Inspection·October 21, 2021

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On October 21, 2021 at 10:15 a.m., during an interview with LPN E/East Wing Unit Manager, she was asked whether she knew why there was a list of residents with their names, room numbers, and diet orders taped to the hallway whiteboard. She stated, That's a list of the residents who need to be taken to the dining room for assistance with meals. It probably should be taken down though, it doesn't have to be there. When she was asked whether that information being taped up in the hallway was a privacy issue, she stated Yes, it is with the names, room numbers and diet orders. On October 17, 2021 at 2:51 p.m., an observation was made of the whiteboard on the [NAME] Wing hallway across from nurses' station. An area on the whiteboard was marked Night Shift Get Ups. The following residents were listed by first and last name: Residents #68, #6, and #33. (Photographic evidence obtained) On October 19, 2021 at 9:45 a.m., an observation was made of the same whiteboard on the [NAME] Wing hallway. Two additional residents (#82 and #2) had been added to the Night Shift Get Ups. (Photographic evidence obtained) On October 20, 2021 at 9:30 a.m., an observation was made of the same whiteboard on the [NAME] Wing hallway. The same five residents' (#68, #6, #33, #82, and #2) first and last names were listed. On October 21, 2021 at 10:09 a.m., an observation was made of the same whiteboard on the [NAME] Wing hallway. The same five residents' (#68, #6, #33, #82, and #2) first and last names were listed. On October 21, 2021 at 10:12 a.m., during an interview with Registered Nurse (RN) D, she was asked whether she knew why there was a list of residents with first and last names listed on the [NAME] Wing hallway whiteboard. She observed the whiteboard and stated, I'm not really sure why that would be on this board. Those are the residents who get up early and need the night staff to help them, but that list is posted in the nutrition room. She opened the nutrition room door directly across from the hallway whiteboard and the same list was observed posted on the cork board. She was asked if having the names on the whiteboard was a privacy issue. She replied, Yes, it is because it's nobody else's business who is scheduled to get up early. A review of the facility's policy titled Resident Dignity and Personal Privacy (revised 4/4/2019) read, Policy: The facility provides care for residents in a manner that respects and enhances each resident's dignity and right to personal privacy. Each resident's right to personal privacy includes confidentiality of his or her personal and clinical affairs. A review of the facility's policy titled HIPAA's Do's and Don't's read, Under HIPAA (Health Insurance Portability and Accountability Act), protected health information (PHI) is individually identifiable health information that is oral, electronic, or on paper and relates to: 2. Health care provided to an individual. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 2 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record reviews and policy and procedure reviews, the facility failed to provide a clean and homelike environment for one (Resident #65) of three residents with enteral feedings (nutrition provided via feeding tube through the gastrointestinal tract) from a total of 35 sampled residents. Specifically, enteral food product was observed splattered on the resident's feeding pump, the pole, the floor, the wall, the mattress, and the resident's bed frame. The findings include: On 10/20/2021 at 2:59 p.m., Resident #65's enteral feeding pump and pole were observed beside her bed. A large amount of different shades of a beige substance was splattered on the pump, the pole, the floor, the wall, the mattress, and the bed frame. (Photographic evidence obtained) The tube feeding was running at the prescribed amount with today's date on the feeding bottle and bagged syringe. During an interview with the Director of Nursing (DON) on 10/20/2021 at 3:10 p.m., he was asked who who was responsible for cleaning the tube feeding pumps. He stated housekeeping wiped them down. Housekeeping staff were responsible for cleaning the pump, the pole, the floor, the walls, the bedframe, and the mattress. He was asked if nursing could clean them as well. He stated, Yes, nursing can clean them when tube feeding product spills on them, but the task is usually done by housekeeping. He confirmed that the mess should have been cleaned up. On 10/21/2021 at 3:08 p.m., Resident #65's enteral feeding product was observed to be splattered on the walls and floors next to the bed, as well as on the mattress and bed frame. (Photographic evidence obtained) A review of Resident #65's medical record revealed that the physician's order sheets dated 10/01/2021 through 10/31/2021 read, Resident was was admitted on [DATE] with diagnoses including: cerebral infarction due to thrombosis of other cerebral artery, pneumonia, acute chronic respiratory failure with hypoxia, Corona Virus -19, pressure ulcer of sacral region Stage III, acute kidney failure, diabetes mellitus type II, urinary tract infection (UTI), hypertension, muscle spasms, metabolic encephalopathy, hyperlipidemia, Vitamin D deficiency, hypothyroidism and muscle weakness. A review of the physician's order sheets dated 10/01/2021 through 10/31/2021 read, Administer Glucerna 1.5 at 25 cubic centimeters (cc) per hour x 22 hours per day via feeding pump. Ensure