Inspection·November 18, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Rights, Dignity and Visitation Rights with an issue date of 4/1/2022 reads, Policy: It will be the policy of this facility that employees shall treat residents with kindness, respect and dignity. The facility promotes the exercise of rights of each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. The facility will ensure that resident can exercise his or her right without interference, coercion, discrimination, or reprisal from the facility. A resident even though determined to be incompetent, should be able to assert these rights based on his or her ability of capability. Procedure: 4. The facility will promote care of our residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his or her individuality preferences activities pursuits goals and desires. Event ID: Facility ID: 106036 If continuation sheet Page 2 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to ensure fall precaution interventions as outlined in the care plan were implemented for 1 of 2 residents, Resident #52, sampled for accident prevention. Findings include: Review of Resident #52's progress note dated 10/08/2022 reads, Res [Resident] sitting on the floor. Found sitting in upright position parallel to the bed facing the hob [head of bed]. Review of Resident #52's progress note dated 10/20/2022 reads, Observed sitting on floor in room in front of closet area. Review of Resident #52's care plan, date initiated 10/14/2022, reads, Focus: At risk for falls and/or fall related injury related to generalized weakness, impaired balance and poor safety awareness. Interventions: Border mattress as ordered initiated 10/14/2022. On 11/17/2022 at 9:55 AM, Resident #52 was observed in her room lying in bed. A scoop or border mattress was not in place on Resident #52's bed. On 11/17/2022 at 10:20 AM, a second observation of Resident #52's room was completed with Staff C, Registered Nurse (RN). A scoop or border mattress was not in place on Resident #52's bed. During an interview on 11/17/2022 at 10:20 AM, Staff C, RN verified there was no scoop mattress in place on Resident #52's bed. Staff C stated Resident #52 had a scoop mattress, but the scoop mattress had torn and needed to be replaced. She reported it has been a few days since Resident #52 used a scoop mattress and the facility had to wait until we got a new one [scoop mattress]. Review of Resident #52's medical chart to include the medication administration records, dated 10/2022 and 11/2022, did not contain documentation of Resident #52 having a scoop or border mattress since the implementation of the care plan intervention on 10/14/2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 3 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 ensure care and services in accordance with professional standards of practice for peripherally inserted central catheters for 2 of 3 residents, Residents #308 and #312, sampled for central venous catheters. Residents Affected - Some Findings include: On 11/15/2022 at 10:20 AM Resident #308 was observed sitting up at the bedside. The resident has a right upper arm midline catheter with a transparent dressing. Under the transparent dressing is a 2 x 2 gauze that has a large amount of blood on it obstructing the view of the insertion site of the midline. The dressing is dated 11/13/2022. The edges on all four sides of the dressing are pulling up and exposing the midline catheter. On 11/16/2022 at 10:25 AM Resident #308 was observed sitting up at the bedside. The resident has a right upper arm midline catheter with a transparent dressing. Under the transparent dressing there is a 2 x 2 gauze with a large amount of blood on it obstructing the view of the insertion site. The four edges of the transparent dressing are pulling up and exposing the midline catheter. Review of the admission record documented Resident #308 was admitted to the facility on [DATE] and included the following diagnoses: Sepsis due to pseudomonas, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, pneumonia due to pseudomonas, personal history of COVID -19, essential (primary) hypertension, and generalized anxiety disorder. Review of the physician orders dated 11/10/2022 reads, Insert/maintain midline IV right upper extremity. Review of the physician orders dated 11/11/2022 reads, Change transparent dressing, measure external catheter length one time a day every seven days. Observe sight for signs and symptoms of infection, infiltration, and or extravasation. Review of the medication administration record (MAR) documented the transparent dressing was changed on 11/13/2022 at 8:00 PM. During an interview conducted on 11/15/2022 at 10:20 AM Resident #308 stated, The edges of my dressing have been like that for a day now. They put that under the transparent dressing because the site was bleeding there has been blood on that gauze ever since they changed it. During an interview on 11/17/2022 at 9:10 AM Staff D, Licensed Practical Nurse (LPN) stated, Midline dressings are changed every seven days and his dressing is dated 11/13/2022, so it's not due