Inspection·September 16, 2022

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents reviewed for changes in condition, Resident #29 and #42, resulting in the residents having to be treated by IV (intravenous) antibiotic therapy due to infection. Delay in notifying the physician of a wound, critical labs, and resident change in condition due to infection can result in the spread of the infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 2 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 3 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 4 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 5 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 6 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 7 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0580 Level of Harm - Immediate jeopardy to resident health or safety were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 8 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the privacy of 1 resident, Resident #69, of 2 residents reviewed for dementia care. Residents Affected - Few Findings include: On 9/12/2022 at 9:08 AM, Resident #69 was observed from the hallway lying in his bed attempting to use a urinal. Resident #69's privacy curtain was not pulled around Resident #69's bed. Resident #69 was not clothed, and his unclothed body was exposed through the open door of his bedroom to passersby. During an interview on 9/12/2022 beginning at 9:10 AM, Staff A, Licensed Practical Nurse, stated Resident #69 is still trying to use the urinal. She confirmed Resident #69's unclothed body was visible through the open door of his bedroom. She reported that she spoke to Resident #69 and told him his door was open so everyone walking down the hall can see you. Staff A added Resident #69 replied oh, that's not good. Review of the facility policy titled ADL (Activities of Daily Living) Care and Assistance, issued 4/1/2022 read 3. Staff should be mindful to provide ADL care with dignity, privacy, and respect to the resident, unless otherwise indicated by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 9 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from medical neglect when they did not immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents, Residents #29 and #42, resulting in a delay of care. Delay in notifying the physician of a wound, critical labs, or resident change in condition can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 10 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 11 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled Abuse and Protection and Response Policy approval date of 1/27/2022 reads, Policy: Abuse as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardian, friends, or other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse holds the highest priority. Definitions: Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor/supervise the delivery of patient care and services to assure that care is provided as needed by the resident. Identification: Policy: Any patient event that is reported to any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 12 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few staff by patient family, other staff or any other person will be considered as possible abuse if it meets any of the following criteria: d. Any complaint of deprivation by an individual caregiver of goods and services necessary to maintain physical, mental, and psychological well-being to include toileting issues. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 13 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 14 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 15 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews. Event ID: Facility ID: 105858 If continuation sheet Page 16 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for 2 of 3 residents, Residents #42 and #29, reviewed with a central venous access devices out of a total sample of 36 residents. Residents Affected - Some Findings include: During an observation conducted on 9/12/2022 at 12:14 PM with the Director of Nursing (DON) Resident #42 was observed resting in bed with a left upper arm single lumen midline catheter. The transparent dressing was dated 9/8/2022 and there was a piece of gauze under the transparent dressing. During an interview on 9/12/22 at 12:19 PM the Director of Nursing (DON) confirmed Resident #42's dressing was dated 9/8/2022 and that there is gauze under the transparent dressing. The dressing should be changed, it does have gauze under the dressing, and it needs to be changed after 48 hours if there is gauze under it. The line was placed on 9/8. It is the original dressing. Dressings with gauze at the insertion dressing site are changed in 24 hours, it should have been changed the next day. Review of the admission record documented that Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the physician order for Resident #42 dated 9/8/2022 reads May insert midline with 1% lidocaine for IV [intravenous] ABX [antibiotic]. Review of The IV Company record for Resident #42 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the physician's order for Resident #42 dated 9/9/2022 reads, Transparent dressing-change q [every] week and PRN [as needed] securement device with each dressing change every day shift every 7 day(s) for prophylaxis AND as needed. 