Inspection·February 7, 2020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few what the code status was. Staff E, LPN said I have never been in that situation. I would check the electronic record for code. I would look on the 3008 that they came to the facility with. On [DATE] at 3:54 p.m. an interview was conducted with Staff J, LPN. He said he would check the sheet for DNR or not. He could also check PCC (electronic medical record system) orders for DNR or not. If they are not a DNR I would call a code. I would go by the yellow slip. That is what the doctor has signed and the family or patient stating you don't want to be resuscitated. On [DATE] at 4:01 p.m. an interview was conducted with Staff C, LPN. Staff C, LPN said I would check in the physical chart for the DNR or status. It's in the chart near the front under advance directives. I am looking to see if they have a signed yellow DNR form or any advance directives in that section. We look in our orders and see what their code status is there in the electronic record and in the chart. It should already be clarified. The surveyor asked if there was a discrepancy how it would be handled. Staff C, LPN said I would have to call 911 and the family or doctor to clarify the code status. I would have someone help me. I wouldn't wait and try and make phone calls. On [DATE] at 4:06 p.m., Staff D, Registered Nurse (RN), said first you do an assessment. Check the chart for code status, check the computer for code status. If they are DNR you don't start resuscitations. You're going to check both places while someone stays with the patient. You call code blue first. Then you check the chart and the orders in the computer. I will check the doctors signature and the family signature. If there is a full code order and they change it, and they have signed the DNR, then we call the doctor and confirm that this was signed by them. Then you go to the chart and change the status. There is a sticker so everybody is aware they are a DNR. If they are not alert and oriented, then I would also ask the family. You would not resuscitate if the yellow legal document was signed, even if the order says full code. I would verify it with the unit manager, clarify it with the doctor. On [DATE] at 4:23 p.m. an interview was conducted with Staff E, LPN. Staff E, LPN confirmed the code status under Resident #61's name in the electronic medical record, was full code. The surveyor asked what she would do if the resident was found without a pulse or respirations. Staff E, LPN said oh, we are calling a code blue. When the surveyor showed Staff E, LPN the yellow Florida DNRO, Staff E, LPN said I like to check the paper chart. They say go to computer, but this (Florida DNRO) is going to over ride what's in the computer. This (order) was updated. The order was 12/14. The DNR is 12/19. That doesn't make me feel good. On [DATE] at 4:36 p.m. an interview was conducted with Staff F, RN/3 pm to 11 pm supervisor. She said yes, the code status is full code. Yes the order is full code. Our process here is we grab the chart and check it. She has a signed DNR. She is a DNR. We would follow this. Staff F, RN pointed to the yellow DNRO. On [DATE] at 10:15 a.m. an interview was conducted with the C wing unit manager, RN. The surveyor asked what the process was to identify the residents' code status. The C wing unit manager said, first its in PCC, and we ask for the chart. Identify the code status by paper, and if it's DNR we don't do CPR. If it's not we start CPR. We call it out and the front desk announces it over head. Someone remains (with the resident). Someone runs the call and gets the chart. The ADON (Assistant Director of Nursing) who was present during the interview said the policy is to confirm the status, either with the chart or PCC. It's in PCC in miscellaneous. The C wing unit manager said the yellow form is in miscellaneous. Staff confirm it with the chart. They look at the date. The latest date. We have to reconfirm the DNR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 2 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #25's admission record revealed an original admission date in 2016 and a current admission date in early 2018. Further review of the medical record revealed a Medical Certification for Medicaid Long-Term Care Services/Patient Transfer Form (3008 Form) dated [DATE] which showed DNR under Advance Care Planning. A review of the yellow Florida DNR order in the medical record at the nurse's station, revealed Resident #25 and her representative signed the DNR form on [DATE]. The physician also signed the order on [DATE]. Review of the [DATE], [DATE], [DATE], and [DATE] social services progress notes all showed Resident #25 was a DNR. A review of the care plan dated [DATE] revealed Resident #25 had advanced directives and documentation in her medical record to include: LW (living will), POA (power of attorney), and DNR. The goal indicated Resident #25's wishes will be honored and maintained through next review date. Interventions included honor the resident's choice for code status. Upon review of the physician's orders in the electronic medical record, the code status under the profile was blank. There weren't any orders reflecting Resident #25's DNR wishes. *photographic evidence was obtained. On [DATE] at 3:14 p.m. an interview was conducted with the social worker. She said, We tell nursing staff. We put the original in the chart. We alert the nursing staff, and then they change it on PCC [the electronic medical record]. We also send emails if needed, if we can't see the staff. She indicated the emails were sent to the unit manager and supervisor, and they change the code status in the resident's electronic medical record. On [DATE] at 3:17 p.m., an interview was conducted with Staff F, RN, and 3 pm to 11 pm supervisor. She stated that on admission they check the 3008 form. If it's blank and the resident is alert and oriented, nursing staff ask the resident if they want to be full code or DNR. The order goes in the computer if they are full code. If they didn't come with the DNR and an established order, then staff have them sign the DNR with their name. Nursing staff would get an order from the physician for a 24 hour DNR. The physician has to sign it within 24 hours. The order would then get changed in the computer. Even if it's a 24 hour order it will be in the electronic medical record. It is also status under advanced directives in the chart. It is also under their name on the code status bar in the electronic medical record. A follow up interview was conducted with Staff F at 4:40 p.m. Staff F confirmed that Resident #25 did not have a code status in the current physician's order. She said if there is an order it would be under the code status. It pulls it up there automatically. She would have an order for full code if she was full code. Staff F, RN said she would pull the resident's chart. That would be where she would find the order. Upon review of the medical record kept at the nurse's station, Staff F, RN confirmed Resident #25 was a DNR. Staff F also said she would expect there to be a DNR order in the electronic record. On [DATE] at 5:33 p.m. an interview was conducted with the DON (Director of Nursing). She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 3 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few face sheet and the 3008 had the advance directive. The care plan also had the advance directive. She confirmed there wasn't an order for DNR in Resident #25's physician's orders. She said when Resident #25 came back from the hospital in [DATE] the order was dropped. When a resident comes with an advance directive they have to contact the doctor and obtain the order, especially a DNR. Other advance directives don't need an order. Only the DNR gets the order. Social services will explain the advance directive. If the resident doesn't choose to have an advance directive, fine. If they want an advance directive then social services explains it and helps them initiate one. Social services has the form. Then once the resident or POA signs it, we send the form to the doctor. Sometimes we call so the doctor gets informed. Then the doctor signs it. We put the order in the chart. Resident #25 went to the hospital and the DNR was dropped when she came back. The DON said yes there is a process where the nurse reviews the advance directive on readmission. They have to look at their bracelet, the order, and the yellow paper. If there is a question, they would not initiate CPR (cardiopulmonary resuscitation) if it says DNR. There was an action plan doing DNR codes and drills. There was an issue, and it used to be weekly. But we reduced it according to the QAPI (quality assurance performance improvement). A staff member will get the code cart. Another staff member will look at the chart. The nurses are to look at the yellow form. There is also a miscellaneous tab they can look at. They look not only at the order, but the actual paper itself. They're going to call the doctor right away and the family member to confirm it. That's why we have the drill. If there is a doubt we have to call the family and the doctor. It will delay the process, but we will do it as fast as we can. At least we will do something. We corrected the record right away. The 3 pm to 11 pm supervisor called the doctor and family right away. On [DATE] at 5:54 p.m., the NHA (Nursing Home Administrator) said the nurses would have followed the order that was in the chart. There were no issues identified. They do drills, just like they do elopement drills. The yellow form was signed and was always in the chart. A review of the policy revised on 12/2016 titled Advance Directives reflected the following information: Policy Overview On admission, the admissions department or designee will notify and provide information to each resident or resident representative, regarding his/her right to make an advance directive. Advance directives are a written method through which a resident or resident's legal representative may provide directions or wishes as to their medical care. Advance directives are used when a resident is unable to make or communicate his/her decisions about medical treatment. It is prepared before any condition or circumstance occurs which causes the resident to be unable to actively participate in decisions about his/her medical care. If a written advance directive does not exist and the resident or resident representative is unable to make a healthcare decision, the community will take such action as is consistent with applicable laws and the policies