Inspection·March 28, 2024

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 care plan was implemented for placement of bilateral fall mats for 1 of 6 residents reviewed for implementation of care plans, Resident #74. Findings include: During an observation on 3/25/2024 at 10:35 AM, Resident #74 was lying in bed. There was one fall mat in place on the floor on the right side of the bed. There was no fall mat on the floor on the left side of the bed. During an observation on 3/26/2024 at 8:18 AM, Resident #74 was lying in bed. There was one fall mat on the floor on the right side of bed. There was no fall mat on the floor on the left side of the bed. During an observation on 3/26/2024 at 1:04 PM with Staff G, Registered Nurse (RN), Resident #74 was lying in bed. There was no fall mat on the floor on the left side of the bed. During an interview on 3/26/2024 at 1:06 PM, Staff G, RN, stated, [Resident #74's name] should have fall mats on both sides of the bed. He even has an order in the system. Not sure why he does not have one. During an interview on 3/27/2027 at 11:43AM with the Director of Nursing stated, If the resident has orders and is care planned for bilateral fall mats, the mats should be in place when the resident is in bed. Review of Resident #74's physician order dated 12/6/2021 read, Floor mats to be placed bedside each side of bed while bed is occupied every shift. Review of Resident #74's care plan initiated on 12/7/2021 read, Focus: [Resident #74's name] is at risk for falls and/or fall-related injury r/t; poor safety awareness, hx [history] of falls, behaviors, incontinence, non-ambulatory, requires assistance with transfers, medication use, limited mobility. Resident has behaviors and has been observed placing himself on the floor . Interventions: 12/06/2021: Floor mats in place when in bed. Review of the facility policy and procedure titled P&P Comprehensive Assessments and Care Plans last reviewed on 1/18/2024 read, Guidelines . 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights . 11. The service provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 2 of 11 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 03/28/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' environments were free of accidents hazards for 1 of 6 residents reviewed for accidents, Resident #55. Findings include: Review of Resident #55's admission record revealed the resident was admitted on [DATE] with the diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, peripheral vascular disease, chronic diastolic congestive heart failure, nonrheumatic aortic valve stenosis and paroxysmal atrial fibrillation. Review of Resident #55's physician order dated 10/3/2023 read, Eliquis Oral Tablet 5 MG [milligrams] orally two times a day for new onset A-fib [atrial fibrillation], aortic stenosis, coronary artery disease. Review of Resident #55's medication administration record for March 2024 revealed the resident received Eliquis 5 milligrams two times a day from 3/1/2024 through 3/24/2024. Review of Resident #55's care plan initiated on 10/30/2023 revealed the resident was at risk for abnormal bleeding related to use of anticoagulant use for the treatment of atrial fibrillation. During an observation on 3/25/2024 at 9:57 AM, Resident #55 was in his room lying in his bed. There was a tabletop double-sided vanity mirror on the resident's bedside table. A slice of glass was missing from the surface of the mirror facing the resident. The missing slice of glass resulted in triangular shaped sharp edges on the mirror surface. During an interview on 3/25/2024 at 9:57 AM, Resident #55 stated, I have not cut myself with it [the mirror] yet, but I am sure I would sometime. During an observation on 3/25/2024 at 10:01 AM with the Administrator, the broken mirror was in Resident #55's room on his bedside table. During an interview on 3/25/2024 at 10:01 AM, the Administrator confirmed the mirror needed to be replaced. During an interview on 3/27/2024 at 8:44 AM, the Director of Nursing stated a broken tabletop mirror should not have been in Resident #55's room. She acknowledged Resident #55 was receiving anticoagulant medication and bleeding would be a hazard associated with anticoagulant use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 3 of 11 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 03/28/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 out of 6 medication carts, and failed to ensure the medications were securely stored in 2 out of 6 halls. Findings include: During an observation of 100 Hall Medication Cart on 3/25/2024 at 9:35 AM with Staff C, License Practical Nurse (LPN), there were one unopened Humalog vial with sticker to refrigerate, one medication cup with a white creamy substance with no identifier, one opened bottle of Brimonidine Tart 0.2% ophthalmic drops with no opened or expiration date, and one opened bottle of Dorzolamide 2% ophthalmic drops with no opened or expiration date. During an interview on 3/25/2024 at 9:40 AM, Staff C, LPN, stated, The insulin will be used during lunch time today. Usually, if they are new residents, we will put the insulin in the medication cart to know that we have one. The white creamy substance is Diflucan to apply to the resident's knee. The eye drops should be labeled with opened and expiration dates. I float to all carts, not sure why these were not labeled. During an observation of 600 Hall Medication Cart on 3/25/2024 at 9:44 AM with Staff D, Registered Nurse (RN), there was one bottle of Timolol Maleate 0.5% ophthalmic drops with opened date of 2/21. During an interview on 3/25/2024 at 9:51 AM, Staff D, RN, stated, I am not sure about the expiration date of the eye drops. They are not listed on the eye drop list provided