2. During an observation on 9/12/2022 at 11:53 AM Resident #29 was observed resting in bed with a left upper arm single lumen midline catheter. The transparent dressing was dated 9/8/2022 and there was a piece of gauze under the transparent dressing. Review of the admission record documented that Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery( heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lung and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 17 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 - Some dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the physician order for Resident #29 dated 9/7/2022 reads Midline/PICC [peripherally inserted central catheter] placement for IV ABX. Review of the physician's order for Resident #29 dated 9/11/2022 reads, Measure arm circumference 2 inches above insertion site with each dressing change, every 7 day(s) for IV maintenance. Review of the physician order for Resident #29 dated 9/9/2022 reads, Transparent dressing change change q week and PRN, securement device with each dressing change. every day shift every 7 days for prophylaxis. Review of the IV Company report for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data-line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/12/2022 at 11:53 AM Resident #29 stated, That was just put in on that day [referring to the date on the transparent dressing]. The dressing has not been changed since they put it in. During an observation on 9/12/22 at 12:19 PM the DON confirmed the dressing was dated 9/8/2022 and that the gauze was under the transparent dressing. During an interview on 9/12/22 at 12:36 PM the DON stated The dressing was dated 9/8/2022. There is no documentation that the resident arm circumference was done. It was ordered and should have been done. The dressing should have been changed and should not have gauze under the transparent dressing. Review of the policy and procedure titled PICC/Midline issue date 4/1/2022 reads, Policy: It will be the policy of this facility to adhere to IV/PICC/midline administration guidelines as set forth by infection control, state, and federal regulations. Licensed nurses shall provide care according to state and federal law. Considerations: central venous catheters include peripherally inserted central catheters (PICC)/midline. Dressing changes: 1. Sterile dressing change using transparent dressings is performed: 24 hours post insertion or upon admission if not dated upon admission, at least weekly, if the integrity of the dressing has been compromised (wet, loose, or soiled). 2. dressing changes will be documented in the clinical record. Review of the policy and procedure titled Central Venous Catheter effective date 02-2009, approval date 1/27/2022 reads Purpose: To provide a general procedure regarding central venous catheters. Procedure: I. 1. Obtain physician order for dressing change refer to appendix B IV line maintenance chart. Appendix B reads: Midline: Transparent dressing changes: On admission or 24 post insertion then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 18 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 and PRN. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 19 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety in 1 of 2 nutrition room refrigerators containing food for resident consumption. Findings include: On 9/13/2022 at 12:02 PM an observation of the refrigerator in the nutrition room on the 400-hallway contained two cartons of regular milk that were expired, dated 9/7/2022 and 9/12/2022 respectively. During an interview on 9/13/2022 at 12:05 PM the Certified Dietary Manager stated, Yes the milk is expired. The evening shift kitchen staff is supposed to put nutritional supplements including milk in the refrigerator in the afternoon and the day shift staff is to check the nutritional refrigerators in the mornings and remove any expired nutritional items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 20 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the proper disposal of garbage and refuse. Residents Affected - Some Findings include: During an observation on 09/12/2022 at 10:22 AM with the Certified Dietary Manager (CDM) of the dumpster area showed a large quality of paper and boxes in front of the dumpster. There were four pieces of wood in front of and beside the dumpster. A large white bucket with a pink/red liquid was to the front left of the dumpster. A blue mattress was just behind and to the right of the dumpster. During an interview on 9/12/2022 at 10:22 AM the CDM stated, The trash should not be around the dumpster. I do not know when the dumpster was last emptied or how often it is emptied. I do not know what the pink liquid is in the white bucket. I think the staff takes the buckets home with them and leave the buckets by the trash can until they take the buckets home. The boards/wood and the mattress should not be around the trash can. During an observation of the dumpster area on 09/12/2022 at 12:20 PM showed the lid of the dumpster was propped up with a piece of wood. Boards were around and in front of the dumpster. During an observation of the dumpster area on 09/15/2022 at 10:00 AM showed the lid of the dumpster propped open with a board. During an interview on 9/15/2022 at 12:08 PM the CDM stated, The dumpster lid should not be propped open with a board. The trash lid should be closed. He stated the staff will prop the lid open because they cannot reach the to throw the trash in. The lid was closed this AM when the cook came in and the raccoons were scurrying around the trash can. Review of the policy and procedure titled Food-Related Garbage and Rubbish Disposal reads, Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 21 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility administration failed to administer the facility in a manner that enables it to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Residents Affected - Few Findings include: Review of the job description for the Administrator with an effective date of 1/17/2022 reads, Purpose of your job position: The primary purpose of your position is to direct the day-to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to our residents at all times. Delegation of Authority: As administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and responsibilities: Administrative functions: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the VP (Vice President) of operations. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. Review of the job description for the Director of Nursing Services dated 9/9/2021 reads, Purpose of your job position: The primary purpose of your position is to plan. organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the administrator to ensure the highest degree of quality care is maintained at all times. Duties and responsibilities, Administrative functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop methods for coordination of nursing services with other resident services to ensure continuity of the resident's total regime of care, develop, implement, and maintain an ongoing quality assurance program for the nursing services department, perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary and monitor the facility's QI (quality improvement) QM (quality management) and survey reports. Assist in developing plans of actions to correct potential or identified problem areas. 