to be changed yet. I don't think there is anything wrong with having gauze under there. Well, the dressing is pulling up, so maybe it should be changed. During an interview on 11/17/2022 at 1:15 PM the Director of Nursing (DON) stated, There should not be any gauze under the transparent dressing, when there is we should change it every 48 hours. Anytime a dressing is compromised we should change them. On 11/15/2022 at 1:13 PM Resident #312 was observed resting in bed. The resident has a left arm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 4 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 double lumen PICC (peripherally inserted central catheter) line with a 2 x 2 gauze under a transparent dressing obstructing the view of the insertion site. The dressing is dated 11/12/2022. On 11/16/2022 at 9:01 AM Resident #312 was observed resting in bed. The resident has a left arm double lumen PICC with a 2x2 gauze under a transparent dressing obstructing the view of the insertion site. The four edges of the transparent dressing are pulling up. The dressing is dated 11/12/2022. Review of the admission record documented Resident #312 was admitted to the facility on [DATE] with the following diagnoses: Acute appendicitis with perforation, localized peritonitis and gangrene with abscess, unspecific protein calorie malnutrition, cutaneous abscess of abdominal wall, cholelithiasis with obstruction, essential (primary) hypertension, generalized anxiety disorder, and recurrent depressive disorder. Review of physician orders dated 11/12/2022 reads, Insert/maintain PICC line LUE (left upper extremity). Review of physician orders dated 11/12/2022 reads, Change transparent dressing, measure external catheter length one time a day every seven days. Observe sight for signs and symptoms of infection, infiltration, and or extravasation. During an interview on 11/16/2022 at 9:55 AM Staff A, LPN stated, I don't think there is anything wrong with the PICC line dressing. Oh yes, it does have gauze under it, I guess it should have been changed before now. On 11/17/22 at 1:00 PM the Director of Nursing observed the PICC line and acknowledged that the dressing was dated 11/12/2022 and had a 2 x 2 gauze under the transparent dressing. On 11/17/2022 at 1:00 PM the DON stated, There should not be any gauze under the transparent dressing, when there is we should change it every 48 hours. Review of the policy and procedure titled, PICC/Midline IV [intravenous] line with an issue date of 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). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 5 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the admission record for Resident #311 documented the resident was admitted to the facility on [DATE] with the following diagnoses: Metabolic encephalopathy, Methicillin Resistant Staphylococcus Aureus infection, left lower leg cellulitis and right lower leg cellulitis, type 2 diabetes mellitus, chronic peripheral venous insufficiency, anemia, hyperlipidemia, atherosclerotic heart disease, primary osteoarthritis, essential (primary) hypertension, and peripheral vascular disease. Residents Affected - Few Review of the Nursing admission assessment dated [DATE] documented left lower leg (front) venous stasis ulcers. Right lower leg front venous stasis ulcers. Coccyx open area to both buttock and coccyx. Small, picked scab to right arm. Review of the Wound Care consult dated 11/8/2022 documented recommendations read, Bilateral legs: cleanse with foam cleaner, apply sorbact [a wound dressing used for traumatic wounds, chronic wounds such as venous, arterial, diabetic foot and pressure ulcer wounds] to open wounds, cover with border foam dressing, apply double layer tubigrip, Pt [patient] elevate legs 3-4 times daily and Wound Care R [right] buttocks, cleanse with foam cleaner, apply sorbact to wound bed, cover with foam dressing. Review of the physician's orders dated 11/8/2022 reads, Bilateral legs: cleanse with foam cleaner, apply sorbact to open wounds cover with border foam dressing, apply double layer tubigrip, Pt elevate legs 3-4 times daily. Wound Care R buttocks- cleanse with foam cleaner, apply sorbact to wound bed, cover with foam dressing. Review of the Treatment Administration Record (TAR) documented the physician ordered treatments as Clean BLE [bilateral lower extremities] with foam cleanser, apply iodosorb gel [used to treat wet ulcers and wounds], barrier cream, cover with alginate, apply ABD [abdominal] pads, wrap with kerlix and secure with tape, cover with tubigrip every day shift every Tues [Tuesday] and Friday for venous ulcers. The TAR did not provide for documentation of the wound care having been provided on 11/8/2022 and 11/11/2022. It was documented this treatment was completed on 11/15/2022. Review of the TAR documented, Clean wounds to bilateral buttocks with foam cleanser, apply barrier cream to periwound, apply silver alginate and cover with foam dressing. Change every Tuesday and Friday. The TAR did not provide for documentation of the wound care having been provided on 11/8/2022 and 11/11/2022. It was