of the state in which the community is located. Policy Detail 1. On admission, the resident and/or legal representative should be provided with a copy of the residents' rights under state law to except or refuse treatment and to formulate an advance directive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 4 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0578 Level of Harm - Minimal harm or potential for actual harm 2. Each resident or resident representative should be asked at time of admission if he/she has executed an advance directive. If the resident or resident representative answers yes, a copy of the advanced directive should be obtained and placed in the resident's medical record. The resident's physician should be informed of the advanced directive so that appropriate orders can be obtained in the resident's medical plan of care. Obtain state specific out of hospital DNR as indicated. Residents Affected - Few 3. Residents who are competent at the time of admission and who have not previously executed an advance directive should be asked if they would like one prepared. The social service department is responsible for assisting residents and/or their families in preparing advance directives. Social services should obtain a copy of the advance directive and place it in the resident's medical record. Social services should verify that there is an appropriate physician's order in the resident's medical record that complies with the resident's request . 6. The resident or the resident representative's decision not to resuscitate must be documented. The DNR decision must be accompanied by appropriate physician orders, physician progress notes and a signed, state approved informed consent form. Telephone consent can be obtained if verified by two witnesses. The medical rationale for a DNR decision should be consistent with excepted medical standards (e.g., CPR would not constitute beneficial medical treatment in view of the resident's physical condition). When the signed consent form is from a person other than the resident, include evidence in the medical records showing the decision is consistent with the resident's expressed desires while he/she was still competent. Alternatively, if the resident expressed no such desires and the decision is made in the best interests of the resident. A review of the policy Do Not Resuscitate (DNR), last revised 9/2017, demonstrated the following: Policy Overview Residents have the right to make choices about their care. They are encouraged to document their wishes and provide the appropriate directives to their family/legal representative, and physician/healthcare provider. Facility will honor do not resuscitate DNR orders, physician orders for life-sustaining treatment POLST, medical orders for life-sustaining treatment (MOLST), physician orders for scope of treatment (POST), and/or any state specific form in process (together DNR order/POLST). When there is a DNR order/POLST in effect, the community will not use cardio pulmonary resuscitation (CPR) to maintain life functions on a resident. Policy Detail Upon admission to the community or soon thereafter, the community admission coordinator or designee will obtain a copy of resident advance directives, when applicable. The community representative will verify and confirm the resident's/legal representative's desire for resident code status, obtain appropriate documentation, and identify resident's desire according to the community's procedure. B. DNR orders must be signed by the resident's healthcare provider on the physicians order summary maintained in the resident's medical record. All counter signatures for verbal physician phone orders shall be obtained in accordance with applicable state regulations. C. Advance directive information and a DNR order/POLST form if appropriate must be completed and signed by the licensed healthcare provider and resident or resident's legal representative, as permitted by state law and placed in the residence medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 5 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few D. Social services or designee shall discuss and provide information regarding advance directives to the resident/legal representative shortly after admission, significant change of conditions and periodically for routine updating of care plans. F. A DNR order/POLST will remain in effect until the resident or legal representative provides the community with a verbal and/or written request to end the DNR order. I. The interdisciplinary care planning team will review advance directives with a resident or legal representative minimally, at the quarterly care planning conference to determine if the resident wishes to make changes. K. The community will provide an annual in-service on community specific identification process and documentation of resident code status to the associates. On [DATE] at 11:08 a.m. in an interview with the DON she said they do not have a policy that speaks to the process of determining the resident's code status during a code. Photographic evidence was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 6 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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** 3. On 2/7/2020 at 2:35 p.m., observation of Resident #1's right lower extremity surgical wound dressing was conducted. The dressing was clean, dry, and intact. The dressing was dated 2/3/2020 to indicate when the dressing had been changed. The resident's direct care Licensed Practical Nurse (LPN) and the Assistant Director of Nurses (ADON)/wound care nurse verified that the dressing was dated 2/3/2020. During an interview with the resident, she said the nurses changed the dressing, All the time. She could not remember how often the dressing was changed. Residents Affected - Some A review of Resident #1's physician's order showed: Clean wound on Right Lower Extremity (RLE) with normal saline. Apply skin prep to peri wound, apply Adaptic to wound bed, cover with dry dressing every 3 days and as needed. A review of the Treatment Administration Record (TAR) for February 2020 revealed a nurse's initials to indicate that the dressing was last changed on 2/6/2019. On 02/07/20 at 2:45 p.m., the ADON/wound nurse verified that according to the discrepancies in the date on the physical dressing (02/03/20) and the date documented on the TAR (02/06/20), the dressing had not been changed as ordered. Based on observation, interview, and record review, the facility did not ensure that three residents (#102, and #165), of 31 sampled residents, received care and treatment in accordance with recognized practice standards. Resident #102, who was recovering from hip surgery and at higher risk for blood clots, was not given his anticoagulant for 7 days because the medication was unavailable. Resident #165, who was recovering from an infection in his shoulder, did not have the surgical dressing on his shoulder changed for 21 days after his admission, due to the facility's failure to obtain orders for dressing changes. Resident #1 did not have her wound dressing changed every 3 days as ordered. Findings Included: 1. Review of the admission Record for Resident #102 revealed that he was admitted to the facility on [DATE], with diagnoses that included: displaced fracture of the left femur, encounter for orthopedic aftercare, unilateral primary osteoarthritis of the right knee. Review of a physician progress note written on 1/3/20, Resident #102 was admitted to the facility following surgical repair of his left hip fracture, which he sustained during a motor vehicle accident. Review of his Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status Score of 15, which indicated he had no cognitive impairment. Under the tab for medical diagnoses, hypertension and hyperlipidemia were checked. The MDS also indicated Resident #102 received an anticoagulant medication. A review of Resident 102's physician's orders included: Enoxaparin Sodium Solution 30 milligrams (mg)/0.3 ml (milliliters) Inject 30 mg subcutaneously one time a day to prevent blood clotting for 21 days. Hold for platelets < (less than) 100,000 (ordered: 12/31/19; start date 1/1/20; end date 1/20/20). Enoxaparin Sodium Solution 30 milligrams (mg)/0.3 ml (milliliters) Inject 30 mg subcutaneously in the morning to prevent blood clotting. Hold if platelets (PLT) <100,000 or Hemoglobin (HGB) <7 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 7 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 notify Medical Doctor (MD). Continue while Non-Weight Bearing (NWB) (ordered: 1/20/20; start date 1/21/20). Level of Harm - Minimal harm or potential for actual harm Compression stockings to left leg every shift. (order date 1/3/20; start date 1/4/20) Residents Affected - Some Non weight bearing lower left extremity every shift, for fracture of left femur (start date: 12/31/19) A review of the Medication Administration Record (MAR) for Resident #102 revealed that the resident did not receive his Enoxaparin as ordered on the following dates: 1/2/20, and 1/12/20 through 1/17/20, for a total of seven missed doses. No initials or reason for the lack of administration was present on the MAR for 1/2/20 and a code 09 was entered on the MAR for 1/12/20 to 1/17/20, which meant to See Nurse's Notes. Review of the corresponding Nursing progress notes revealed the following: 1/12/20: Enoxaparin: reordered. 1/13/20: Enoxaparin: spoke with pharmacy and per pharmacy, medication is suspended. Order needs clarification from MD. 1/14/20: Enoxaparin: not available. 1/15/20: Enoxaparin: pending approval from MD. 1/16/20: Enoxaparin: medication reordered. Not available in med dispenser. Will arrive today. 1/17/20: Enoxaparin: pharmacy to deliver. An observation of Resident #102 was conducted on 1/21/20 at 10:45 a.m. He was lying in bed, dressed, with his left leg in an immobilizer brace. He appeared calm and alert. Resident #102 stated, I was in a car accident and fractured my left hip. I had to have surgery, and then I was sent here for rehab. I was pretty upset because my doctor told me that it was important to watch out for blood clots after my surgery. I have arthritis in my right leg, and my left leg has this immobilizer and I am not supposed to put weight on my leg. So, my doctor told me he put me on an anticoagulant to keep me from getting a blood clot. They gave me the injection in my stomach, you know, and then I didn't get it for almost a full week. When I asked the nurse why I wasn't getting it, the nurse told me that the facility didn't have it in stock. That is just