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 22 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 23 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 24 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled ANE (Abuse, Neglect and Exploitation) and Investigations issue date of 4/1/2022 reads Policy: It will be the policy of this facility honor resident rights and address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents symptoms in accordance with federal law. It will be the policy of this facility to ensure that all alleged violations of federal or state laws, which include mistreatment, neglect, abuse (verbal mental physical or sexual, injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint) not in accordance with regulation to treat residents' symptoms will be reported immediately to the administrator/DNS abuse coordinator designee. Appropriate agencies will be notified in accordance with existing laws. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 3. Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, and grievances. They will also be given the name of the facilities designated abuse contact person as well as numbers for state agencies. This will be done through resident council, family council, in service training, one to one if indicated, information posted in the facility. The facility environment will be monitored to prevent any additional ANE through: Monitoring staff actions while caring for residents. The facility will monitor reported events to determine if any pattern, trend, or frequency exists to attempt to minimize the occurrence or injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 25 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 26 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 27 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. During an interview on 9/15/2022 at 1:25 PM the Director of Nursing stated, I should have reviewed and brought both concerns to QAPI [Quality Assurance and Performance Improvement] when we did not complete the skin assessments and when we needed to get midlines and antibiotics. We should have completed full house skin sweeps and identified any other concerns. Absolutely should have investigated these and brought them to QAPI. We failed the residents, and we can do much better. During an interview on 9/16/2022 at 9:05 AM the Administrator stated, I am ultimately responsible for the running of the facility, but the Director of Nursing is responsible for all the clinical operations. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 28 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews. Event ID: Facility ID: 105858 If continuation sheet Page 29 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 - Some 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** 3) Review of the admission record for Resident #79 documented the resident was admitted to the facility on [DATE] with diagnoses that include unspecified dementia with behavioral disturbance, generalized anxiety disorder and psychotic disorder with delusions due to known physiological condition. Review of Resident #79's Preadmission Screening and Resident Review (PASRR) Level I Screen showed the facility had not completed Section IV: PASRR Screen Completion that documented whether Resident #79 may or may not be admitted to a nursing facility or whether Resident #79 required a Level II evaluation based on diagnoses of serious mental illness or intellectual disability. During an interview on 9/13/2022 at 1:38 PM, the Social Services Assistant verified Resident #79's Level I PASRR was incomplete and did not document whether Resident #79 may or may not be admitted to a nursing facility or whether Resident #79 required a Level II evaluation based on diagnoses of serious mental illness or intellectual disability. Based on observation, interview, and record review the facility failed to maintain accurate and complete medical records for midline catheter dressing changes for 2 of 3 residents, Residents #42, and #29, and Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents, Resident #79. Findings include: 1. During an observation on 9/12/2022 at 12:14 PM Resident #42 was observed resting in bed with a left upper arm single lumen midline catheter. The transparent dressing was dated 9/8/2022 and there was a piece of gauze under the transparent dressing. Review of the admission record documented that Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the physician's order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV [intravenous] ABX [antibiotic]. Review of The IV Company record for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data-line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the physician order for Resident #42 dated 9/9/2022 reads Transparent dressing-change q [every] week and PRN [as needed] securement device with each dressing change every day shift every 7 day(s) for prophylaxis and as needed. Review of the medication administration record for Resident #42 documented staff initials for the dressing change as being completed on 9/10/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 30 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 - Some During an observation conducted on 9/13/22 at 12:15 PM Resident #42 was observed resting in bed with a left upper arm midline dressing with a date of 9/8/2022 with gauze under a transparent dressing. During an interview on 9/12/22 at 12:19 PM the Director of Nursing (DON) confirmed Resident #42's dressing was dated 9/8/2022 and that there was gauze under the transparent dressing. The dressing was dated 9/8/2022 and was documented as completed on 9/10, that is incorrect documentation. The dressing is dated 9/8 and was not changed on 9/10. Staff should not document that something has been done if it was not done. 2) During an observation on 9/12/2022 at 11:53 AM Resident #29 was observed resting in bed with a left upper arm single lumen