documented this treatment was completed on 11/15/2022. Review of the TAR documented the order Bilateral legs, cleanse with foam cleaner, apply sorbact to open wounds cover with border foam dressing, apply double layer tubigrip, Pt (patient) elevate legs 3-4 times daily and Wound Care R (right) buttocks, cleanse with foam cleaner, apply sorbact to wound bed, cover with foam dressing was documented with an X for each day of the month which indicates this wound care as ordered by the physician was not completed. Review of the TAR documented the physician orders Bilateral legs: cleanse with foam cleaner, apply sorbact to open wounds cover with border foam dressing, apply double layer tubigrip, Pt elevate legs 3-4 times daily was documented with an X for each day of the month which indicates this wound care as ordered by the physician was not completed. Review of the weekly skin checks completed on 10/26/2022, 11/2/2022, and 11/9/2022 did not document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 6 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the assessment of the wounds' size, length, depth, and documentation of drainage or odors. There was no documentation of the weekly skin check having been completed on 11/16/2022. During an interview conducted on 11/17/2022 at 8:10 AM Resident #311 stated, They don't always do my dressings. Last week they forgot to do them twice. I did see the wound care doctor last week and will see him every two weeks. I don't know what exactly what he recommended but they [his office] sent it here for them to know. During an interview on 11/17/2022 at 10:20 AM the Assistant Director of Nursing (ADON) stated, We need to call the doctor and get his wound care orders clarified. No, he has not gotten the wound care treatment that was in the physician recommendation on 11/8/2022 and I really don't know why it wasn't done or clarified sooner than today. I am not the wound care nurse all the time. I am assigned to do it today. Normally, when a resident comes back from the doctor the nurse will get the orders and if there are any problems the charge nurse will assist. It does not look like this happened. There are no wound measurements except when the wound doctors saw him. There should be documentation weekly of what the wound measurements are, and we should have them in the chart. During an interview on 11/17/2022 at 10:40 AM the DON stated, We should have documentation of wound sizes in the chart. I did not know that we were not doing the right dressings according to the recommendations from the wound care doctor. We should have called and clarified the orders and did not. We should not have continued the other orders. We do not have wound measurements every week. Review of the policy and procedure titled, Wound Care issue date of 4/1/2022 reads, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the 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 a week or as needed by a licensed nurse. 6. Wound care procedures and treatments should be performed according to physician orders. 10. Document in the clinical record when treatments are performed. 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. Based on observation, interview, and record review, the facility failed to ensure pressure ulcers received necessary treatment and services consistent with professional standards of practice to include measurements for pressure ulcers for 2 of 2 residents, Residents #81 and #311, reviewed for pressure ulcers. Findings include: 1. Review of the medical record for Resident #81 documented the resident was admitted to the facility on [DATE] with diagnosis to include pneumonia, idiopathic neuropathy, protein calorie malnutrition, and folate deficiency. During an interview on 11/15/22 at 11:32 AM Resident #81 states, There is a wound on my back. I go out to the physician every other Monday for wound care. During an interview on 11/17/22 at 10:00 AM Resident #81 stated, Wound care, the nurses here change it two times a week. I go to the center every other week. I am not due till next Monday. Wound care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 7 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0686 does not happen three times a week in the facility. Level of Harm - Minimal harm or potential for actual harm Review of the Skin/Wound Note dated on 4/8/22 completed by Resident #81's attending Advance Practicing Registered Nurse (APRN) documents the system review and lacks wound measurement. Dated 7/25/22 the Skin/Wound Note completed by the attending APRN documents the system review and lacks wound measurements. Residents Affected - Few Review of the {Wound Care Center name] physician's Progress Note Details dated 9/19/22 reads, Wound #1 Mid back. Revised Home Health Wound Care Orders -Risk for injury and infection - Orders valid for 30 days - The Grove: Please irrigate wound with dakins solution or equivalent, pat dry. Skin prep to peri-wound. Please pack tunneling at 10 o'clock lightly with Prisma AG or equivalent. Cover with bordered foam dressing. Please change dressing Wednesday and Friday. Patient to return to