Inspection·July 27, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Resident Rooms, last reviewed on 8/21/2022, read, Medications: (includes all prescriptions and over-the-counter drugs, which must be ordered by the physician in the facility) . Noxzema or any medicated creams or powders . Note . Many of our residents, due to mental impairments or poor eyesight, might inadvertently drink or eat some of the above items causing irreparable harm. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105809 If continuation sheet Page 2 of 5 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 105809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Center 10676 Marvin Jones Blvd Live Oak, FL 32060 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 - Some 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 record review, the facility failed to ensure expired foods and test strips were discarded in the kitchen and walk-in cooler areas and failed to ensure the equipment were cleaned to maintain sanitary standards (Photographic evidence obtained). Findings include: During a walk-through tour of the kitchen on 7/24/2023 at 9:26 AM with the Dietary Manager (DM) and the Dietary Director (DD), the interior door of the ice machine had a black slimy buildup, the blender (chopper/grinder) had water nesting in the bottom of the base, the can opener had a buildup of dried food particles on and around the blade and base of the can opener, the walk-in cooler had three containers of cottage cheese with an expiration date of 7/14/2023 and a nectar juice container dated 5/29/2023. The test strips for the sanitation solution had an expiration date of 7/15/2023. During an interview on 7/24/2023 at 9:35 AM, the Dietary Manager (DM) verified the presence of a black slimy substance on the interior door of the ice machine, and confirmed that the can opener had food particles located on the blade and base, the blender bowl (chopper/grinder) should have been inverted to prevent wet-nesting, the blender bowl had water standing in the bottom from being washed and placed back on the base, and the test strips had an expiration date of 7/15/2023, and stated that she was not aware that the test strips were expired. During an interview on 7/24/2023 at 10:45 AM, the Dietary Director (DD) stated that the expired products should have been discarded according to the policy. Review of the facility policy and procedure titled Sanitation and Infection Control dated 7/28/2021 read, 4. Food Storage: a. Food that is stored is protected from contamination and growth of any pathogenic organisms. b. Among the food protection measures that are performed by the dietary department are . Foods with expiration dates are used prior to the date on the package. Review of the facility policy and procedure titled Cleaning Food Preparation Appliances dated 7/28/2021 read, Policy: Small appliances and food appliances such as mixers and food processors will be cleaned and sanitized after each use. Procedure . 4. Rinse parts with warm water and place in dishwasher or sink. Wash and rinse following procedures for automatic or hand dish washing. 5. Air dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105809 If continuation sheet Page 3 of 5 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 105809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Center 10676 Marvin Jones Blvd Live Oak, FL 32060 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 Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards to prevent the possible development and transmission of infection during wound care for 1 of 2 residents reviewed for wounds, Resident #3 (Phoyographic evidence obtained). Residents Affected - Few Findings include: During an observation of wound care for Resident #3 on 7/26/2023 at 9:33 AM with the Wound Care Nurse and the Risk Manager/Registered Nurse (RN), the resident's leg was resting on top of a pillow with a barrier over the pillow. The Risk Manager lifted the resident's right leg revealing stains to the wound dressing on the bottom at the right heel. The Wound Care Nurse removed the soiled dressing. The Risk Manager placed the resident's leg back down on the barrier. The Wound Care Nurse proceeded to clean the wound. The Risk Manager lifted the resident's right foot and the Wound Care Nurse cleansed Resident #3's right heel. Blood stains were observed on the middle portion of the barrier. After cleaning the wounds, the resident's leg was placed back down on the contaminated blood-stained barrier. The cleaned open heel wound came in contact with the contaminated barrier and the open wound on the back of the resident's leg rested on the contaminated barrier. The Risk Manager folded the edge of the contaminated barrier by placing both hands on the bottom portion of barrier. The Risk Manager lifted the resident's leg and touched the open wound located on the back of the resident's right leg. The Wound Care Nurse covered the wounds to the right heel areas and open knee wound areas. Resident #3's wound located on the back of the leg was left uncovered. The Wound Care Nurse began to wrap the resident's wounds with gauze roll. The Risk Manager put her hand on the gauze roll to prevent the roll from falling while the Wound Care Nurse was wrapping the resident's leg. The resident's right leg was wrapped with gauze and placed on top of the contaminated barrier. During an interview on 7/26/2023 at 10:04 AM, the Wound Care Nurse stated, I did not need [the Risk Manager's name] to roll the wound with me. We could have placed a clean pad down after cleaning the wounds. I am not sure if the heel touched the pad. She should have just stood there and supported the leg once we were ready to wrap. I did not want [Resident #3's name] leg to fall since she moves. There is a risk for infection. During an interview on 7/26/2023 at 10:07 AM, the Risk Manager stated, I could not see if the foot was touching the pad from where I was standing. I closed the pad into itself in trying to keep it from coming into contact with me. The wounds were covered when I touched the roll of gauze. Review of Resident #3's physician order dated 7/18/2023 read, Right heel: Cleanse with NS [Normal Saline] or wound cleanse. Pat dry. Slightly moisten 4x4 collagen sheet and apply to wound. Apply absorbent pad, wrap with gauze roll from the bottom of toes to below the knee. Daily and PRN [as needed]. May include all wounds in gauze wrap. 1 time per day, every day at 7:00 AM. Review of Resident #3's physician order dated 7/18/2023, read, Right Lateral ankle: Cleanse with NS or wound cleanse. Pat dry. Apply 2x2 xeroform to wound. Cover with absorbent pad, wrap with gauze roll from the bottom of toes to below knee. May include heel wound in wrap. Daily and PRN. 1 time per day, every day at 7:00 AM. Review of Resident #3's physician order dated 7/24/2023 read, Right lower lateral ankle, Cleanse with NS, or wound cleanse and pat dry. Moisten and apply 1x1 collagen to wound. Wrap with rolled gauze. 1 time per day, every day at 7:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105809 If continuation sheet Page 4 of 5 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 105809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Center 10676 Marvin Jones Blvd Live Oak, FL 32060 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 - Few Review of Resident #3's physician order dated 7/25/2023 read, Right shin/leg: Cleanse open blister areas with NS or wound cleanse. Pat dry. Apply xeroform to areas. Apply absorbent pad and wrap with gauze wrap. (may include all foot in wrap) 1 time per day, every day at 7:00 AM. During an interview on 7/26/2023 at 12:20 PM, the Director of Nursing stated, The wound should not have come in contact with the area [contaminated barrier]. Review of the facility policy and procedure titled, Wound Care, last reviewed on 8/21/2022, read, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in Procedure . 12. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on a clean field. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105809 If continuation sheet Page 5 of 5