleged perpetrator, and the other had knowledge of the activity of improper disposition of medications.Review of written statement dated 3/31/2025 written by Staff E, Licensed Practical Nurse (LPN) read, I put the medications from the residents in a bag on Saturday night/Sunday morning. I left them at the church on Sunday around 8:10AM. I tried to scan them on the computer and didn't scan. Pharmacy told me long time ago if a medication does not scan the facility can destroy them or the pharmacy can. I cut off the names and facility and I pulled the sticker. I have never donated any meds that were able be scanned.Review of written statement dated 4/2/2025 written by Staff E, LPN, read, I donated medications from the facility and asked permission before I did it from the previous DON [Director of Nursing]. I have donated medications before. Back in Cuban, we donated medication to the church. [Name of Church] asked if they know any places that will donate medications. That's when I asked the previous DON and he said it was ok. I cut off the facility name and patient name and put the medications in a plastic bag and put them in my care. I am helping others who are in need and can't afford medications. It didn't dawn on me to ask new administration or DON. I only donate medications to [Name of church].Review of Staff E, LPN Disciplinary Action Record dated 4/3/2025 read, Terminated for misconduct r/t [related to] disposition of discontinued medication. Corrective Action: Termination.Review of Staff E, LPN Health Care Provider Complaint Form date reported 4/3/2025 read, Complaint Description: On 3/31/2025 employee knowingly and admitted ly removed medication belonging to the facility from the premises.Review of written statement dated 3/31/2025 written by Staff F, Registered Nurse read, [Staff E's name] let me know she was donating medications to the church. I didn't know what she was bringing out. I did know she was taking medications out of the building. A while back it started. I don't know when she started taking them out. I don't know about last weekend. I didn't see her take medications out of the building.Review of Staff F, RN phone interview dated 4/2/2025 read, Yes, I know she was donating medications from the facility she was donating medications to the church. Medications that you cannot return to [Name of pharmacy] expired medications and hospice medications. I did not tell anyone else. Review of Staff F, RN Disciplinary Action Record dated 4/4/2025 read, Terminated for misconduct r/t disposition of discontinued meds. Corrective Actions: Termination.Review of Staff F, RN, Health Care Provider Complaint Form date reported 4/3/2025 read, Complaint Description: On 3/31/2025 [Staff F's name], while working as supervisor, knowingly allowed another employee to remove non-narcotic medications belonging to the facility from the premises.Review of written statement dated 4/1/2025 written by the Regional of Clinical Director (RCD) read, I received the medication list from the pharmacy on the medications that were delivered to the church. I review the manifest from the pharmacy and compared it to the current residents. No resident missed any medications. The medications reviewed were to be returned to the pharmacy.Review of written statement dated 4/3/2025 written by the Director of Clinical Services (DCS) read, On 4/3/2025 this writer spoke with [Previous Administrators Name], the previous DON regarding statement provided by [Staff E's name] which stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105724 If continuation sheet Page 2 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete [Previous Administrator's Name] told her it was okay to donate the centers discontinued medications. [Previous Administrator's name] stated to this writer he had never told [Staff E's name] it was okay to donate the centers discontinued medications. He stated he did tell her she could donate the expired over the counter medications.Review of investigating police dispatch dated 4/3/2025 documented [Case Number].Review of the Adverse Incident Facility log did not document a report for the incident of alleged misappropriation of residents' medications and investigation by law enforcement.During an interview on 8/14/2025 at 8:05 AM the Director of Nursing (DON) stated, I was the DON at the time of the incident. We discussed what had happened and since the medication was discontinued and the residents were not charged and we had reviewed the medication record and seen no resident was affected we decided not to report it. The facility was the victim because we are the ones that were charged for the medications. Residents are not charged for those medications once they are discontinued.During an interview on 8/14/2025 at 12:18 PM with the Pharmacy Consult stated, They had first said it was the [Name of Pharmacy] driver