Health inspection·November 7, 2024

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/7/2024 at 10:20 AM, Staff G, CNA, stated, The kitchen sends the nutritional shake with the tray. [Resident #62's name] did not have her nutritional shake on her meal tray. During an interview on 11/7/2024 at 10:22 AM, the Dietary Manager stated, I have a list in the kitchen with the residents' names who have an order for nutritional shakes. The kitchen aide did not check the list, and she missed it. Review of the facility policy and procedure titled Food and Nutrition Services with the last review date of 7/23/2024 read, Policy Statement: Each resident is provided with a nourishing, palatable, well-balance diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 2 of 7 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 105770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were accurate for 1 (Resident #69) of 2 residents reviewed for oxygen therapy. Findings include: During an observation on 11/4/2024 at 9:53 AM, Resident #69 was lying in bed with her eyes closed, receiving oxygen at 3 liters per minute via nasal cannula. During an observation on 11/5/2024 at 9:10 AM, Resident #69 was lying in bed, receiving oxygen via nasal cannula. Review of Resident #69's physician order dated 8/31/2024 read, Titrate oxygen for O2 [NAME] [oxygen saturations] below 90% starting at 2 L/min [liters per minute] and go up 1 L/min until O2 above 90%. Ok to use a mask or non-rebreather mask once at 10 L/min. Notify MD [medical doctor] when 02 Sats below 90%. As needed for 02 SAT below 90%. Review of Resident #69's Treatment Administration Record for November 2024 showed no documentation for oxygen use on 11/4/2024 and 11/5/2024. During an interview on 11/6/2024 at 10:55 AM, the Director of Nursing stated, [Resident #69's name] orders should have been changed to continuous oxygen. The staff are expected to document based on the orders and the services the resident is receiving. During an interview on 11/7/2024 at 11:26 AM, Staff D, Licensed Practical Nurse (LPN), stated, I did not know she had a prn [as needed] order for oxygen. I might have overlooked that. Normally you go into the system and click off if the resident is using the oxygen. Review of the facility policy and procedure titled Charting and Documentation with the last review date of 7/23/2024 read, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . 2.The following information is to be documented in the resident medical record . c. Treatment or services performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 3 of 7 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 105770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing direct care to the residents and failed to ensure staff used proper PPE (Personal Protective Equipment) while providing high-contact care to the residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases. Residents Affected - Some Findings include: 1) During an observation on 11/4/2024 at 1:05 PM, Staff D, Licensed Practical Nurse (LPN), returned to the medication cart. Without performing hand hygiene, Staff D removed medication for Resident #36 and wheeled Resident #36 to her room. Staff D administered Resident #36's medications in her room and wheeled her back to the hall without performing hand hygiene. Staff D returned to the medication cart, and without performing hand hygiene, walked away and went to grab a box of cigarettes for Resident #36. Staff D returned to the medication cart, and without performing hand hygiene, wheeled Resident #44 back to her room. During an observation on 11/5/2024 at 9:05 AM, Staff D, LPN, entered Resident #15's room and administered the medications. Staff D exited the room, and without performing hand hygiene, started to document on the computer. Without performing hand hygiene, Staff D began to pour medications for Resident #5 and administered the medication in the resident's room. Staff D exited the room without performing hand hygiene. Staff D heard Resident #5 coughing. Staff D entered the resident room to check if he was ok. Staff D proceeded to put medication away in the medication cart without performing hand hygiene. During an interview on 11/6/2024 at 10:10 AM, the Infection Preventionist stated, Staff should be performing hand hygiene in between each resident. Washing your hand to prevent infection is something everyone can control. During an interview on 11/7/2024 at 8:44 AM, Staff D, LPN, stated, I have been a nurse for seven years. I know better than that. You should do hand hygiene in between any interaction you have with residents. During an interview on 11/7/2024 at 11:40 AM, the Director of Nursing (DON) stated, Staff should be preforming hand hygiene in between each resident contact. 