Health inspection·August 1, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm her IV antibiotics, Meropenem (used to treat infections caused by bacteria), Intravenous Solution, 1 gram, infusing into the PICC line IV site in her right upper arm. The PICC line IV site was observed to be covered with a transparent dressing, with the edges lifting on three sides from her skin. There was a 2 x 2 gauze pad observed under the transparent dressing. The dressing had a date of 7/24/24 and a time of 11:00 PM documented. Residents Affected - Few During an interview on 7/31/2024 at 9:55 AM, the Assistant Director of Nursing (ADON), stated, PICC line dressing changes are once a week and prn (Pro Re Nata/as needed). There should be something circular [antimicrobial sponge] at the [insertion] site. There should also be something other than Tegaderm [transparent occlusive dressing], there should be gauze or a split sponge under the Tegaderm. The only reason to change the dressing more often than once a week would be if the dressing was stained, like with blood. That's why we have the prn order. There is also an order to check the site for signs and symptoms of infection every shift. The gauze under the Tegaderm just gives something to grab when pulling off the Tegaderm. During an interview on 7/31/2024 at 10:15 AM, Staff A, Licensed Practical Nurse (LPN), stated, We do [PICC line] dressing changes every week. The kit has an occlusive dressing. The gauze in the kit is to dry the site. I only apply an occlusive (transparent) dressing. Gauze should not be under the occlusive dressing at all. If there is gauze, it should only be there, or on any wound, for 24 hours. During an interview on 7/31/2024 at 10:40 AM the Director of Nursing (DON), stated, We change the dressings on PICC lines once a week and prn, if it is saturated or loose. The dressing would have the round thing (antimicrobial disc) and the clear dressing (transparent occlusive dressing) on top. There should be no gauze. The kits have gauze, and sometimes when the line is first put in, it can be bloody and need the gauze. If there is gauze, the dressing needs to be changed within 24 hours. During an interview on 7/31/2024 at 12:15 PM, Staff A, LPN, stated, I gave her [Resident #71] morning antibiotics this week [7/29/2024, 7/30/2024, 7/31/2024]. I didn't change it [PICC line dressing] earlier this week, because I didn't think it needed to be changed. During an interview on 8/1/2024 at 11:15 AM, Staff F, LPN, stated, I took care of [Resident #71's name] last weekend [7/27/2024, 7/28/2024]. I remember she had a PICC line and was getting IV antibiotics. I gave them [the IV antibiotics] on my shift. There is usually gauze under the occlusive dressing, I had no idea it wasn't supposed to be there. During an interview on 8/1/2024 at 12:00 PM, Staff G, LPN, stated, I would have been the one to give her [Resident #71] antibiotics. I'm sure I gave the antibiotics both days [7/27/2024 and 7/28/2024]. The dressing was intact, but I did not notice there was gauze under the occlusive dressing. I didn't know the policy says there shouldn't be any gauze under the transparent occlusive dressing. I know gauze dressings are supposed to be changed every two days, but I didn't notice that there was gauze. During an interview on 8/1/2024 at 12:45 PM, the DON, stated The nurses are supposed to assess PICC sites every shift and change the dressings once a week or as needed, if the dressing is loose or soiled. There should not be any gauze. I expect the nurses to assess the insertion site and quality of the dressing and change it according to our policy. Review of the policy and procedures titled, Central Venous Catheter Care and Dressing Changes, last revised 3/2022, review date of 1/11/2024, read, Purpose - The purpose of this procedure is to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 FORM CMS-2567 (02/99) Previous Versions Obsolete prevent complications associated with therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines - 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 2. Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM dressing; b. at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or c. immediately if the dressing or site appear compromised. Event ID: Facility ID: 105808 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 Based on observation, interview, and record review, the facility staff failed to follow physician orders and ensure that oxygen was administered consistent with professional standards of practice for 3 out of 4 residents reviewed for respiratory care (Resident #27, #30 and #46) Residents Affected - Few Findings include: 1. Review of Resident #27's admission record documented diagnoses that included unspecified systolic congestive heart failure, anemia unspecified, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #27's physician orders dated 9/7/2022 read, Deliver oxygen at 2L [liters]/min [minute] via nasal cannula. During an observation on 7/29/2024 at 12:34 PM Resident #27 was resting in bed, oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. During an observation on 7/30/2024 at 7:44 AM Resident #27 was resting in bed, oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. During an observation on 07/30/24 at 02:45 PM of Resident #27, conducted with Staff A, Licensed Practical Nurse (LPN), it showed oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. Staff A, LPN, during the observation, changed the oxygen administration to 3 liters per minute. During an interview on 7/30/2024 at 2:47 PM Staff A, LPN stated, That is not correct [the oxygen]. I'm not sure how it got on that high. Her orders [Resident #27] are for 2 liters and I will change that. I should check oxygen when I am administering medications. I am not aware of any reason we would have needed to change the rate of the oxygen. Review of the nursing progress notes for the period of 7/14/2024 through 07/30/2024 did not document the need to increase the oxygen administration dosage, changes in the resident's respiratory status, or notification to the physician of a change in the resident's oxygen administration rate. During an interview on 8/1/2024 at 7:30 AM the Director of Nursing (DON) stated, I expect staff to assess residents on oxygen at a minimum daily and make sure that we are following the orders for correct oxygen administration. 