Health inspection·February 9, 2023

F 0641 Resident #15 was inaccurately completed for the resident receiving insulin injections and insulin order changes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106009 If continuation sheet Page 2 of 8 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 106009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for 4 of 29 residents, Residents #2, #18, #41 and #48. Findings include: 1. Review of Resident #2's admission record revealed the resident was admitted to the facility on [DATE] with a history of heart failure, unspecified dementia, unspecified severity, anemia, other specified anxiety disorders, chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease stage 3, other reduced mobility, zoster without complications, muscle weakness, altered mental status, unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #2's progress note dated [DATE] reads, Quarterly Assessment- Met with resident who was up in wheelchair, dressed, alert, and oriented with mild confusion and able to make needs known. Daughter present for care plan. resident and daughter has [Sic.] no complaints or concerns regarding care. Resident vision and hearing appears WNL [within normal limits]. Discussed Advance Directives: Per daughter, resident is a DNR. Social Services to follow up regarding AD. Resident is social gets out of room often, attends activities and shows no signs of depression. Review of Resident #2's care plan dated [DATE] reads, No Advance Directives executed: Full Code. Dated Initiated: [DATE]. Review of Resident #2's paper chart on [DATE] at 11:00 AM revealed no Do Not Resuscitate Order signed. During an interview on [DATE] at approximately 10:45 AM, the Social Services Director stated, Daughter travels constantly. We are waiting until she comes back to do the Do Not Resuscitate (DNR) form. During an interview on [DATE] at 11:00 AM, Resident #2's Daughter stated, Mother is a DNR. I gave the forms to the facility. 2. Review of Resident #18's admission record revealed the resident was admitted on [DATE] with a history of Alzheimer's disease, aphasia, generalized anxiety disorder, ventricular tachycardia, type 2 diabetes mellitus, syncope and collapse, other symbolic dysfunctions, cognitive communication deficit, depression, unspecified mood disorder, essential hypertension. angina pectoris, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #18's care plan dated [DATE] revealed Advance Directives was executed and DNR was initiated on [DATE]. Review of Resident #18's progress note dated [DATE] reads, Quarterly Care Plan: Met with resident and daughter. Resident is alert with confusion. Able to make needs known. Resident is currently in PT. PT gave report. Nurse manager attended. Updated family on medications. Family has no concerns and happy with how her care has improved. Advance Directives review: DNR. Resident self-propels in wheel chair, is very social and attends activities. Resident has some HOH [hard of hearing], wears (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106009 If continuation sheet Page 3 of 8 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 106009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628 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 glasses and see podiatry. Social Services will continue to follow as needed. Level of Harm - Minimal harm or potential for actual harm Review of Resident #18's paper chart revealed Full Code Agreement dated [DATE] signed by the Resident #18's Daughter. Residents Affected - Few During an interview on [DATE] at 8:28 AM, Staff B, Registered Nurse (RN), stated, I would look at the code status in the electronic chart to see if the resident is a full code or Do not resuscitate. If the advance directive is not documented, I will then go to the paper chart and verify code status. Normally I assume she is a full code if the code status is empty. During an interview on [DATE] at 9:56 AM, the Regional Director of Nursing stated, Our education is to go to the chart. If Resident #18 was unresponsive, we would have done CPR [cardiopulmonary resuscitation]. During an interview on [DATE] at 9:57 AM, the Director of Nursing stated, I expect nurses to verify advance directives in resident chart. 3. Review of Resident #41's admission record revealed the resident was admitted to the facility on [DATE] with a history of chronic obstructive pulmonary disease, unspecified abnormalities of gait and mobility, essential hypertension, unspecified protein calorie malnutrition, anxiety disorder, other symbolic dysfunctions, cognitive communication deficit, chronic respiratory failure, low back pain, shortness of breath, heart failure, morbid obesity due to excess calories, major depressive disorder, recurrent, mild, unspecific mood disorder, other idiopathic peripheral autonomic neuropathy, hyperlipidemia, gastro esophageal reflux disease without esophagitis, overactive bladder, anemia, other reduced mobility, need for assistance with personal care, difficulty in walking, muscle weakness, drug induced subacute dyskinesia, COVID-19, paranoid schizophrenia, and acute respiratory failure with hypoxia. Review of the physician order dated [DATE] for Resident #41 reads, Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. Review of the physician order dated [DATE] for Resident #41 reads, Code: 0= No behaviors 