WCC (wound care center) on Monday. Please discontinue use of donut neck pillow. Wound Treatment: Wound #1 - Back Wound laterally: Medline. Cleanser: Dakin 0.125% 16 (oz) [ounces] 3 X Per Week [three times per week]. Discharge Instructions: Use Dakin solution as directed. Cleanser: Wound Cleanser: 3 x Per Week. Discharge Instructions: Use wound cleanser as directed. Peri-Wound Care: Cavilon No Sting Barrier Film, 1 x 2 inches Wipe 3 x Per Week. Primary Dressing: Prisma 4.3 (in) [inches] 3 x Per Week. Secured with: 3M Tegaderm Foam Adhesive Bordered Dressing, Small Oval, 4 x 4.5 (in/in) 3 x Per Week. Review of the physician order for wound care dated 9/20/22 at 09:50 reads, Wound to mid back to be irrigated with dakin's solution or equivalent, pat dry. Skin Prep to peri- wound. Pack tunneling @ 10 o'clock lightly with Prisma ag [alginate] and cover with bordered foam dressing. Please change dressings Wednesday and Friday. PT [Patient] to return to WCC (Wound Care Center) on Monday. On Monday every evening shift every Mon [Monday], Wed [Wednesday] related to unspecified Protein Malnutrition wound care. Review of the [Wound Care Center name] Consultation report dated 10/7/22 reads, Continue with previous wound care order. Dated: 10/10/22 - Continue to pack wound with Prisma ag or equivalent. Follow up in two weeks. Dated: 11/7/22 - Continue with current wound care orders. Follow up in two weeks. Review of the [Wound Care Center name] physician's Progress Note Details dated 11/7/22 reads, History of Present Illness (HPI): The following HPI elements were documented for the patient's wound: Location: mid back. Duration: many weeks. Context: he is at a nursing facility and sleeps on his back and sits in chairs with pressure on his back. Modifying Factors: Patient wound(s)/ulcer(s) are worsening due to protuberant [bulging] bone at the ulcer site. Active Problem: pressure ulcer of other site, stage 3. Pressure ulcer of unspecified part of back, stage 3. Follow up appointments: Return Appointment in 2 weeks. Home Health: Wound #1 Midline Back: Revised Home Health Wound Care Orders -Risk for injury and infection - Orders valid for 30 days - The Grove: Please irrigate wound with dakins solution or equivalent, pat dry. Skin prep to peri-wound please pack undermining with Prisma ag or equivalent. Cover with bordered foam dressing. Please change dressing Wednesday and Friday. Pt to return to WCC on Monday. Please discontinue use of donut neck pillow. WOUND #1 - Back - Wound Laterality: Midline. Cleanser: Dakin 0.125% 16 (oz) 3 x Per Week. Discharge Instructions: Use Dakin Solution as directed. Cleanser: Wound Cleanser: 3 x Per Week. Discharge Instructions: Use wound cleanser as directed. Peri-Wound Care: Cavilon No Sting Barrier Film 1 x 2 (in/in) Wipe 3 x Per Week. Primary Dressing: Prisma 4.3 (in) 3 x Per Week. Secured with: 3M Tegaderm Foam Adhesive Bordered Dressing, Small Oval, 4 x 4.5 (in/in) 3 x Per Week. Review of TAR (Treatment Administration Record) for the months of September, October, and November 2022 documented per the nurses' initials wound care was completed on Monday and Wednesday only. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 8 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0686 Level of Harm - Minimal harm or potential for actual harm TAR was documented with the physician's order as: Wound to Mid back to be irrigated with Dakin's solution or equivalent, pat dry. Pack tunneling @ 10 o'clock lightly with Prisma ag and cover with bordered foam dressing. Please change dressings Wednesday and Friday. PT to return to WCC (Wound Care Center) on Monday. Every evening shift every Mon, Wed related to unspecified Protein Malnutrition wound care Start date 9/21/22. Residents Affected - Few During an interview conducted on 11/17/22 at 10:51 AM the Director of Nursing (DON) stated, I see the order, wound care should be done three times a week. During an interview conducted on 11/17/22 at 3:16 PM the DON stated, I have been looking and I don't see any wound measurements, even from the wound center. My expectation would be for my nurses to document the wound measurement. During an interview conducted on 11/18/22 at approximately 8:15 AM the Administrator stated, The nurse transposed the order upon entry into the computer. Record review of resident Minimum Data Set (MDS) dated [DATE] Brief Interview for Mental Status (BIMS) score 14. [13 to 15 points = intact cognition] Review of the Weekly Skin Assessments for the period of 4/4/22 to 11/14/22, for a total of 33 weekly notes, wound measurements had not been documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 9 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure residents maintained acceptable parameters of nutritional status for 2 of 4 residents, Residents #104 and #23, reviewed for nutrition. Residents Affected - Few Findings include: Review of the admission record documented Resident #104 was admitted to the facility on [DATE] and included the following diagnoses: multiple rib fractures left side, rhabdomyolysis, Non ST elevation myocardial infarction (a heart attack), repeated