Health inspection·April 20, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 4/17/23 at 10:10 AM, Resident #78 was lying in bed, nasal cannula was in place, with the oxygen concentrator administering oxygen at 2.5 L/min [liters per minute]. Residents Affected - Few During an observation on 4/18/23 at 12:20 PM, Resident #78 was sitting in her wheelchair, nasal cannula in place, with the oxygen concentrator administering oxygen at 2.5 L/min. During an observation on 4/19/23 at 8:08 AM, Resident #78 was lying in bed, nasal cannula in place, with the oxygen concentrator administering oxygen at 2.5 L/min. Review of the admission documented Resident #78 was admitted to the facility with a diagnosis of, but not limited to: hypertensive heart disease, with heart failure and shortness of breath. Review of the physician's order, dated 10/4/21, read O2 [oxygen] at 2L/min. via nasal cannula for shortness of Breath. During an interview on 4/19/23 at 8:10 AM, Resident #78 stated she did not change the level of her oxygen. During an interview on 4/19/23 at 8:55 AM, Staff A, LPN confirmed Resident #78's oxygen concentrator was administering oxygen at 2.5 L/min [liters per minute]. Based on observation, interview and record review the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 2 of 3 residents, Residents #86 and #78. Findings include: 1. During an observation on 4/17/2023 at 10:02 AM, Resident #86 was sitting at the edge of her bed with oxygen being administered at 3 liters per minute via nasal cannula. Review of Resident #86 physician orders, dated 11/18/2022, read O2 @ 2L via NC PRN check O2 q shift [oxygen at 2 liters via nasal cannula as needed check oxygen every shift]. During an observation on 4/18/2023 at 9:05 AM, Resident #86 was lying in bed with oxygen being administered at 3 liters per minute via nasal cannula. During an observation on 4/19/2023 at 7:45 AM Resident #86 was lying in bed with eyes closed, oxygen was being administered at 3 liters per minute via nasal cannula. During an interview on 4/20/2023 at 8:05 AM Staff E, License Practical Nurse (LPN), confirmed Resident #86 was being administered oxygen at 3 liters per minute. Staff E stated, It was above 2 liters (L) per minute at 3 liters, the oxygen needs to be adjusted. During an interview on 4/19/2023 at 8:16 AM, the Director of Nursing stated, I need to check that the patient does not readjust her O2 [oxygen] let me look at [Resident #86's name's] care plan. I checked the orders they are 2 liters of oxygen. The order is prn; I'm not sure if [Resident #86's name] changed the number, if she does, we will definitely increase [Resident #86] oxygen if needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105855 If continuation sheet Page 2 of 6 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 105855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ruleme Center 2810 Ruleme St Eustis, FL 32726 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 Nurses should monitor and make sure they are following the orders. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/19/2023 at 10:50 AM Resident #86 stated, I have not adjusted my oxygen level in these past few days. I did adjust it once before back when I had double pneumonia and felt I could not breathe, but that was months ago I have not touched it since then. Residents Affected - Few Review of the policy and procedure titled Oxygen Administration, last review date 2/20/2022, read General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physician's orders and/or facility protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105855 If continuation sheet Page 3 of 6 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 105855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ruleme Center 2810 Ruleme St Eustis, FL 32726 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On [DATE] at 10:21 AM an observation of Resident #68's room was completed. Resident #68 was not in her room. There was no facility staff in the room. A plastic bag that contained a topical steroid with anti-infective cream was stored in a coffee cup on Resident #68's dresser. There was an unbagged skin protectant moisture barrier cream lying on Resident #68's bedside table that was positioned horizontally across Resident #68's bed. (Photographic evidence obtained) Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 4 medication carts and failed to ensure all medications were stored in locked compartments to permit only authorized personnel to have access for 2 of 4 residents, Residents #13 and #68. Findings include: 1. During an observation of the North [NAME] Hall medication cart #2 conducted on [DATE] at 9:38 AM with Staff F, License Practical Nurse (LPN), there was one open Latanoprost ophthalmic solution with no open or expiration date and one expired bottle of Artificial Tears dated [DATE]. During an interview on [DATE] at 9:42 AM, Staff F, LPN stated, Eye drops should be dated when they are opened and if medication is expired, we should toss it. During an observation of North [NAME] Hall medication cart #1 conducted on [DATE] at 9:46 AM with Staff B, LPN there were three open bottles of Artificial Tears with no open or expiration date, one open Basaglar insulin pen with no open or expiration date and one expired Liraglutide Solution insulin pen dated [DATE]. During an interview on [DATE] at 9:53 AM, Staff B, LPN stated, The artificial eye drops, staff should have dated the eye drops upon opening them. The insulin pens should be labeled with their open and expiration date and if the medication is expired nursing staff should dispose of the medication. During an interview on [DATE] at 8:15 AM, the Director of Nursing stated, Once medication was opened, the date should be added. Any expired medication should be thrown out. Review of the policy and procedure titled, Medication Storage with an approval date of [DATE] read, Policy Interpretation and Implementation: 4. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 8. Drugs should be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing system. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 2. During an observation on [DATE] at 11:23 AM, Resident #13 had medications on the bedside table. Items observed were Peri Guard ointment skin protectant, Vitamin A&D ointment, Skin Repair cream, and DermaKlenz wound cleanser. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105855 If continuation sheet Page 4 of 6 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 105855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ruleme Center 2810 Ruleme St Eustis, FL 32726 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on [DATE] at 8:15 AM, Resident #13 had medications on the bedside table. Items observed were Peri Guard ointment skin protectant, Vitamin A&D ointment, Skin Repair cream, and DermaKlenz wound cleanser. During an observation on [DATE] at 8:25 AM, Resident #13 had medications on the bedside table. Items observed were Peri Guard ointment skin protectant, Vitamin A&D ointment, Skin Repair cream, and DermaKlenz wound cleanser. During an interview on [DATE] at 8:30 AM, Staff A, LPN stated, I'm not sure if the resident is allowed to have any of the medications at bed side. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105855 If continuation sheet Page 5 of 6 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 105855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ruleme Center 2810 Ruleme St Eustis, FL 32726 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, labeled, or discarded in the kitchen and 1 of 2 nourishment rooms. Residents Affected - Some Findings include: During an observation of the kitchen conducted on 04/17/23 at 09:16 AM with the Certified Dietary Manager (CDM) of the walk-in cooler there was what appeared to be bulk ham, pork tenderloin, sliced cheese, and pre-packaged pancakes that were not in their original containers, did not have identifying labels and were not dated. On the counter and rack for clean pots and pans there were dirty cloths and scrub pads. An interview was conducted with the CDM on 4/17/23 at 9:23 AM. The CDM verified the bulk ham, pork tenderloin, sliced cheese, and pancakes in the walk-in cooler were not in their original packaging and did not have identifying labels or dates. The CDM confirmed that dirty cloths and scrub pads should not be placed on the counters or pot and pan rack. Review of the policy and procedure located in the Dietary Services Manual titled, Food Safety, last reviewed 12/2022, read, Any food that is not in its original packaging must be labeled. Review of the policy and procedure titled, Food Receiving and Storage, last reviewed 12/20/2022 read, 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). An observation was made with the CDM on 4/19/23 at 11:05 AM of the Northbrook nourishment room. There was one opened container of Jevity 1.5 and one opened container of Glucerna 1.2 that were not labeled or dated. During an interview on 4/19/23 at 11:18 AM the CDM confirmed there were two open drinks with no date or label. The foods or products in the nourishment rooms should have an open date and a resident's name. Review the policy and procedure titled, Food Receiving & Storage, last reviewed 12/20/2022, read, 14. Food items and snacks kept on the nursing units must be maintained as indicated: d. beverages must be dated when opened and discarded after twenty-four (24) hours. E. other opened containers must be dated and sealed or covered during storage. Review the policy and procedure titled, Refrigerator and Freezers, last reviewed 12/20/2022 read 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105855 If continuation sheet Page 6 of 6