5) During an observation on 11/4/2024 at 1:47 PM, Staff E, CNA, exited Resident #31's room after completing incontinence care with a pair of used gloves in their hand. Staff E proceeded down the hallway and threw the gloves in the trash bin at the medication cart. Without performing hand hygiene, Staff E proceeded down the hallway to Resident #233's room, and entered Resident #233's room to assist the resident without performing hand hygiene. During a telephonic interview on 11/7/2024 at 11:00 AM, Staff E, CNA, stated, I washed my hands before I left the room, and then realized I had not thrown away the gloves, so I carried the gloves down to the nurses cart and threw them away there. During an interview on 11/7/2024 at 11:45 AM, the Director of Nursing stated she expected staff to sanitize their hands before and after direct care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 4 of 7 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 105770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy and procedure titled Handwashing/Hand Hygiene with the last review date of 7/23/2024 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation . 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. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device) . c. after touching a resident; d. after touching the resident's environment . f. immediately after glove removal . 5. The use of gloves does not replace hand washing/hand hygiene. 3) During an observation on 11/4/2024 at 12:52 PM, Staff A, Certified Nursing Assistant (CNA), entered Resident #77's room, and without performing hand hygiene, donned gloves and carried a gait belt [a transfer belt worn around the resident's waist that staff hold onto to help transfer a resident with balance issues] to Resident #77's bedside to assist the resident in transferring from his wheelchair to his bed. Before transferring Resident #77, Staff A doffed her gloves, and without performing hand hygiene, proceeded down the hallway to the equipment storage area near the nursing station outside 200 Hall. Staff A set the gait belt down, and without performing hand hygiene, grabbed the sit-to-stand lift [an electric standing and raising piece of equipment used to enable residents to be raised up from a seated position and transferred to a bed, chair, toilet, or wheelchair] and proceeded back to Resident #77's room. Without performing hand hygiene, Staff A donned gloves and assisted the resident to transfer from his wheelchair to his bed using the sit-to-stand lift. At 12:58 PM, Staff A doffed her gloves, and without performing hand hygiene, exited Resident #77's room and brought the sit/stand lift back to the equipment storage area. Staff A then proceeded down the hall, and without performing hand hygiene, entered Resident 40's room. Staff A passed Resident #40 their personal care items on their bedside stand without performing hand hygiene. During an interview on 11/6/2024 at 9:27 AM, the Assistant Director of Nursing (ADON) stated, The expectation for staff is that they do hand hygiene every time you [Staff] go in a room and do anything with a resident, including, anything where you come in contact with the resident or surfaces. Gloves do not replace hand hygiene. During a telephone interview on 11/6/2024 at 11:52 AM, Staff A, CNA, stated, I should have used the sanitizer for my hands before I donned my gloves when I helped with [Resident #77's name]. Before I entered [Resident #40's name] room, I should have used the hand sanitizer or wash my hands. 4) Review of Resident #34's medical record showed the resident was admitted on [DATE] with diagnoses including sepsis due to Escherichia coli (E. coli), stage 2 pressure ulcer of sacral region, urinary tract infection, retention of urine, malignant neoplasm of prostate, type 2 diabetes mellitus, acute pyelonephritis, hydronephrosis, obstructive and reflux uropathy, and bacteremia. Review of Resident #34 physician order dated 10/20/2024 read, Enhanced Barrier Precautions: PPE required for high resident care activities. Indication: wounds, indwelling medical device, infection and/or MDRO [Multi-Drug Resistant Organism] status. During an observation on 11/5/2024 at 8:44 AM, there was an Enhanced Barrier Precautions (EBP) sign attached to Resident #34's door facing the hallway. Staff B, CNA, exited Resident #34's room into the hallway and spoke to Staff C, CNA. Without performing hand hygiene, Staff B and Staff C entered Resident #34's room and donned gloves. Without wearing a gown, Staff B proceeded to the right side of Resident #34's bed and Staff C proceeded to the left side of the resident's bed. Resident #34's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 5 of 7 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 105770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indwelling urinary catheter was intact and the tubing was draped across the bed and down the left side of the bed with the catheter bag hanging directly to the left of where Staff C was standing to reposition