falls, protein calorie malnutrition, thoracic disc degeneration, pulmonary embolism (a blood clot in the lungs), pleural effusion (a buildup of fluid between the lungs and the chest), cognitive communication deficit, essential hypertension (high blood pressure), hyperlipidemia (high cholesterol), and unspecified dementia. Review of weights for resident #104 documented: 153.4 pounds on 10/12/2022, 154.2 pounds on 10/13/2022, 153.8 pounds on 10/14/2022, 152.2 pounds on 10/24/2022, 147 pounds on 11/2/2022 and 141 pounds on 11/7/2022. This reflects an 8.08% weight loss in one month. Review of the physician orders dated 10/12/2022 reads, CCHO [consistent carbohydrate] diet, regular texture, thin consistency. Review of the Nutritional progress note dated 11/8/2022 reads, Resident is having sig [significant] wt. [weight] loss x 30 days. NSG [nursing] reported resident being resistant to meals and spitting meals out. Speech has no concerns with swallowing and chewing on a CCHO diet. Visited resident last week for food preferences (see previous note). Intakes reported varied. Wounds have been reviewed and supplements in place. Recommend 1) appetite stimulant of MD [medical doctor] choice, 2) house shakes BID [two times a day] r/t [related to] varied intakes. Will continue to monitor and follow up. Review of the physician orders for the period of 11/8/2022 through 11/18/2022 did not document orders for house shakes or for an appetite stimulant. Review of the Nursing progress notes for the period of 11/8/2022 through 11/18/2022 did not document the physician was notified regarding the dietary recommendations or of the resident's significant weight loss. During an interview on 11/17/2022 at 1:45 PM Staff C, Registered Nurse (RN) stated, I would call any dietary recommendations to the doctor. I did not see this, and it was not called. She is not on an appetite stimulant, and she is not on any house shakes. I just didn't see this. During an interview on 11/17/2022 at 2:10 PM the Director of Nursing (DON) stated, She does not have these nutrition recommendations followed and we should have called the doctor after the dietician made the recommendations. I know that we were having trouble getting house shakes. There are other things that could be ordered I guess. Review of the care plan for Resident #104 reads, Resident is a risk for an alteration in nutrition and/or hydration r/t [related to]: receives therapeutic diet, hx [history] of falls, MI [myocardial infarction] procal [pro calorie] malnutrition, muscle weakness, cognitive deficit, HTN [hypertension], hyperlipidemia, cancer, anemia, proteinuria, dementia, alt labs, wounds, spits out foods: Provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 10 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tray set up, provide diet as ordered, offer alternative as needed, honor food preferences, encourage adequate intake at meals, keep fresh water at bedside, observe for sx/sx [signs/symptoms] of dehydration, update physician if noted, Registered dietician consult as needed, administer medications as ordered, observe for side effects and effectiveness, labs as ordered, report findings to physician, observe for sx/sx of chewing/swallowing difficulties and aspiration, notify physician if noted, SLP [Speech-Language Pathologist]or OT [Occupational] screen as needed, Weights as ordered and as needed, Notify physician of significant weight changes if noted. Review of the policy and procedure titled, Weights and Weight Loss, with an issue date of 4/1/2022 reads, Policy: It will be the practice of this facility to implement the following systems regarding weight documentation. Procedure: 5. Significant weight loss shall be addressed by the physician and/or RD (Registered Dietician) through discussion with the resident and/or resident representative for known preferences and desires and development and implementation of interventions to attempt to address the weight loss. 2. Review of Resident #23's lunch meal ticket on 11/15/22 at 12:57 was documented for the resident to receive a gravy sauce with the meal tray. The lunch tray is observed to not have gravy on the tray. During an observation on 11/16/22 at 9:39 AM Resident #23's breakfast meal tray is observed to not have gravy on the tray. During an interview on 11/15/22 at 12:57 PM Resident #23 stated, I never get gravy on my tray. I have to ask for gravy all the time to help me swallow. By the time staff comes back the food is cold. During an interview on 11/16/22 at 9:39 AM Resident #23 stated, I never get gravy on my tray. I have to ask the staff for gravy all the time to help me swallow. The Speech Therapist (ST) has been working with me and the kitchen. Several times the ST has gone to the kitchen to help get my order straight and still nothing. During an interview on 11/16/22 at 1:02 PM Resident #23 stated, I want to be clear I never have extra gravy on my tray. The staff has to go into the kitchen to get me gravy. During an interview on 11/16/22 at 12:47 PM the Regional Dietary Manager stated, The process for the line is for one person to set up the tray according