in the binder. Eye drops usually are good for 28 days. If medication is expired, it should be removed from the cart. I am unable to see on my list if it is expired. During an observation of 500 Hall Even Side Medication Cart on 3/25/2024 at 9:57 AM with Staff E, LPN, Unit Manager, there was one medication cup with 6 pills with no identifier, one medication cup with white liquid creamy substance with no identifier, and one opened bottle of Dorzolamide HCI and Timolol Maleate ophthalmic drops with no opened or expiration dates. During an interview on 3/25/2024 at 10:04 AM, Staff E, LPN, stated, I am not sure why the medication cup is in the cart. Maybe, the resident was not awake, or they refused, and nurse was going to re-approach. I have no idea what the white substance is. I do not know if eye drops have an expired date after opening or go by manufacture recommendations. Let's go talk to [Staff F, LPN's name]. She oversees this cart. During an interview on 3/25/2024 at 10:07 AM, Staff F, LPN, stated, The medication cup is for a resident who was not in his room when I went to give him his medication. He usually is running around the building, and he gets back to me. The white substance is lotion for the legs. I actually forgot to put the lotion on during the medication pass of the resident it belongs to. During an observation on 3/25/2024 at 10:21 AM, there was one tube of PeriGuard Skin Protectant with Vitamin A, D, E and aloe vera and zinc on Resident #60's drawer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 4 of 11 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 03/28/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 3/25/2024 at 10:26 AM, there was one Aspercreme with Lidocaine Pain Relief Liquid roller on top of Resident #15's drawer. During an interview on 3/27/2024 at 1:36 PM, the Director of Nursing stated, Unopened insulin should be in the fridge until ready to use. There should not be any medication in a cup, especially not labeled. Eye drops should be labeled with an opened and expiration dates when opened. Eye drops expire after 28 days. If the nurse is unsure, she should call pharmacy. The nurse should check if the resident is in the room first. If medication is pulled before checking and resident is found not to be in the room, I would take medication with me and find the resident, bring him back to his room, and administer the medications. Both [Residents #60's name] and [Resident #15' name] are not able to self-administer medications. 2. During an observation on 3/25/2024 at 11:30 AM, Resident #98 had a medicine cup on her bedside table with a small dime size round orange tablet in the cup (Photographic evidence obtained). During an interview on 3/25/2024 at 11:34 AM, Staff B, LPN, stated, That's a Tums [pointing at the orange tablet in the cup]. She [Resident #98] was in the middle of breakfast. She usually takes it right away. I should have stayed with her, but I didn't. I shouldn't have left it there. During an interview on 3/27/2024 at 4:28 PM, the Director of Nursing (DON) stated, I don't see an order for [Resident #98's name] self-administration of medication. Review of the facility policy and procedure titled, Medication/Biological Storage, last reviewed on 1/18/2024, read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure . 2. The nursing staff shall be responsible for maintaining mediation storage and preparation areas in a lean, safe and sanitary manner . 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems . 10. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications must be labeled separately from food and must be labeled accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 5 of 11 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 03/28/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was properly labeled and dated or discarded in 2 of 3 nourishment rooms (Hall 500/600 and Hall 400). Residents Affected - Few Findings include: On 3/25/2024 from 9:10 AM to 9:20 AM, a tour of the three nourishment rooms was conducted with the Certified Dietary Manager (CDM). During an observation on 3/25/2024 at 9:10 AM with the Certified Dietary Manager (CDM), the freezer in the 500/600 Hall nourishment room contained a food item in a brown paper bag with no date. During an interview on 3/25/2024 at 9:10 AM, the CDM stated, that [the food item and brown paper bags] shouldn't have been left in there. During an observation on 3/25/2024 at 9:15 AM, the freezer in the 400 Hall nourishment room contained five individual frozen pops [tube of frozen flavored water] with no label. The refrigerator of the nourishment room contained three individual tubes of yogurt with an expiration date of 2/24/2024 and one individual tube of yogurt with an expiration date of 3/24/2024. During an interview on 3/25/2024 at 9:17 AM, the CDM stated, These [five frozen pops] should have been labeled. They have no label. Three yogurts expired last month and one expired yesterday. These should have been thrown away. Review of the facility policy and procedure titled Refrigerated Storage last reviewed on 1/18/2024, showed the policy read, Policy: Foods and Nutrition Services (FNS) staff should maintain safe refrigerated storage areas. Refrigerated items should be properly stored, labeled, and maintained by dietary staff . Procedure . 