in place and infusing per physician's orders. On at 1400 and off at 1200 two times a day. Check tube for placement every shift, before medications and before flushes. Every day and night shift. Flush peg tube with 250 cc every 6 hours. Flush peg tube with 30 cc water before and after medications with 5 cc water between each medication. A review of the Minimum Data Set (MDS) assessment dated [DATE] read: Section K: B. Feeding tube nasogastric or abdominal (PEG) (Percutaneous Endoscopic Gastrostomy). A review of Resident #65's care plan, dated 09/28/2021, revealed: [Resident #65] is at risk for decreased nutritional status & dehydration related to g-tube/NPO (nothing by mouth). Diagnosis of respiratory failure requiring feeding tube. Interventions included: Check for tube placement and gastric contents/residual volume as ordered. NPO as ordered. Provide site care as ordered. Activities of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 3 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daily living (ADL) self-care performance: She is requiring total care with activities of daily living. She has a g-tube for feeding. EATING: Total assist; G-tube for feeding/NPO. On 10/21/2021 at 9:48 a.m., during an interview with the Housekeeping Supervisor, he confirmed that the housekeeping staff were responsible for cleaning up any enteral food product that was splattered on the resident's feeding pump, pole, walls, floors, furniture, bedframe, or mattresses. He stated in other places he'd worked, it was always the nursing staff who cleaned the pumps, but here the housekeeping staff were expected to do it. A review of the facility's policy and procedure entitled Infection Control (revised July 2014) revealed: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 2. The objectives of our infection control policies and practices are to: b: Maintain a safe, sanitary, and comfortable environment for residents, f: Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment, 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. A review of the facility's policy and procedure entitled Daily Patient Room Cleaning (revised 6/2016) revealed: Every room to be cleaned is that resident's home - treat it as such. The goal of cleaning is infection control. 3. Spot clean. With a cloth and disinfectant spot clean all vertical surfaces. 5. Damp mop floor with germicide solution damp mop floor working from back corner to door. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 4 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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, staff interviews, and medical record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #12) of 35 residents in the sample. Residents Affected - Few The findings include: A review of Resident #12's medical record revealed a history of venous ulcers on her right lower extremity (leg) which required wound care two times per week and as needed. On 10/19/2021 at 10:30 a.m., wound care was observed for Resident #12 in her room. Wound care was performed by Licensed Practical Nurse (LPN) I/Wound Care Nurse. She was asked how long she had been the facility's wound care nurse and she replied, About two weeks, but I've been an LPN for a couple of years. She was asked if she had performed wound care for Resident #12 before today and she stated, Yes, yesterday (10/18) was the first time I performed her wound care, so today is the second time. She was asked what the wound care would include and she replied, After the old dressing is removed, the wounds are cleansed with normal saline. The open areas will have Silver Sulfadiazine Cream 1% put on them, and then calcium alginate is placed over those areas. An absorbent pad is placed over each wound area and then wrapped with gauze followed by ace wraps for compression. The current wound care order was verified through a review of the resident's medical record and was dated 7/23/2021. LPN I was asked whether she had worked with Silver Sulfadiazine Cream 1% before. She stated she had. When asked whether she knew how it worked, she stated, I know it helps stop the growth of bacteria. LPN I began the wound care treatment. Hand hygiene was performed with each glove change, and gloves were changed between each task throughout the provision of wound care. LPN I removed the resident's ace wraps, then the gauze wraps. She placed the ace wraps and gauze wraps in a red biohazard bag which was on the resident's bed. Large absorbent pads were removed, and a small amount of light tan drainage was observed on each pad. Those pads were also placed in the red biohazard bag on the resident's bed. Under the pads was 4 x 4 gauze which also showed small amounts of light tan drainage. That was also placed in the red biohazard bag on the resident's bed. No odors were noted. No calcium alginate was observed on any part of the right lower extremity during the dressing removal. LPN I then cleansed the wounds with 4 x 4 gauze soaked in normal saline and patted each area dry. She applied Silver Sulfadiazine Cream 1% with a freshly opened wooden spatula/tongue depressor. She applied a heavy amount of the cream to several wound areas on the right lower leg. The amounts applied were observed to be thick and overlapping the wound area onto the intact skin. LPN I applied the first cut piece of calcium alginate on top of one area of the Silver Sulfadiazine Cream 1%. She was asked to stop what she was doing and was then asked how much Silver Sulfadiazine Cream 