midline catheter. The transparent dressing was dated 9/8/2022 and there was a piece of gauze under the transparent dressing. Review of the admission record documented that Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery( heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lung and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the physician order for Resident #29 dated 9/7/2022 reads Midline/PICC [peripherally inserted central catheter] placement for IV ABX. Review of the physician order for Resident #29 dated 9/11/2022 reads Measure arm circumference 2 inches above insertion site with each dressing change, every 7 day(s) for IV maintenance. Review of the physician order for Resident #29 dated 9/9/2022 reads Transparent dressing change Change q [every] week and PRN [as needed], securement device with each dressing change, every day shift every 7 days for prophylaxis. Review of the IV Company record for Resident #29 dated 9/8/2022 reads Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. Review of the medication administration record for Resident #29 documented staff initials for the dressing change as being completed on 9/11/2022. During an interview on 9/12/2022 at 11:53 AM Resident #29 stated That [midline] was just put in on that day [9/8/22]. The dressing has not been changed since they put it [midline] in. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 31 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 - Some During an observation on 9/12/22 at 12:19 PM the Director of Nursing (DON) confirmed the dressing was dated 9/8/2022 and that the gauze was under the transparent dressing. During an interview on 9/12/22 at 12:36 PM the DON stated The dressing was dated 9/8/2022 and was documented as having been completed on 9/11, that is incorrect documentation. The dressing is dated 9/8 and was not changed on 9/11. Staff should not document that something has been done if it was not done. Review of the policy and procedure titled PICC/Midline issue date 4/1/2022 reads Policy: It will be the policy of this facility to adhere to IV/PICC/midline administration guidelines as set forth by infection control, state, and federal regulations. Licensed nurses shall provide care according to state and federal law. Considerations: central venous catheters include peripherally inserted central catheters (PICC)/midline. Dressing changes: 1. Sterile dressing change using transparent dressings is performed: 24 hours post insertion or upon admission if not dated upon admission, at least weekly, if the integrity of the dressing has been compromised (wet, loose, or soiled). 2. dressing changes will be documented in the clinical record. Review of the policy and procedure titled Central Venous Catheter effective date 02 - 2009, approval date 1/27/2022 reads Purpose: To provide a general procedure regarding central venous catheters. Procedure: I. 1. Obtain physician order for dressing change refer to appendix B IV line maintenance chart. Appendix B reads: Midline: Transparent dressing changes: On admission or 24 post insertion then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change and PRN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 32 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process when the administrative staff failed to investigate, develop, and implement appropriate plans of correction to identify and correct quality deficiencies of the facility failing to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings Include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 33 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 34 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. During an interview on 9/15/2022 at 1:25 PM the Director of Nursing stated, I should have reviewed and brought both concerns to QAPI when we did not complete the skin assessments and when we needed to get midlines and antibiotics. We should have completed full house skin sweeps and identified any other concerns. Absolutely we should have investigated these and brought them to QAPI. We failed the residents, and we can do much better. Review of the policy and procedure titled Quality Assurance and Performance Improvement Program the last approval date of 12/7/2022 reads, Policy Statement: The facility shall develop, implement, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 35 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few maintain an ongoing facility wide quality assurance and performance improvement program that builds on the quality assessment and assurance program to actively pursue quality of care and quality of life goals. Policy interpretation and implementation the primary purpose of the quality assurance and performance improvement plan is to establish data- driven, facility wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Five strategic elements: 3. feedback, data systems and monitoring. A. Systems are in place to monitor care and services. B. Systems are designed to incorporate feedback from caregivers, residence, family, and staff as appropriate. C. Care processes and outcomes are monitored using performance indicators. These performance indicators are measured against quality benchmarks and targets that the facility has established. D. Adverse events are tracked, monitored, and investigated as they occur. E. Action plans are implemented to prevent recurrence of adverse events. QAPI action steps: 13. Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include a. clinical outcomes: pressure ulcers, infections, medication use, pain, falls, etc. 14. Set measurable goals for improvement that may include percentage of reductions (or increases) from the measured baseline of a particular goal. 16. Recognizing patterns in systems of care that can be associated with quality problems. 17. Prioritizing identified quality issues based on risk of harm and frequency of occurrence and determining which will become the focus of PIPS [Performance Improvement Plans].18. Planning, conducting and documenting PIPS.19. Conducting root cause analysis to identify the issues that contribute to recognized problems. 20. Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provides significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. Review of the policy and procedure titled ANE (Abuse, Neglect and Exploitation) and Investigations issue date of 4/1/2022 reads Policy: It will be the policy of this facility honor resident rights and address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents symptoms in accordance with federal law. It will be the policy of this facility to ensure that all alleged violations of federal or state laws, which include mistreatment, neglect, abuse (verbal mental physical or sexual, injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint) not in accordance with regulation to treat residents' symptoms will be reported immediately to the administrator/DNS abuse coordinator designee. Appropriate agencies will be notified in accordance with existing laws. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 3. Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, and grievances. They will also be given the name of the facilities designated abuse contact person as well as numbers for state agencies. This will be done through resident council, family council, in service training, one to one if indicated, information posted in the facility. The facility environment will be monitored to prevent any additional ANE through: Monitoring staff actions while caring for residents. The facility will monitor reported events to determine if any pattern, trend, or frequency exists to attempt to minimize the occurrence or injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 36 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 37 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Residents Affected - Few Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 38 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 39 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews. Event ID: Facility ID: 105858 If continuation sheet Page 40 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 prevent the possible spread of infection during wound care and medication administration. Residents Affected - Some Findings include: 1. During an observation on 9/14/22 beginning at 10:20 AM of Staff B, Licensed Practical Nurse (LPN), performing wound care to the coccyx and right below the knee amputation stump for Resident #29 it showed Staff B, LPN reached into her pocket for scissor with a gloved hand. Staff B proceeded to use the scissors to cut a piece of dressing, Calcium Alginate, without sanitizing the scissors. Staff B applied the Calcium Alginate to Resident #29's coccyx wound. Staff B, LPN, was observed to clean the right below the knee amputation stump wound from the outer edges of the skin to the center of wound. The wound is observed to be open in the center with white tissue and reddened edges. Staff B was observed to cut a second piece of Calcium Alginate with the same scissors and applied Calcium Alginate to Resident #29's right below the knee amputation stump. Resident #29 was receiving intravenous antibiotic therapy specifically for infection to the coccyx wound. During an interview on 9/14/22 at 10:40 AM Staff B, LPN stated I missed the sequence/order of wound care and I cleaned from outside in. I shouldn't have reached in my pocket with my gloved hand. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). 2. During an observation of medication administration on 9/13/2022 at 7:40 AM Staff O, LPN poured medications without performing hand hygiene for Resident #9, entered Resident #9's room without performing hand hygiene, administered the medications and returned to the medication cart to prepare medications for another resident without performing hand hygiene. During an observation of medication administration on 9/13/2022 at 7:45 AM Staff O, LPN poured medications without performing hand hygiene for Resident #40, entered the Resident #40's room without performing hand hygiene, administered the medications and returned to the medication cart to prepare medications for another resident without performing hand hygiene. During an observation of medication administration on 9/13/2022 at 7:55 AM Staff O, LPN poured medications without performing hand hygiene for Resident #21, entered the Resident #21 room without performing hand hygiene, administered the medications and returned to the medication cart and began to prepare medications for another resident. During an interview on 9/13/2022 at 8:04 AM Staff O, LPN stated, Oh, I guess I should have used the hand sanitizer or washed my hands. I just got nervous being watched. During an observation of medication administration on 9/13/2022 at 8:15 AM Staff P, LPN poured medications without performing hand hygiene for Resident #90, entered the resident's room, administered the medications, and began preparing medications for another resident. During an interview conducted on 9/13/2022 at 8:30 AM Staff P, LPN stated, I know I should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 41 of 42 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 105858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Health and Rehabilitation Center 701 Medical Court East Inverness, FL 34452 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 washed my hands, it's just so busy this morning and I need to get a discharge done and no one told me, and I don't have the paperwork done. I just forgot. During an observation of IV (intravenous) medication administration conducted on 9/13/2022 at 12:15 PM Staff A, LPN prepared medications for Resident #42 without performing hand hygiene, entered the Resident #42's room, put on gloves without performing hand hygiene, removed the IV tubing from the midline catheter and administered 10 milliliters of normal saline without cleaning the hub of the needleless connector before administering the normal saline. During an interview conducted on 9/13/2022 at 12:30 PM Staff A, LPN stated, I did not clean the connector and I should have, I should have washed my hands before I put my gloves on. During an interview conducted on 9/14/2022 at 1:33 PM the Director of Nursing stated, Staff should use hand sanitizer before pouring medications and when they leave resident rooms. It is the standard to clean the connector on a midline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105858 If continuation sheet Page 42 of 42