who was dropping off the medication. I went in and spoke to the Administrator, and I was given more information and after the investigation it was a nurse dropping off the medication at the church not the [Name of Pharmacy] Driver.During an interview on 8/14/2025 at 1:45 PM the Medical Director stated, I was made aware of it [discontinued medication being taken by nursing staff and donating to a church] today prior to today I was not made aware. What could the facility have done different, the medications were already discontinued. Residents were not financially responsible. There were no controlled drugs. There was no harm since the medications were already discontinued and not given to the residents. They might have tried to tell me, I just had open heart surgery, and I have no recollection. I think it should have been reported to the licensing board, it's a unique situation. If it was a controlled substance, then it should have been escalated to the level of reporting it to know whom ever needs to know.During an interview on 8/14/2025 at 2:18PM the Director of Nursing stated, After the discussions we didn't feel there was any harm to the patient and it was more directed to the facility. So, we did not report it.During an interview on 8/14/2025 at 2:23 PM with the ADM stated, It is difficult at first glance its possible it should have been reported. As I hear more about the event no resident was affected and it was the facility medication. However, my initial reaction would be to report the incident.Review of the facility policy and procedure titled Abuse & Neglect Prohibition with a last review date of 12/19/2024 read, Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Fundamental Information: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. Reporting and Response. 1. The center will report all allegations and substantiated occurrences of abuse, neglect, and misappropriation of property to the state/federal agency and law enforcement officials as designated by state/federal law. Event ID: Facility ID: 105724 If continuation sheet Page 3 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 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 Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed as prescribed for 1 of 2 residents, Resident #9 sampled for wound care, and failed to ensure the administration of intravenous antibiotics per the physician orders for 1 of 2 residents, Resident #114, for residents being administered intravenous therapy. Residents Affected - Few Findings include: 1) During an observation on 8/11/2025 at 9:46 AM Resident #9 was lying in bed. There was a white bordered foam dressing (a wound dressing of an advanced, all-in-one wound dressing that features a central, absorbent foam pad surrounded by a self-adhesive, waterproof breathable border) on Resident #9's lower left leg. The wound dressing was not dated for the date it was changed and did not have the initials of the nurse who provided the wound care. The upper right corner of the dressing was peeling off. (Photographic evidence obtained) During an interview on 8/11/2025 at 9:46 AM Resident #9 stated, I have not had wound care done for four days now. Review of Resident #9’s physician order dated 6/7/2025 read, Wound Care: Left Anterior Shin: Collagen Powder & Calcium Alginate: Cleanse area with wound cleanser and pat dry. Apply Collagen Powder [provides structural support, stimulates new tissue growth, and inactivates harmful enzymes] to wound. Apply Calcium Alginate [this forms a gel to manage wound fluid and protect the wound bed] and cover with ABD [abdominal] pad [serves as a secondary dressing to secure the primary layers and absorb additional drainage]. Wrap with kerlix and secure with tape [used to provide cushioning, protection, and absorption of excess fluid]. Wrap with ACE bandage (wrapping from base of foot and going up) [to secure the dressings in place and to provide compression that helps reduce swelling and improve circulation to the wound area]. Offer resident pain medications 30-60 mins [minutes] prior to treatment, document: Yes= Accepted, NO = Declined - everyday shift for wound care and as needed for wound care. During an interview on 8/13/2025 at 9:24 AM with the Wound Care Nurse stated, I was out for 10 days and normally her dressing is an abdominal pad and gauze wrapped. When I came in on Monday [8/11/2025] I did see that she [Resident #9] had the wrong dressing. I do not know who did the dressing or what happened there. Dressings should be dated and initialed. During an interview on 8/13/2025 at 2:02 PM the Director of Nursing (DON) stated, Nursing staff should follow doctor's orders as they are written. We have had no issues with supplies. Dressing should be applied as per the order, and the dressing should be dated. Review of the facility policy and procedures titled Clean Dressing Change with a last review date of 12/19/2024 read, Purpose: To ensure the licensed nurse or therapist completes dressing change in accordance with State and Federal Regulations, and National Guidelines. Guidance Steps in the Procedure: 1. Verify and review physician's order for procedure. 