1% she should use on each wound area. She stopped what she was doing, but did not answer the question. It was explained to her that a minimal amount of Silver Sulfadiazine Cream 1% with no more than 1-2 millimeters in depth should be used on each wound, and the Silver Sulfadiazine Cream 1% should not extend onto the intact skin. She stated, Thank you, okay and then removed the thickness of the Silver Sulfadiazine Cream 1% from each wound area and from the intact skin. She proceeded with wound care as ordered, and covered each wound area with calcium alginate followed by large absorbent pads followed by gauze wrap and then ace wraps. On 10/20/2021 at 8:55 a.m., during an interview with LPN I, she was asked if calcium alginate had been used on the wound dressing change for Resident #12 when she changed the dressing on Monday, 10/18/21. She paused and stated, Yes, I think so. Yes, I used calcium alginate on the wound Monday. It was explained that during the dressing change on Tuesday, 10/19/21, there was no calcium alginate on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 5 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 the wound that LPN undressed before treating and redressing the leg. That would have been Monday's dressing you removed. She stated, I did put calcium alginate on the wound Monday. When I removed the dressing on Tuesday, I took the calcium alginate off and showed you the drainage. I said her (the resident's) drainage and swelling were less than the day before. It was explained that large abdominal pads and 4 x 4 gauze were all that was removed from the leg on Tuesday. She replied, I'm pretty sure there was calcium alginate, too. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 6 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility policy and procedure review, the facility failed to ensure appropriate catheter care was provided to one (Resident #65) of six residents with indwelling urinary catheters from a total of 35 residents in the sample. Failure to ensure proper catheter care is provided, creates a potential for urinary tract infections and negative health outcomes for the resident. The findings include: On 10/20/2021 at 2:59 p.m., Resident #65 was observed resting in bed with her eyes closed. She did not respond to her name being called or open her eyes. Resident #65's urinary catheter tubing and bag were hanging from the side of the bed frame. The bag, exposed at the bottom, was resting on the floor. The catheter bag had no date on it. The catheter tubing was observed with a large amount of rust/orange-colored sediment inside the tubing, and the same rust/orange color coated the inside of the catheter tubing. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) on 10/20/2021 at 3:10 p.m., he was asked if the catheter bag should be resting on the floor. He replied No, it should not be on the floor. He was asked how often urinary catheter bags were changed, and he replied once a month. He was asked if they could also be changed as needed, and he replied yes. He was asked if the catheter bag should be dated when changed, and he stated yes. He was asked to observe the condition of the current catheter bag for Resident #65. He observed it and stated, It should have been changed. A review of Resident #65's clinical record revealed the physician's order sheets dated 10/01/2021 through 10/31/2021 read: Resident was admitted on [DATE] with diagnoses including pressure ulcer of the sacral region - Stage III, acute kidney failure, diabetes mellitus type II, and urinary tract infection (UTI). (Copy obtained) Further review of Resident #65's clinical record revealed physician's order sheets dated 10/01/2021 through 10/31/2021 read: Change catheter 18 french (fr) size as needed for blockage/leakage related to urinary tract infection (UTI), site not specified. Change drainage bag with catheter change as needed. Change foley catheter 18fr on the 20th of each month and document every night shift starting on the 20th and ending on the 21st every month related to UTI and kidney failure. (Copy obtained) A review of the Minimum Data Set (MDS) assessment dated [DATE] read: Section H: Indwelling catheter. (Copy obtained) A review of Resident #65's care plan, dated 09/28/2021, revealed: [Resident] has indwelling catheter with obstructive uropathy, multiple pressure ulcers with terminal condition. Interventions included: Catheter care as ordered. Change catheter as ordered and as needed. Ensure proper positioning of drainage tube at all times, keep drainage bag below waist level at all times. Keep drainage bag covered at all times. Monitor signs/symptoms of infection: pain burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, chills, altered mental status, change in behavior, change in eating patterns. Position/secure tubing to prevent traumatic removal (Copy obtained). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 7 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure for Catheter Care revealed: Routine catheter care helps prevent infections and other complications. Maintenance: Inspect the catheter and tubing to detect compression or kinking that could obstruct urine flow. Keep the drainage tube and collection bag lower than the bladder. Empty the collection bag every shift and as needed. Monitoring: 20. Report the following to the nurse responsible for the resident's care: a. Signs or symptoms of urinary tract infection (UTI): change in urine such as a foul odor, bloody or cloudy urine and appearance. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 8 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #101) of a total of 35 residents in the sample. Residents Affected - Few The findings include: On October 18, 2021 at 1:08 p.m., Resident #101 was observed sitting in his wheelchair in his room with the television on. He was asked how he was doing, and he replied, My back hurts. He was asked whether he had made anyone aware of that, and he replied No, net yet. He was encouraged to ring his call bell to let the staff know he was in pain. He rang the call bell at 1:10 p.m. Certified Nursing Assistant (CNA) K entered the resident's room at 1:28 p.m. Resident #101 let her know his back hurt and he wanted to get back to bed. Another CNA was summoned to assist with getting the resident back to bed. CNA K told Resident #101 that she would let the nurse know his back was hurting him. On October 19, 2021 at 8:15 a.m., Resident #101 was observed sitting up in bed eating breakfast. He was asked if his back hurt this morning, and he replied, Yes, it hurts. He was asked whether he let the nurse know that his back hurt. He stated, Well, shouldn't they know? CNA F entered the room. Resident #101 was asked whether he wanted to share anything with CNA F. He looked at CNA F and stated, Yes, my back hurts. I'm in pain. CNA F stated she would let the nurse know. On October 20, 2021 at 9:30 a.m., an interview was conducted with CNA G in Resident #101's room. She was asked if she was caring for Resident #101 on her assignment today. She stated, Yes, I am. She was asked whether Resident #101 ever complained to her of pain. She stated, Yes, all the time. She was asked what she did when the resident told her he was in pain. She stated I go tell the nurse I think he has scheduled pain medicine. On October 20, 2021 at 12:25 p.m., Resident #101 was observed sitting up in his wheelchair in his room. His lunch tray was in front of him on his overbed table. He was asked if he was having any pain. He stated Yes, I am. He was asked where his pain was located. He stated, Like where my belt would go, but in the back. He was asked if he had let the nurse know, and he replied, I've let them know two or three times. It don't make no damn difference. Nobody does anything about it. He was asked if he had received any pain medication today. He stated No, none. Can I get back in bed? That helps a little at least. On October 20, 2021 at 1:05 p.m., an interview was conducted with Licensed Practical Nurse (LPN) E/East Wing Unit Manager. She was asked whether Resident #101 had ever complained of pain. She replied, Yes, as a matter of fact, the Tylenol hasn't been working, so the APRN (Advanced Practice Registered Nurse) wrote an order for him for PRN (as needed) Norco (narcotic pain medication) yesterday afternoon. The family mentioned he was having trouble sleeping too, so she wrote an order for a very low dose of scheduled Trazadone (an antidepressant and sedative), too. LPN E was asked how it was determined that the Tylenol and Melatonin orders were not effective for the resident's pain and insomnia if they had not been given since his admission date of 9/29/2021. She stated, He's had the PRN Tylenol. The Melatonin, I think he used that at home and he said it made him groggy in the morning, so he probably never requested it here. The Unit Manager was advised that no PRN doses of Tylenol or Melatonin had been signed out on the MAR (Medication Administration Record) since the resident was first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 9 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admitted . She stated, I know we just had an in-service on signing out PRN medicines. She was asked how recently that in-service was. She stated, I don't remember the date, but it was recent. She was asked if she would expect to see as needed doses of medication signed out as given on the MAR when they were administered. She replied yes. A review of Resident #101's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including: encephalopathy, rhabdomyolysis, acute and chronic respiratory failure, congestive heart failure, major depressive disorder, anxiety, pain (unspecified), dementia, and muscle weakness. A review of his Care Plan, dated 9/30/2021 (revised 10/5/2021), revealed: Focus: (Resident #101) is at risk for pain related to diagnosis rhabdomyolysis, rheumatoid arthritis, and others. Goal: (Resident #101) should voice level of comfort on a scale of 1-10 through the review date. Interventions: Administer analgesics as ordered. Monitor for side effects of pain medication. Observe for signs of relief/effectiveness with interventions. Utilize non-medication interventions for pain relief. A review of current physician's orders revealed: 9/30/2021: Pain evaluation: scale 0-10 every shift 9/30/2021: Tylenol 325mg: give 2 tablets by mouth every 6 hours as needed for pain 1-4 or fever (do not exceed 3 grams) 10/1/2021: Methotrexate 250mg/10ml: inject 0.9ml SQ every Friday (d/c 10/19/21) arthritis 10/1/2021: Prednisone 2.5mg: give one tablet by mouth daily (OA) 10/4/2021: Melatonin 3mg: give one tablet by mouth every 24 hours as needed for insomnia 10/19/2021: Norco Tablet 5/325: give 1 tablet by mouth every 4 hours as needed for non acute pain 10/19/2021: Methotrexate 250mg/10ml: inject 0.9 IM every Friday (start 10/22/21) arthritis 10/19/2021: Trazadone 25mg: give one tablet by mouth at bedtime (insomnia) 10/19/2021: VS (vital signs) every shift