4. Dietary staff will label, date, and monitor refrigerated food, including, but not limited to leftovers to ensure use by use-by dates, or frozen (where applicable) discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 6 of 11 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 03/28/2024 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 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 garbage and refuse was properly contained in dumpsters. Residents Affected - Few Findings include: During an observation on 3/25/2024 at 9:24 AM, two garbage and refuse dumpsters were observed with the Certified Dietary Manager (CDM). The right-side lid on the left dumpster was open. After the lid was closed, there were vertical gaps running from the top to the bottom of the right and left side lids of both dumpsters. During an interview on 3/25/2024 at 9:25 AM, the CDM stated, The dumpster lid should not have been left open. It should have been closed. There should not be gaps when the lids are closed. Animals can get in. Review of the facility policy and procedure titled, Disposal of Garbage and Refuse, last reviewed on 1/18/2024, showed the policy read, Policy: It will be the policy of this facility to properly dispose of garbage and refuse. Procedure . 5. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 7 of 11 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 03/28/2024 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 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. 3. Review of Resident #2's laboratory results for a urinalysis with reflex to urine culture read, blood 3+ [can be significant for proteinuria], and leukocyte esterase 3+ [may indicate a urinary tract infection]. The report showed normal range results for blood and leukocyte esterase as negative. During an interview on 3/27/2024 at 11:31 AM, the DON verified the lab urine culture results were received for Resident #2. She stated the results were reviewed by the charge nurses, and they have a protocol that they are to follow that includes contacting the physician and any order obtained are to be documented. During an interview on 3/27/2024 at 12:12 PM, Physician #1 stated, The patient has a chronic catheter and the patient was asymptomatic at the time of the notification. I did not recommend the patient to be treated with antibiotics due to the patient being asymptomatic. Review of Resident #2's medical record did not show any documentation of the communication with the physician of the lab results and there being no new orders. Review of the facility policy and procedure titled Charting and Documentation last reviewed on 1/18/2024 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Based on record review and interview, the facility failed to ensure resident records were complete for 2 of 6 residents reviewed, Residents #2 and #57. Findings include: 1. Review of Resident #57's physician order dated 3/2/2024 read, Order Summary: Cleanse wound to sacrum with NS [normal saline], pat dry, apply medihoney and calcium alginate to wound bed, skin prep wound edges and cover with clean dry dressing . Order Summary: Cleanse left heel with NS, pat dry, apply skin prep, apply ABD [abdominal] pad and wrap with Kerlix. Review of Resident #57's physician order dated 3/22/2024 reads, Cleanse right buttock with NS, pat dry, apply medihoney to wound bed then cover with calcium alginate, skin prep wound edges and cover with dry dressing. Review of Resident #57's Treatment Administration Record for March 2024 revealed no documentation for cleansing sacrum wound on 3/8/2024, 3/16/2024, 3/18/2024, and 3/25/2024, no documentation for cleansing left heel wound on 3/8/2024, 3/18/2024, and 3/25/2024, and no documentation for cleansing right buttock wound on 3/8/2024. During an interview on 3/26/2024 at 4:19 PM, Staff F, Registered Nurse, stated, I don't know there is a blank in the treatment record. I know I did the treatment every day. I don't know why those particular days didn't save, but they were done. He is a large man. I need help from the aides. They can attest to that too. During an interview on 3/26/2024 at 4:19 PM, the Director of Nursing (DON) stated, I spoke to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 8 of 11 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 03/28/2024 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 0842 nurse. She remembers doing them but did not document it [wound care treatments] in the system. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 3/27/2024 at 11:00 AM, Resident #57 was lying in bed, with a urinary catheter drainage bag hanging on the bottom right side of the bed. Residents Affected - Few During an interview on 3/27/2024 at 11:03 AM, Resident #57 stated, The catheter was placed here in the facility after I had some discomfort in my stomach. Review of Resident #57's progress note dated 12/13/2023 at 9:36 PM read, 14f 15cc (14 French 15 milliliters) foley catheter in place and flowing, family and provider aware. Review of Resident #57's progress note dated 1/2/2024 at 2:17 PM read, Resident currently has Foley catheter in place due to retaining urine. PA gave verbal okay to add Obstructive Uropathy as diagnosis. During an interview on 3/27/2024 at 11:46 AM, Physician #2 stated, The plan was to follow up with a urologist and do a trial and removal. My Physician Assistant states on 1/2/2024 a message was sent for an order for a urologist consultation. Review of Resident #57's medical record did not contain documentation of an order to follow up with a urologist. During an interview on 3/27/2024 at 1:32 PM, the Director of Nursing (DON) stated, I am not able to trace when the appointment was made because I do not have a call log. The nurse should have made a note in the system to document when she called and made an appointment for the resident and the follow up conversation with the Physician Assistant for the resident to follow up with a urologist after the placement of the catheter. Review of the facility policy and procedure titled Indwelling Catheters last reviewed on 1/18/2024 read, Policy: It will be policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 9 of 11 