to the meal ticket. A second person is to confirm items are on the tray according to the meal ticket at the end of the line. If the gravy was left off the tray; it is not supposed to be. The Regional Dietary Manager confirmed Resident #23's meal ticket reads add gravy to tray. During an interview on 11/16/22 at 1:10 PM the ST stated, [Resident #23's name] was taught compensatory measures for swallowing and techniques to help with swallowing. The gravy is to help as needed for foods that are not as moist. The ST confirmed the dietary order is to have an additional two ounces of gravy on the meal trays. Review of Resident #23's admission record dated 11/7/22 documented diagnosis to include dysphasia oropharyngeal phase (difficulty initiating a swallow). Review of dietary orders dated 11/9/22 read, No Salt Added regular texture thin consistency. Add Gravy to trays. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 11 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the policy and procedure manual titled, Dietary, Provide Diet to Meet the Needs of Each Resident with an issue date of 4/1/2022 reads, Policy: The purpose of the food and nutrition services (FNS)/dietary department is to provide high quality, nutritious, palatable and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerances, and personal, religious and cultural preferences, based on reasonable efforts. Therapeutic diets will be served as prescribed by attending physicians or their designee. 3. To promote optimal nutritional status of each resident through medical nutritional therapy (MNT), in accordance with written orders for nutritional care and consistent with each individual's physical, cultural, and religious needs and personal preferences. Event ID: Facility ID: 106036 If continuation sheet Page 12 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for oxygen administration for 2 of 3 residents, Residents #309 and #310, reviewed for respiratory care. Residents Affected - Few Findings include: 1. On 11/15/2022 at 2:07 PM Resident #309 was observed resting in bed with the head of bed elevated. Oxygen is being administered at 4 liters via nasal cannula, there was no humidification bottle. On 11/16/22 at 10:06 AM Resident #309 was observed resting in bed, with the head of the bed elevated. Oxygen is being administered at 4 liters via nasal cannula, there was no humidification bottle. On 11/17/22 at 8:48 AM Resident #309 was observed with oxygen being administered at 4 liters via nasal cannula with no humidification. Review of the admission Record documented Resident #309 was admitted to the facility on [DATE] and included the following diagnosis: fracture of left femur, fracture of right clavicle (collar bone), fracture of the 4th thoracic vertebra (spine), age related osteoporosis (a condition in which bones become weak), post hemorrhagic anemia (low blood count due to bleeding), essential tremor, paroxysmal atrial fibrillation (an irregular heart beat), breast cancer, and essential (primary) hypertension. Review of the physician order dated 11/14/2022 reads, Oxygen at 3 liters/minute-NC [nasal cannula] humidified every shift for SOB [shortness of breath]. During an interview on 11/17/2022 at 8:50 AM Resident #309 stated, I can't reach that oxygen machine and I can't really move all that well. The nurses give me the oxygen and help me adjust the tube in my nose, but I can't touch the machine. During an interview conducted on 11/17/2022 at 9:00 AM Staff B, Licensed Practical nurse (LPN) stated, Her oxygen is running at 4 liters and there is no humidification and there should be. We should check it daily and we should be following the doctor's order for the rate and if it should have humidification. During an interview conducted on 11/17/2022 at 9:35 AM the Director of Nursing (DON) stated, I expect that all staff follow doctors' orders for oxygen and providing humification at higher doses of oxygen. 2. On 11/15/22 at 10:13 AM Resident #310 was observed resting in bed with the head of the bed elevated. Oxygen was being administered at 3.5 liters via nasal cannula. On 11/17/22 at 8:51 AM Resident #310 was observed resting quietly in bed with the head of the bed elevated and oxygen was being administered at 3.5 liters nasal cannula with humidification. Review of the admission record documented Resident #310 was admitted to the facility on [DATE] with diagnosis to include: Displaced intertrochanteric fracture of left femur, chronic obstructive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 13 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm pulmonary disease, emphysema, chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (low levels of oxygen), dysphagia (difficulty swallowing), history of falling, essential (primary) hypertension, chronic kidney disease, unspecified dementia without behavioral disturbances, anemia in CKD (chronic kidney disease), and dependence on supplemental oxygen. Residents Affected - Few Review of the physician order dated 10/29/2022 reads, Oxygen at 2 l [liters]/min [minute] via n/c [nasal cannula] every shift for hypoxia. During an interview conducted on 11/17/2022 at 9:00 AM Staff B, LPN stated, Her oxygen is running at 3.5 liters and should be running at 2 liters. We should check it daily and we should be following the doctor's orders for the rate. Review of the policy and procedure titled, Oxygen Administration with an issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident. 