A review of Resident #101's October 2021 MAR (Medication Administration Record) revealed: No doses of PRN Tylenol were documented as having been adminsitered between 10/1 and 10/20/21. No doses of PRN Melatonin were documented as having been adminsitered between 10/1 and 10/20/21. A new order for Norco 5/325 (milligrams) mg: Give one tablet by mouth every 4 hours as needed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 10 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0697 non-acute pain - written 10/19/21 at 2:00 p.m. Level of Harm - Minimal harm or potential for actual harm A new order for Trazadone 25 mg: Give one tablet by mouth every day at bedtime for insomnia - written 10/19/21 at 9:00 p.m. Residents Affected - Few A pain evaluation scale 0-10 (zero indicating no pain at all and 10 indicating the worst possible pain) showed that from October 1st through October 7th, all spaces were signed off, but levels were all marked as X. From October 7th (evening shift) through October 19th, all spaces were signed off and marked as zero, indicating the resident had no pain. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 11 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to 1) Assist residents in obtaining needed dental care, and 2) Provide or obtain from an outside source, dental services to meet the needs of each resident for one (Resident #82) of a total of 35 residents in the sample. Specifically, the facility failed to obtain dental care for oral pain noted on 2/8/21 per the resident's physician's order. Residents Affected - Few The findings include: On 10/17/21 at 3:00 p.m., Resident #82 was observed in bed. An odor was coming from the resident's mouth. Secretions were also observed coming out of the right side of his mouth. On 10/18/21 at 10:40 a.m., Resident #82 was observed seated in a Geri chair. His lips were dry and cracked, and he could not open his mouth when asked. On 10/21/21 at 9:16 a.m., during an interview with Registered Nurse (RN) D, she stated the certified nursing assistant (CNA) had just helped the resident into the Geri chair. She stated oral care was provided during the morning care routine. When asked whether the resident could open his mouth, she replied no. She added that staff used oral care swabs for oral hygiene. She confirmed that even after oral care had been provided, the resident still had bad breath. A review of Resident #82's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included multiple sclerosis, functional quadriplegia and gastrostomy. He had current physician's orders for oral care every shift, and instructions to refer to an outside dentist due to oral pain on 2/8/21. Also ordered was chlorhexidine gluconate 0.12%, give 15 milliliters by mouth every shift to prevent gingivitis. (Copies obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/24/21, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating that resident did not participate in the cognitive status screening. He was noted as totally dependent on staff for bed mobility, transfers, eating and toilet use. A review of his current care plan revealed that Resident #82 had a potential for alteration in nutrition/hydration due to requiring enteral nutritional to meet 100% of his nutritional/fluid needs. He received no nutrition or hydration orally. Interventions included oral care and dental consults as ordered. A review of the Oral Hygienist's note, dated 06/10/21, indicated the resident had limited communication, access and cooperation. He presented with slightly pursed lips and the oral hygiene was fair, generally heavy plaque, food, bleeding and calculus present. Another Oral Hygienist's note, dated 08/05/21, indicated the resident had limited communication, access and cooperation. He presented with slightly pursed lips and the oral hygiene was poor with generally heavy plaque, food, bleeding and calculus present. On 10/21/21 at 2:44 p.m., during an interview with the Regional Nurse Consultant, she was asked about the resident's order for a consultation with the outside dentist due to oral pain on 2/8/21. She stated the resident was insured through Medicaid, so the only outside provider would be through a particular acute care hospital. She added that the waiting list was too long, and the resident had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 12 of 13 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 105737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MacClenny Nursing and Rehab Center 755 S 5th St MacClenny, FL 32063 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seen the outside dentist as ordered. She was then asked for evidence of notification of the outside dentist. She confirmed that there was nothing documented to verify that the outside dentist had been contacted. She added that the in-house dental hygienist was still seeing Resident #82. She confirmed that he had poor oral hygiene and was offered pain medication. A review of the facility's policy and procedure entitled Dental Services (Revised 08/29/2017), revealed that the facility provided each resident with access to dental services. Resident will be referred to dentist based on assessed need. Facility staff will assess dental status through the interdisciplinary resident assessment process and daily provision of care. The physician, residents and family/responsible party may request dental services at any time. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105737 If continuation sheet Page 13 of 13