29. Apply clean dressing as ordered and ensure dressing is dated. 2) Review of Resident #114’s medical record documented the resident was readmitted to the facility 8/11/25 with diagnosis to include sepsis, acute kidney failure, pericardial effusion, protein calorie malnutrition, diabetes, congestive heart failure, colon resection and conversion to open for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105724 If continuation sheet Page 4 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 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 extracorporeal anastomosis, gastrointestinal hemorrhage, malignant neoplasm of sigmoid colon, colostomy, and malignant neoplasm of rectum. Review of Resident #114’s hospital record documented a physician order for Meropenem [a powerful, broad-spectrum antibiotic used to treat serious bacterial infections] 1 gram IV [intravenously] every 8 hours for 4 doses. During an observation of the medication administration on 8/13/25 at approximately 9:20 AM with Staff B, Licensed Practical Nurse (LPN) for Resident# 114, Staff B administered Meropenem 1 gram IV. Review of the Medication Administration Record (MAR) for the period of 8/12/2025 – 8/13/2025 read Meropenem 1 gram IV administer three times a day, time ranges 0600-1000, 1400-1400 [2:00 PM], 1800-2200 [6:00 PM – 10:00 PM], upon rising, for 4 doses. Meropenem 1 gram IV was administered on 8/12/25 at 9:55 AM, 8/12/25 at 1:15 PM, 8/12/25 at 6:02 PM and on 8/13/25 at 9:22 AM, it was them discontinued following this dose, number four. During an interview on 8/13/25 at approximately 9:35 AM Staff B, LPN stated, “The medication is to be administered upon rising, we have a four-hour window to give the medication.” During an interview on 8/14/25 at 9:55 AM the Director of Nursing stated, “The scheduling of every 8 hours was not discussed with [Physician #1’s name]. The medication [Meropenem] was put into the system as our TID [three times a day] times, not as prescribed every 8 hours. During a telephone interview on 8/14/25 at 10:17 AM Physician #1 stated, “Since it [the administration] was one day, there is no detrimental harm to the patient. The potential for harm would be if this administration schedule continued with elevated levels of Meropenem. If this was an error in giving the medication or misunderstanding in scheduling times that should be corrected.” During a telephone interview on 8/13/25 at 12:25 PM Pharmacy Consultant stated, “The Meropenem order should have been administered as prescribed every 8 hours. Especially with antibiotics there is no flexibility.” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105724 If continuation sheet Page 5 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, the facility failed to ensure oxygen was administered per the physician order for 2 of 5 residents, Residents #18 and #54, sampled for respiratory care and failed to ensure nebulizer masks were in a plastic storage bags when not in use for 1 of 3 residents, Resident #82. Residents Affected - Few Findings include: 1. During an observation on 08/11/25 at 09:20 AM Resident #54 had oxygen administered at via nasal cannula (NC) at 3 liters per minute. Review of Resident #54 medical record documented the resident was admitted to the facility on [DATE] with diagnosis to include acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation, non-ST elevation myocardial infarction, and dependence on supplemental oxygen Review of the physician order for Resident #54, dated 02/19/2025 at 08:50 AM read, “Oxygen via nasal cannula 2 liter per minute (lpm) continuously every shift.” During an interview on 08/13/25 at 12:02 PM the DON stated, “The physician orders should be followed for oxygen administration.” 2. During an observation on 08/11/2025 at 9:15 AM Resident #18 had oxygen administered at 4 lpm via NC. Review of Resident #18’s medical record documented the resident was admitted to the facility on [DATE] with diagnosis to include dependence on supplemental oxygen and shortness of breath. Review of Resident #18’s physician order dated 04/17/2025 at 11:14 AM read, “Oxygen via nasal cannula 2 liter per minute (2L/min) continuously every shift.” During an interview on 08/13/25 at 12:02 PM the DON stated, The physician orders should be followed for oxygen administration. Review of the policy and procedure titled “Oxygen Administration” last revision date on 08/2023, last approved on 12/19/24 read, 1. Check physician’s order. 11. Turn the unit on to the desired flow rate and assess equipment for proper functioning. 