unacceptable. A physician's progress note written on 1/20/20 revealed: Continue Lovenox (Brand name for Enoxaparin), while patient is non weight bearing on his lower left extremity. Check platelets weekly while on Lovenox, and if platelets are less than 100,000, stop Lovenox and call me. Lab results on 1/3/20, 1/4/20, 1/9/20 and 1/21/20 revealed all platelet values were well within the normal range. An interview was conducted with the Unit Manager, Staff G, on 1/24/20 at 11:10 a.m. Staff G reviewed the Medication Administration Record (MAR) for Resident #102. Staff G confirmed that the Enoxaparin was not administered to Resident #102 from 1/12/20-1/17/20. Staff G said There's an 09 in the box for each of those days, and that means that something was written in the nursing notes to explain why the medication was not given. Let me look at each date, and the note that goes with it. After reviewing the notes with the surveyor, Staff G said Well, the medication wasn't given for those dates, and the nurse kept documenting that the Enoxaparin wasn't available, or that the order had to be clarified. The nurse should have communicated this information to me or the DON (Director of Nursing), instead of just not giving him the medication for all those days. 2. Review of the admission Record revealed that Resident #165 was admitted on [DATE] with medical diagnoses that included: infection and inflammation reaction due to internal joint prosthesis, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 8 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 presence of right artificial shoulder joint. His physician's orders included: Level of Harm - Minimal harm or potential for actual harm Ceftriaxone 1 gm at bedtime for shoulder infection (start date: 1/4/20, end date: 2/1/20) Dry dressing to surgical site right shoulder (front) as needed for soiling, dislodgement (start date: 1/21/20) Residents Affected - Some Call ortho to clarify frequency of right shoulder dressing changes (order date: 1/21/20). An observation of Resident #165 was conducted on 1/23/20 at 11:40 a.m. He was lying in bed, dressed in a t-shirt and sweatpants, with an abductor pillow under his right arm. Resident #165 stated, I can't believe it. I was in the hospital for an infection in my shoulder joint. I came here to have antibiotics and rehab and get better. But these people didn't even touch my dressing or look under it. I am so worried about getting a worse infection because nobody even thought to look at it until you surveyors came. I mean, I've been sweating, and I'm not taking showers like usual. So, you think they would have changed the dressing by now. Just this week , after you all are here, they are getting the orders from the doctor. I haven't seen my Orthopedic doctor for follow-up yet, and I don't know when it will be scheduled. Review of Resident #165's Medication Administration Record (MAR) for January 2020 revealed the order to call the ortho to clarify frequency of right shoulder dressing changes was present with a start date of 1/22/20; however, the order was not clarified until 1/24/20. Review of Resident 165's care plan (initiated 1/3/20) revealed a focus of actual impairment to skin integrity of surgical incision to right shoulder. The goal initiated on 1/3/20 and revised on 1/6/20 was to have no worsening of skin alteration through review date. A second goad initiated 1/17/20 was for no complications related to right shoulder surgical incision . Interventions to assist in reaching these goals included: Assistance with turning and repositioning as needed (initiated 1/5/20); Evaluate skin condition on a daily and weekly basis (initiated 1/3/20); Keep skin clean and dry, use lotion on dry skin. Do not apply to area of skin breakdown, wound or between toes (initiated 1/5/20); Maintain right arm abduction pillow and sling (initiated 1/5/20); and Ortho follow up as ordered (initiated 1/17/20). Review of the resident's attending physician's History and Physical for a date of service of 1/9/20, revealed Chief Complaint/Nature of Presenting Problem: admitted after hospitalization for right shoulder hardware infection. History of present illness: .Patient was sent to Freedom Square Skilled Nursing Facility on 1/3/20, after being hospitalized at [name of local hospital] on 12/18/19, because of right shoulder pain. Patient was diagnosed with infected right shoulder prosthesis. Patient had a revised right shoulder arthroplasty, an antibiotic spacer was placed, and the patient will be on IV Ceftriaxone [antibiotic] for 6 weeks . Plan: .Ceftriaxone 1 gram IV at bedtime until 2/1/20. Weekly Complete Blood Count (CBC) with differential and Basic Metabolic Panel (BMP). A progress note by the resident's nurse practitioner on 1/7/20 and 1/13/20 revealed the plan included Follow-up with Ortho . However, a review of the physician's orders revealed this was not carried over to the orders. A review of the Weekly Wound Data Collection Flow Sheets for 1/8/20 and 1/15/20 revealed that Resident #165 had a right shoulder surgical wound present on admission [DATE]). Many of the fields on these forms were left blank to include the size of the wound, a description of the wound base, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 9 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 