1= Fear/Panic 2= Anger 3= Screaming/Yelling 4= Danger to self/others 5= Delusions 6= Hallucinations 7= Other (describe in nursing note) interventions- A= Music/aromatherapy B= Reminiscence, reality orientations C= Exercise, activities D= 1:1 E= Reduce Stimulation F=PRN [as needed] give Outcome- I =improve S=Same W=worse every day shift for Behavior monitoring. Review of Resident #41's Medication Administration Record for [DATE], [DATE], and February 2023 for Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. revealed staff initials and checkmarks for day, evening and night shifts. No Y or N was documented. Review of Resident #41's Medication Administration Record for [DATE], [DATE], and February 2023 Code: 0= No behaviors 1= Fear/Panic 2= Anger 3= Screaming/Yelling 4= Danger to self/others 5= Delusions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106009 If continuation sheet Page 4 of 8 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 106009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 6= Hallucinations 7= Other (describe in nursing note) interventions- A= Music/aromatherapy B= Reminiscence, reality orientations C= Exercise, activities D= 1:1 E= Reduce Stimulation F=PRN [as needed] give Outcome- I =improve S=Same W=worse every day shift for Behavior monitoring. revealed the code 0 for [DATE], [DATE], [DATE], and [DATE]. Review of Resident #41's progress note dated [DATE] reads, Resident, who is alert yells out frequently instead of using call light for assist. Educated resident on the use of call light for assistance. Voiced understanding by verbalizing teach back method. Review of Resident #41's progress note dated [DATE] reads, Resident observed frequently licking lips and running tongue over bottom chin area resulting in chaffing to area. Lop balm applied to upper and lower lips. Review of Resident #41's progress note dated [DATE] reads, Late Entry from [DATE] Resident having increased anxiety. Sitting in her room calling out help me help me and when staff goes to help her she says she does not remember what she needed, when she was in the dining room for lunch she continued to say help me help me and wanting to go back to her room before eating. Collected urine to rule out uti [urinary tract infection]. Review of Resident #41's progress note dated [DATE] reads, Resident was in her wheelchair going down the hall saying help me help me the can [certified nursing assistant] asked her what she needed and she stated my room, the cna showed her room, this resident goes back in forth to her room mutli [Sic.] times a day with no issues. Approximately 10 minutes later she is yelling I can't breath [Sic.] went to her room and she is lying in her bed with hob [head of bed] elevated and her oxygen in place. O2 [oxygen] sats [saturation] 96% on room air. PRN neb [nebulizer] given with good results. Will continue to observe. Review of Resident #41's progress note dated [DATE] reads, Resident sitting in TV room yelling help me help me this nurse went to check on her and asked her what is the matter and she stated she was scared of the other resident that was gonna hurt her. Removed the other resident who was not bothering her at all and asked her to come out of the TV and go back to her room, she said ok. Approximately 5 minutes later she is yelling the same thing again about the other resident. Was able to get her back to her room. During an interview on [DATE] at 9:36 AM, Staff E, Licensed Practical Nurse (LPN), stated, [Resident #41's name] is anxious at times. No harm. She will shout out help me help me. When documenting for behaviors, I will check off if I see she is okay. If she has a behavior later in the day, I will write it in the notes. 4. Review of Resident #48's admission record revealed the resident was admitted to the facility on [DATE] with a history of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance mood disturbance and anxiety, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris, anxiety disorder, depression, lack of physical exercise repeated falls, essential hypertension, history falling, unspecified urinary incontinence, other reduced mobility, long term (current) use of antithrombotic/antiplatelet, hyperlipidemia, cerebral infraction, allergic rhinitis, muscle weakness, difficulty in walking, need for assistance with personal care, dysphagia, other symbolic dysfunctional, and cognitive communication deficit. Review of the physician order dated [DATE] for Resident #48 reads, Behaviors- Monitor for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106009 If continuation sheet Page 5 of 8 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 106009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. Review of Resident #48's Medication Administration Record for [DATE], [DATE], [DATE] and [DATE], for Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. revealed staff initials and checkmarks for day, evening and night shifts. No Y or N was documented. Review of Resident #48's progress note dated [DATE] reads, The CNA came to this nurse for assistance with getting the resident up to toilet him and provide care. The resident refused, this nurse educated the resident on the importance of getting up and resident continued to refuse. Attempted to redirect the resident in attempts to get him up and resident still refused. After several attempts the