Resident #34 in bed. While standing on each side of Resident 34's bed, Staff B and Staff C gathered up the linen under Resident #34's back and legs. While standing on each side of Resident #34, Staff B and Staff C had their lower bodies pressed against the resident's linen covered mattress, and without wearing gowns, pulled Resident #34's body toward the head of the bed. After repositioning Resident #34 in bed, Staff B and Staff C readjusted the resident's top blankets to cover the resident, doffed their gloves, and exited Resident #34's room without performing hand hygiene. During an interview on 11/6/2024 at 9:27 AM, the Assistant Director of Nursing (ADON) stated, The expectation for staff is that they do hand hygiene every time you [Staff] go in a room and do anything with a resident, including, anything where you come in contact with the resident or surfaces. When they [residents] are on EBP, the process is you should gown and glove. Gloves do not replace hand hygiene. During an interview on 11/6/2024 at 10:08 AM, Staff B, CNA, stated, I should have been wearing a gown and gloves when lifting [Resident #34's name] on EBP up in bed and when providing direct care. I was not wearing a gown. I washed my hands in the hallway before I picked up [Resident #34's name] tray and entered the room. I performed hand hygiene in the hallway before I entered the room the first time with the tray. During an interview on 11/6/2024 at 10:33 AM, Staff C, CNA, I wasn't wearing a gown when we pulled [Resident #34's name] up in bed. I was told we didn't have to if we were just pulling them up in bed when they are on EBP. I washed my hands before I went in the room. During an interview on 11/7/2024 at 11:45 AM, the Director of Nursing stated, The staff should wear PPE only when providing prolonged direct care, such as transfers that are max assist and when changing linens. The residents already feel some type of way and we do not want to make them feel they are contaminated. I would not expect them [the staff] to wear PPE for meal delivery, adjusting a resident in their bed, covering them up with linen, or giving them something. If so, they would be contact precautions. Review of the signage posted on Resident #34's door read, Enhanced Barrier Precautions: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device Care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 7/23/2024 read, Policy Statement: Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EPBs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity (as apposed to entering the room) . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing, b. bathing/showering, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.), h. wound care (any skin opening requiring a dressing) . 5. EBPs are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 6 of 7 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 105770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 2) During an observation on 11/5/2024 at 1:15 PM, Staff D, LPN, started preparing medications for Resident #21 without performing hand hygiene. Staff D locked the medication cart, entered Resident #21's room and administered the medications without performing hand hygiene. After taking the medication, the resident knocked over her water container onto the floor. Staff D exited the resident's room without performing hand hygiene, went to get a towel to clean up the water, and returned to clean up water off of the floor. At 1:21 PM, Staff D exited Resident #21's room without performing hand hygiene and returned to the medication cart. Staff D unlocked the cart and prepared medications for Resident #44 without performing hand hygiene. Staff D locked the medication cart, entered Resident #44's room and administered the medications without performing hand hygiene. At 1:24 PM, Staff D exited Resident #44's room, returned to the medication cart and began preparing medications for Resident #37 without performing hand hygiene. Staff D entered Resident #37's room and administered the medications. Without performing hand hygiene, Staff D returned to the medication cart. During an interview on 11/5/2024 at 1:56 PM, the Assistant Director of Nursing stated, I talked to [Staff D's name] about not washing his hands between residents and he said that he did hand sanitizer between residents. I then went and reviewed the video tape which showed that he did not use the hand sanitizer and did not wash his hands. During an interview on 11/5/2024 at 2:27 PM, Staff D, LPN, stated, As soon as you left, I realized that I had not done hand hygiene/washed hands between residents. I know better. I have been taught that since the beginning. Review of the facility policy and procedure titled Administering Medications with the last review date of 7/23/2024 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 22. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 7 of 7