3. During an observation on 08/11/2025 at 9:42 AM Resident #82 was lying in bed. Resident #82’s nebulizer treatment mask was lying on top of the nebulizer machine and was not stored in a plastic storage bag. (Photographic evidence obtained) Review of Resident #82’s physician order dated 4/1/2025 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG [milligram] /3ML [milliliter] (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed for SOB [Shortness of breath] or wheezing. Review of Resident #82’s Medication Administration Record for the month of August documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105724 If continuation sheet Page 6 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 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 Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML was last administered on 8/10/2025 at 0153 [1:53AM]. During an interview on 8/13/2025 at 9:27 AM Staff C, Unit Manager stated, The nebulizer mask should be in a plastic bag when not in use. Residents Affected - Few During an interview on 8/13/2025 at 2:05 PM the DON stated, Nebulizer masks should be in a bag when not in use. Review of the policy and procedure titled “Aerosol (Nebulizer) Therapy” with a last review dated of 12/19/2024 read, Procedure: 16. Clean nebulizer once treatment is completed. c. Reassemble and place in plastic storage bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105724 If continuation sheet Page 7 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to ensure kitchen equipment was maintained in a safe and clean operating manner and failed to ensure the cleaning schedule was followed for the kitchen and food service equipment.Findings include:During an observation of the kitchen on 08/11/25 beginning at 09:10 AM with the Food Service Director (FSD) the table mounted can opener was observed to have a large amount of brown, black, and rust colored buildup of dirt and food debris. The stove's catch drawer had a heavy buildup of black and brown food particles.During a tour of the kitchen on 08/13/25 beginning at 06:20 AM with the Administrator and FSD, an observation of an additional counter can opener showed the can open had a brown/black discoloration of a clump-like build up visible on the blade. The prep table was observed to have a large area of food debris on the base of the prep table. A stainless-steel counter had a sticky residue around the coffee equipment.During an interview on 8/11/2025 at 9:30 AM the Food Service Director verified the buildup of debris and food particles on the stove equipment and can openers. The FSD confirmed the stove catch-drawer should have been cleaned. Review of a document provided titled Sanitation Survey Form check list dated 2019 documented headings that included: General Sanitation, Refrigerator/Freezers, Stoves, Dish machine, Garbage & Pest Control, Sink Area Three Compartment Sink, Dish room, Equipment, Storeroom, Dining Room, Food Safety, and Personnel.During an interview on 8/13/2025 at 8:55 AM with the Director of Clinical Services (DCS) a blank checklist was reviewed. A request was made to the DCS for completed checklists and the DCS stated, There were none completed.During an interview on 8/13/2025 at approximately 9:25 AM the FSD confirmed the cleaning schedule was not being followed. Review of the policy and procedure titled Kitchen Sanitation dated 8/2023 read; cleaning and sanitation of equipment ensures removal of residual food, chemicals, and bacteria. The Food and Nutrition staff shall maintain the sanitation of the kitchen through compliance with written, comprehensive cleaning schedules developed by the Food and Nutrition Manager or designee. Procedure: List daily cleaning duties on job task and on a Cleaning Schedule. 1. Use the Food and Nutrition Cleaning Tasks & Frequencies as the guideline for equipment cleaning. 2. Post cleaning assignments for each position at least weekly. 3. Initial and date the cleaning schedule upon completion of the assignment. Event ID: Facility ID: 105724 If continuation sheet Page 8 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement a performance improvement plan related to an identified concern by failing to monitor the effectiveness of the plan when it was identified license staff were aware of and/or were removing residents' medications from the facility and donating them to a local organization.Findings include:Review of written statement dated 3/31/2025 written by Staff E, Licensed Practical Nurse (LPN) read, I put the medications from the residents in a bag on Saturday night/Sunday morning. I left them at the church on Sunday around 8:10AM. I tried to scan them on the computer and didn't scan. Pharmacy told me long time ago if a medication does not scan the facility can destroy them or the pharmacy can. I cut off the names and facility and I pulled the sticker. I have