2. During an observation on 7/29/2024 at 12:39 PM Resident #30 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 3 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside of the reach of the resident. During an observation on 7/30/2024 at 7:48 AM Resident #30 was in bed with oxygen being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 Residents Affected - Few administered via nasal cannula. The oxygen concentrator was set at 3 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. Review of Resident #30's admission record which documented diagnoses that included heart failure, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus without complications, aphasia following cerebral infarction, dysphasia following cerebral infarction, and essential primary hypertension. Review of Resident #30's physician orders dated 12/20/2023 read, Continuous O2 [oxygen] at 2L [liters] via NC [nasal cannula]. Review of Resident #30's progress notes for the period of 7/19/2024 through 7/30/2024 did not provide for documentation of changes in condition, a change in respiratory status, shortness of breath, or the physician having been notified of a change in the administration of oxygen. During an observation on 7/30/2024 at 2:48 PM Staff A, LPN verified the oxygen was running at 3 liters per minute. During an interview on 7/30/2024 at 2:48 PM Staff A, LPN stated, Her orders [Resident #30] are for 2 liters of oxygen. I should check daily for what oxygen is running at. During an interview on 7/31/2024 at 9:42 AM the DON stated, The nurses should be checking oxygen every day, when they go from portable tanks to concentrators, and when they have any changes in their respiratory functioning. 3. During an observation on 7/29/2024 at 10:29 AM Resident #46 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 5 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. During an observation on 7/30/2024 at 7:43 AM Resident #46 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 6 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. During an interview on 7/30/2024 at 7:44 AM Resident #46 stated, I do not change the machine, sometimes I take my oxygen off at my nose, but I can't reach the machine to change it. Review of Resident #46's admission record documented diagnoses that included acute and chronic respiratory failure, unspecified whether with hypoxia [low oxygen] or hypercapnia [high carbon dioxide], type 2 diabetes mellitus without complications, heart failure, unspecified, and essential (primary) hypertension. Review of Resident #46's physician orders dated 12/20/2023 reads, O2 at 3 L/m via nasal cannula. During an observation on 7/30/2024 at 2:44 PM Staff A, LPN verified that the oxygen was running at 6 liters per minute, During an interview on 7/30/2024 at 2:48 PM Staff A, LPN stated, It [the oxygen] is on 6 liters and should be on 4 liters. I am responsible for making sure that the oxygen is running at the right rate. We should be following physician orders for oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 8/01/2024 at 9:09 AM the DON stated, I expect staff to follow physician orders for oxygen use. They should check at least daily. Review of the policy and procedure titled, Oxygen Administration last approval date of 01/11/2024 read, Purpose: The purpose of the procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the procedure: 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. Event ID: Facility ID: 105808 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy and procedure review, the facility failed to ensure food is safely stored, covered, and/or labeled in the areas of the nutrition room and food trays delivered to the floors. Residents Affected - Some Findings include: During an observation on 7/29/24 at 10:00 AM of the nutrition room on the first floor, inside the refrigerator was an open package of Bologna not dated or sealed. (Photographic evidence obtained). During an interview on 7/29/24 at 10:00 AM the Dietary Manager stated, Its dietary's responsibility to check the nourishment rooms in the morning and clean them out as needed. During an interview on 7/29/24 at 10:00 AM the Dietary Manager confirmed the bologna was not sealed in the package or dated. During an observation on 7/30/24 at 7:51 AM of the breakfast meal delivered to the first floor from main kitchen, showed half cut bananas not covered on individual resident trays. (Photographic evidence obtained). During an interview on 7/30/24 at 7:52 AM the Administrator, who walked up at the time the trays were delivered, said, I do not know why the cut bananas were not covered. During an interview on 7/30/24 at 8:10 AM the Dietary Manager stated, I am not sure why the bananas that are cut in halves are not wrapped. A request was made for the policy and procedure related to food tray delivery. During an interview on 8/1/24 at 10:14 AM the Dietary Manager stated, There is no food tray delivery policy and procedure. Review of the policy and procedure titled, Foods Brought by Family/Visitors, reviewed on January 11, 2024, read, Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation: 1. Family members and visitors are asked to inform nursing staff when foods are brought for a resident. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. a. Nonperishable foods are stored in re-sealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the date. 6. The nursing staff will discard perishable foods within 3-5 days. 7. The nursing and /or food service staff will discard any foods prepared for the resident that shows obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 7 of 7