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 03/28/2024 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 staff followed transmission-based precautions for 1 3 residents on transmission-based precautions, Resident #458, failed to ensure staff performed hand hygiene during medication administration in 2 of 8 observations of medication administration, and failed to ensure staff wore gloves during insulin administration in 2 of 3 observations, to prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: 1. During an observation on 3/27/2024 at 9:18 AM, with Staff C, Licensed Practical Nurse (LPN), Resident #458's room door was closed, with a sign on the door reading, Contact Precautions in addition to standards precautions . Everyone must: Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting. Wear gown before entering and remove upon exiting. Wear gloves before entering and remove upon exiting. Upon entering the resident room, Staff H, Certified Nursing Assistant (CNA), was finishing providing resident care. Staff H was standing next to the left side of Resident #458' bed, wearing a surgical mask and gloves. Staff H had no gown. Staff H had a large clear bag with solid sheets and was placing damp towels inside the large bag. Staff H closed the bag, removed the gloves, and exited Resident #458's room (photographic evidence obtained). During an interview on 3/27/2024 at 9:33 AM, Staff C, LPN, stated, [Staff H, CNA's name] should have been wearing a gown when in [Resident #458's name] room since she is providing direct patient care. During an interview on 3/27/2024 at 9:35 AM, Staff H, CNA, stated, I gave [Resident #458's name] a bed bath and changed all his bed linen. I was told I just cannot touch his right foot. That is why I was not wearing a gown. When a contact precaution sign is on the door, you should wear gloves and a gown before entering the room. Review of Resident #458 physician order dated 3/25/2024 read, Contact Isolation-Pseudomonas/MRSA in wound every shift until 4/14/2024. During an interview on 3/27/2024 at 3:04 PM, the Director of Nursing (DON) stated, The wound was covered and there was no drainage. The staff did not have to wear a gown. I was trained that unless staff was going to provide wound care, they should not gown. In order for a staff member to know if the wound dressing is on or off or there is drainage, they would have to enter the room and go near the resident. Review of the facility policy and procedure titled Infection Prevention and Control Program with the last review date of 1/18/2024 read, Policy: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Procedure . The Infection Prevention and Control Program includes . 2. Written standards and guidelines for the program, which include . c. Standard and transmission-based precautions to be followed to prevent the spread of infections. A. Selection and Use of PPE [Personal Protective Equipment]. During an interview on 3/28/2024 at 7:30AM, the DON stated, I do not have another policy other than the overall infection control policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 10 of 11 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 03/28/2024 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 - Few 2. During an observation on 3/26/2024 at 8:30 AM, Staff A, LPN, did not perform hand hygiene, prepared medications, and administered them to Resident #81. Staff A administered Resident #81's insulin via injection in the resident's left upper arm. Staff A did not don gloves for administration of insulin and did not perform hygiene after the administration. During an interview on 3/26/2024 at 8:36 AM, Staff A, LPN, stated, I didn't do hand hygiene. I don't wear gloves for injections. We don't have to. During an observation on 3/26/2024 at 8:49 AM, Staff A, LPN, administered medications to Resident #318 without performing hand hygiene prior to preparing or after administering the medication. Staff A administered an insulin injection in Resident #318's left upper arm without donning gloves prior to medication administration. During an interview on 3/27/2024 at 10:17 AM, the Director of Nursing stated, I expect nursing staff to perform hand hygiene before and after each medication administration between residents. I don't know if the staff are supposed to wear gloves when administering injections; I would need to look at the policy. During an interview on 3/27/2024 at 1:43 PM, the Director of Nursing stated, Staff should wash or sanitize their hands in between each resident interaction. The staff should be wearing gloves at all times when administering any type of injection. Review of the facility policy and procedure titled, Medication Administration via Injection, last reviewed on 1/18/2024, read, Policy: It will be the policy of this facility to administer medications via injection in accordance with physician orders, professional standards of practice and infection control techniques. Procedure . 5. Perform hand hygiene and don gloves prior to administration of medication. 6. Properly prepare the injection site, generally via use of alcohol pad. 7. Administer injection of medication in accordance with physician orders . 9. Remove and discard gloves and perform hand hygiene. Review of the facility policy and procedure titled, Hand Hygiene, last reviewed on 1/18/2024, read, 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 to help prevent the spread of infections to other personnel, residents, and visitors . 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 . b. Before and after direct contact with residents; c. Before preparing or handling medications; i. After contact with a resident's intact skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106036 If continuation sheet Page 11 of 11