never donated any meds that were able be scanned.Review of written statement dated 4/2/2025 written by Staff E, LPN, read, I donated medications from the facility and asked permission before I did it from the previous DON [Director of Nursing]. I have donated medications before. Back in Cuban, we donated medication to the church. [Name of Church] asked if they know any places that will donate medications. That's when I asked the previous DON and he said it was ok. I cut off the facility name and patient name and put the medications in a plastic bag and put them in my care. I am helping others who are in need and can't afford medications. It didn't dawn on me to ask new administration or DON. I only donate medications to [Name of church].Review of Staff E, LPN Disciplinary Action Record dated 4/3/2025 read, Terminated for misconduct r/t [related to] disposition of discontinued medication. Corrective Action: Termination.Review of Staff E, LPN Health Care Provider Complaint Form date reported 4/3/2025 read, Complaint Description: On 3/31/2025 employee knowingly and admitted ly removed medication belonging to the facility from the premises.Review of written statement dated 3/31/2025 written by Staff F, Registered Nurse read, [Staff E's name] let me know she was donating medications to the church. I didn't know what she was bringing out. I did know she was taking medications out of the building. A while back it started. I don't know when she started taking them out. I don't know about last weekend. I didn't see her take medications out of the building.Review of Staff F, RN phone interview dated 4/2/2025 read, Yes, I know she was donating medications from the facility she was donating medications to the church. Medications that you cannot return to [Name of pharmacy] expired medications and hospice medications. I did not tell anyone else. Review of Staff F, RN Disciplinary Action Record dated 4/4/2025 read, Terminated for misconduct r/t disposition of discontinued meds. Corrective Actions: Termination.Review of Staff F, RN, Health Care Provider Complaint Form date reported 4/3/2025 read, Complaint Description: On 3/31/2025 [Staff F's name], while working as supervisor, knowingly allowed another employee to remove non-narcotic medications belonging to the facility from the premises.Review of written statement dated 4/1/2025 written by the Regional of Clinical Director (RCD) read, I received the medication list from the pharmacy on the medications that were delivered to the church. I reviewed the manifest from the pharmacy and compared it to the current residents. No residents missed any medications. The medications reviewed were to be returned to the pharmacy.Review of written statement dated 4/3/2025 written by the Director of Clinical Services (DCS) read, On 4/3/2025 this writer spoke with [Previous Administrators Name], the previous DON regarding statement provided by [Staff E's name] which stated [Previous Administrator's Name] told her it was okay to donate the centers discontinued medications. [Previous Administrator's name] stated to this writer he had never told [Staff E's name] it was okay to donate the centers discontinued medications. He stated he did tell her she could donate the expired over the counter medications.Review of the Quality Assurance and Performance Improvement (QAPI) Committee Performance Improvement Plan initiation date 4/1/2025 read, Issue: Discharge medications given to local church. System: Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105724 If continuation sheet Page 9 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Re-education to all nurses regarding disposition of discontinued medications. They will scan the medications to be returned into [Name of Pharmacy] Monitoring: [Name of Pharmacy] manifest will be reviewed to ensure discontinued medications were returned to the pharmacy. Resolution Date: 7/1/2025.Review of the quality assurance and performance plan did not document what system would be put into place to monitor the effectiveness of the corrective actions.During an interview on 8/14/2025 at approximately 1:10 PM the RCD stated, There was a gap in their QAPI process, and the facility did not have any audits to provide at this time to prove that they were monitoring for compliance after the incident.During an interview on 8/14/2025 at 1:45 PM the Medical Director stated, I was made aware of it [medication being taken by nursing staff and donated] today prior to today I was not made aware. They might have tried to tell me, I just had open heart surgery, and I have no recollection.During an interview on 8/14/2025 at 2:18 PM the Director of Nursing stated, The nurses put the discontinued medications in the return bin in the medication room and scan them into the pharmacy and bag them. It will stay there until pharmacy receives it. There was a break