resident still refused. Will attempt to get up the resident after lunch and try again. Review of Resident #48's progress note dated [DATE] reads, Resident refused to get a shower, cna reported to nurse and nurse attempted to get the resident up for a shower and continued to refuse. This nurse was notified and spoke with the resident and educated him on the importance of getting a shower and personal hygiene. He verbalized understanding and continue to refuse. Notified family via phone call but no answer. Review of Resident #48's progress note dated [DATE] reads, Resident refusing to let staff preform care for him, this nurse educated resident on importance of personal care and continued to refuse. This nurse reached out to his family as requested by family and daughter in-law stated someone would be there within the hour. During an interview on [DATE] at 9:42 AM, with Staff E, LPN, stated, [Resident #48's name] is pleasant. He will wander at times and go into other residents' room, but we monitor him. During an interview on [DATE] at 10:15 AM, the DON stated, My expectation is for staff to properly document the actual behaviors on the Medication Administration Record. Review of the facility policy and procedure titled Documentation in Medical Record reviewed on [DATE] reads, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106009 If continuation sheet Page 6 of 8 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 106009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practice standards during wound care to help prevent the possible development and transmission of communicable diseases and infections. Residents Affected - Few Findings include: On 2/8/2023 at 9:13 AM, during an observation of Staff C, Licensed Practical Nurse (LPN), Unit Manager, and Staff D, Certified Nursing Assistant (CNA), providing wound care for Resident #11, Staff C performed hand hygiene and donned gloves. Staff C removed the soiled dressing from the resident's right heel wound. Staff C did not remove the soiled gloves and did not perform hygiene. Staff C cleansed the wound and patted it dry and completed the wound care and exited the room. After performing hand hygiene, Staff C gathered supplies to provide wound care to the resident's left heel. Staff C performed hand hygiene, entered the room, placed the wound supplies on the bedside table without applying a barrier. Staff C donned gloves and then placed a barrier on the bedside table and began to open the supplies and placed them on the barrier. Staff C removed the soiled dressing. Staff C did not remove the soiled gloves or perform hand hygiene. Staff C cleansed the wound to the left heel. Staff C removed the gloves, did not perform hand hygiene, and exited the room to collect swabs. Upon completion of the wound care, Staff C collected the soiled supplies, removed the gloves, and exited the room without performing hand hygiene. During an interview on 2/8/2023 at 9:41 AM, Staff C, LPN, Unit Manager, stated that she did not remove her gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. During an interview on 2/9/2023 at 9:24 AM, the Director of Nursing (DON) stated, I expect my staff to remove gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. Review of the facility policy and procedure titled Clean Dressing Change reviewed on 1/4/2023 reads, Policy Explanation and Compliance Guidelines . 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hand and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze . 14. Wash hands and put on clean gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106009 If continuation sheet Page 7 of 8 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 106009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment in the food preparation, storage, and sanitation area of the kitchen. Residents Affected - Some Findings include: On 2/6/2023 at 9:20 AM, during a tour of the kitchen, the surveyor observed multiple areas of the ceiling with flaking and cracking appearance in the food prep area. The wall by the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier. The walk-in freezer had a large buildup of ice on the floor under the condenser unit, creating a slipping or tripping safety hazard. The kitchen had 4 of 6 light fixtures with cracked or broken light coverings. During an interview on 2/6/2023 at 9:30 AM, the Certified Dietary Manager (CDM), verified the ceiling had a flaking and cracking appearance over the food prepping area, the wall at the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier, and the freezer floor had a large buildup of ice on the floor under the condenser unit. The CDM confirmed that 4 light coverings were either cracked or broken. During an interview on 2/6/2023 at 1:15 PM, the Maintenance Director stated that the ceiling and wall needed to be repaired and light fixtures needed to be replaced. The Maintenance Director verified that there should not be a buildup of ice on the floor in the walk-in freezer. Review of the facility policy and procedure titled General Kitchen Sanitation dated October 1, 2018 reads, Procedure: 1. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities and equipment. Review of the facility policy and procedure titled Cleaning Schedules dated October 1, 2018 reads, Policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106009 If continuation sheet Page 8 of 8