5. Oxygen therapy may be humidified or non-humidified, depending on the needs of the resident, the plan of care or physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 14 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 proper infection control standards were maintained for hand hygiene during medication administration for 4 of 5 observations. Residents Affected - Some Findings include: During a medication observation conducted on 11/15/2022 at 9:50 AM, Staff B, Licensed Practical Nurse (LPN) poured medications without performing hand hygiene for Resident #51. Staff B entered the room of Resident #51 without performing hand hygiene, administered the medications, left without performing hand hygiene and went back to the medication cart and began pouring medications for another resident. During an observation of medication administration conducted on 11/15/2022 at 9:58 AM, Staff B, LPN prepared medications for Resident #12 without performing hand hygiene, entered Resident #12's room without performing hand hygiene, and administered oral medications. Staff B, LPN donned gloves without performing hand hygiene, administered an inhaler, doffed gloves, left the room, returned to the medication cart and began preparing medications for another resident without performing hand hygiene. During an observation of medication administration conducted on 11/15/2022 at 10:04 AM, Staff B, LPN prepared medications for Resident #13 without performing hand hygiene, entered Resident #13's room without performing hand hygiene, administered the oral medications, donned gloves without performing hand hygiene, administered an inhaler, doffed gloves, left the room and returned to the medication cart without performing hand hygiene and began preparing another resident's medications. During an interview on 11/15/2022 Staff B, LPN stated, I should have washed my hands after I took off my gloves. I can't remember if I used hand sanitizer, but I did not use it on my way into the room. During an observation of medication administration for Resident #312 on 11/16/2022 at 9:08 AM Staff A, LPN donned gloves without performing hand hygiene, connected intravenous (IV) tubing to the 50 milliliter bag of antibiotics, removed the cap on the end of the IV tubing, primed the tubing, removed all the air, and hung the tubing over the IV pole, the uncapped end of the tubing was observed hitting the IV pole and pump three times. Staff A, LPN doffed gloves and donned a new set of gloves without performing hand hygiene, cleaned the needleless connector for one second and administered 10 milliliters of normal saline and connected the IV tubing to the PICC (peripherally inserted central catheter) line. During an interview on 11/16/2022 at 9:55 AM Staff A, LPN stated, I should have washed my hands before and after I put on gloves. I should have cleaned the connector longer. I should have put the cap back on the IV line. During an interview on 11/16/2022 at 1:00 PM the Director of Nursing stated, Staff should all follow infection control standards when giving medications. Review of the policy and procedure titled, Hand Hygiene with an issue date of 4/1/2022 reads, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 2. All personnel shall follow the handwashing/hand hygiene procedures in preventing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 15 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 FORM CMS-2567 (02/99) Previous Versions Obsolete transmission of healthcare-associated infections. 5. Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications; e. Before and after handling an invasive device (e.g., urinary catheters access sites); f. Before donning sterile gloves; l. After contact with objects (medical equipment) in the immediate vicinity of the resident; m. After removing gloves. 7. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Event ID: Facility ID: 106036 If continuation sheet Page 16 of 17 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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 ensure the handrails in one residential hallway, Hall 300, of six residential hallways were maintained in good repair. Residents Affected - Few Findings include: An observation of the handrails in Hall 300 on 11/16/2022 at 1:00 PM revealed the handrails were cracked and broken with exposed metal and sharp edges. (Photographic evidence obtained) During an interview on 11/16/2022 at 1:02 PM, the Administrator reported the facility had been aware of the cracked and broken handrails with exposed metal and sharp edges. He reported the facility had been unable to find replacement handrails and confirmed no other action had been taken to repair or secure the handrails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 17 of 17