in the process. We did audits and education. After the discussions we didn't feel there was any harm to the patients, and it was more directed to the facility.During an interview on 8/14/2025 at 2:23 PM the Administrator stated, I am not sure they [facility staff] have documentation to show what they did after to monitor after the incident [the removal of medications from the facility]. Typically, if you say you are going to monitor there should be supporting documentation. I am not in a position to say that did not happen.Review of the policy and procedure titled Quality Assurance and Performance Improvement-QAPI with a last review date of 12/19/2024 read, Policy: Each center maintains a Quality Assessment and Assurance QA&A Committee, which is responsible for developing the quality Assessment and Performance Improvement (QAPI) plans. The committee develops, implements, monitors, and maintains appropriate data driven programs that focuses on indicators of the outcomes of care and quality of life; plans of action to address quality issues identified internally or by regulatory agencies. Centers must present evidence of their ongoing QAPI program implementation and compliance with the requirements. Responsibilities: The QAA Committee oversees and identifies all efforts that improve the quality of care in the center by monitoring performance measures, directing improvement actions, and evaluating the effectiveness of quality management activities. Procedure. 3. Develop center specific data collection schedule. A. Follow time frames as indicated on the QAA Committee Calendar, Refer to RM Guide Section 7 QAA/QAPI. b. Adjust the frequency and intensity of data collection based upon center identified issues and priorities. 5. Assign responsibility to collect and report the data. f. Monitor data measure for changes and sustained improvement. g. Measure the success of actions implemented and track performance to ensure improvements are realized and sustained. Event ID: Facility ID: 105724 If continuation sheet Page 10 of 11 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 105724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ocala Oaks Rehabilitation Center 3930 E Silver Springs Blvd Ocala, FL 34470 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure an effective pest control program.Findings include:During a tour of the kitchen on 08/13/25 at 6:45 AM with the Administrator (ADM) and Food Service Director (FSD), a counter mounted can opener was observed for cleanliness at which time a live insect was observed running around the blade of the can opener. A live insect was observed on the utility care, one was observed on the coffee counter, and one was observed on the ceiling strip on the exterior back wall.During an interview on 08/13/2025 the ADM and FSD confirmed the pest sightings in the dietary department/kitchen. The FSD stated, There have been roaches sighted in the kitchen on numerous occasions in the past couple of weeks and notification has been placed on the pest log.Review of documentation provided by the facility from [Name of the Pest Control Company] dated 5/13/25 titled, [Name of Pest Control Company] Elimination Division read, Location: Kitchen area interior. Findings: Cockroaches noted during service. Cockroaches in kitchen above drop ceiling.Review of documentation provided by the facility from [Name of the Pest Control Company] dated 7/29/25 titled, [Name of Pest Control Company] Elimination Division read, Location: Kitchen area interior. Findings: Cockroaches noted during service. In steam table, behind ovens and dish area.During an interview on 8/13/25 at 8:25 AM with the ADM while reviewing the Pest Control policy and procedure the ADM stated, It is my expectation that pest sightings are reported, placed on the pest logs, and the pest control company notified.Review of the policy and procedure titled Pest Control dated 8/2023, read, Routine inspections are conducted for evidence of pest. Insect or pest sightings are documented in the pest control book and communicated to the maintenance supervisor. Procedure: 2. Train employees on preventative measures, unsanitary conditions. 3. Contract with a commercial licensed pest control vendor for a monthly service with unlimited callback to address problem areas. 4. Keep all food storage and preparation areas clean. 5. Clean up food spills promptly. 6. Store dry foodstuffs in closed containers or bins, including food in resident rooms. 7. Keep center grounds free of trash and brush. Keep the dumpster area clean and the lid closed. 8. Cover exterior openings in the building foundation with screen wire or wire mesh. 9. Maintain intact screens on windows that open. 10. Caulk (and periodically re-caulk) cracks around windows and vents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105724 If continuation sheet Page 11 of 11