drainage/odor, undermining/tunneling, and wound pain. Both notes documented Summary: resident admitted with surgical site to R [right] shoulder, orders do not remove dressing and abductor pillow until seen by ortho. These notes were signed by the Assistant Director of Clinical Services, Staff H). No physician order could be located to not remove the dressing. Additionally, the wound flow sheets did not detail which physician prescribed that order, nor did it state when it was ordered. Residents Affected - Some The Weekly Wound Date Flow Sheet on 1/22/20 was the first time an actual description of the wound was documented: Summary: Resident admitted with surgical site to right shoulder, 16 sutures present; incision is well approximated, no redness, swelling or signs/symptoms present. Orders for dry dressing PRN in progress, will continue to monitor. (signed by Staff H). An interview was conducted with the Unit Manager, Staff G, on 1/24/20 at 11 a.m. The Unit Manager reviewed the Medication Administration Record (MAR) for Resident #165 and confirmed that the resident's dressing had not been changed since admission (a period of 21 days). Staff G confirmed that there were no orders in place for a dressing change until 1/21/20, 18 days post admission, and the order to clarify the dressing change written on 1/21/20 had not been acted upon. As of 1/24/20 at 11 a.m., no clarification had been received. Staff G also verified that no follow-up was scheduled with the Orthopedic physician. Staff G stated, I would have expected one of the nurses to call the doctor and get orders for a dressing change soon after admission, especially since he already had an infected wound. I would have expected the nurses to find out/schedule when he would see his orthopedic surgeon for follow-up. An interview was conducted with the Director of Nursing (DON) on 1/24/20 at 1:00 p.m. The DON confirmed that Staff H did not enter an actual Physician's Order not to remove Resident 165's dressing. A review of the facility policy titled Physician Order Chart Audit, revised in July 2015, revealed: Policy Overview: The resident's physician order section of the medical record and electronic orders will be reviewed every twenty four hours for accuracy on a designated shift. Policy Detail: 2) In reviewing each order, the charge nurse will verify the following: a) Order has been written correctly. b) All medications are transcribed accurately to the Medication Administration Records (MAR). c) Documentation is completed in the medical record related to the new orders. 4) Notify health care provider as indicated for any discrepancies found in the orders. A review of the facility policy titled Procedure: Wound Care, revised in October 2010, revealed: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Procedure Guidelines: A) Verify that there is a Health Care Provider's order for this procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 10 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure that Schedule IV medications were stored in a permanently affixed compartment of the refrigerator in two (A-wing and C-wing) of two medication storage rooms, and the facility failed to ensure that medications were stored at the proper temperatures in one (C-wing) of two medication storage rooms. Findings Included: Observation on 1/23/20 at 10:20 a.m. with the Manager of Clinical Services/Staff N of the medication storage room on the A-Wing revealed a locked refrigerator with an attached freezer. The refrigerator was unlocked for inspection. Observation revealed an 8 ounce measuring cup, which contained a Ziploc bag with a dropper and a vial of Ativan (Lorazepam) 2 milligrams (mg)/milliliter (ml). The medication was labeled and belonged to a current resident. Staff N stated that it was a vial of Ativan, belonging to one of the residents, and that it was from his pharmacy. When asked if it was acceptable to store Ativan in this manner, Staff N said I believe it's okay. I mean, it's in a locked room, in a locked fridge. On 1/23/20 at 10:45 a.m., Staff N unlocked the medication room on the C-Wing. The refrigerator had the temperature log displayed on the front of the fridge. The log was titled Acceptable Temperature Ranges and revealed Fridge; 35-46 degrees Fahrenheit (F). (aim for 40). Take Immediate Corrective Action if the temperature is greater than or equal to 47 degrees F, or if it is less than/equal to 34 degrees F. The temperature reading at 6 a.m. was logged as 44 degrees F. After unlocking the refrigerator, the door was opened and revealed a thermometer on the left wall inside the fridge. The temperature on the thermometer read between 79-80 degrees F. Staff N confirmed the thermometer reading at almost 80 degrees. The refrigerator contained antibiotics, inhalants, and vials of insulin. There was also a plastic EDK kit (Emergency Drug Kit) on the middle shelf. The surveyor was able to lift out the EDK from the refrigerator. It had a green tie on it, indicating that the contents had not yet been removed. The label on the outside read E kit: Ativan Injection. 1 ml vial. Strength: 2 mg/ml. Quantity: 3. Staff N verified that the EDK kit had 3 vials of Ativan in it. The kit was returned to the refrigerator and locked. The surveyor asked Staff N if the Ativan should be stored in this manner. Staff N said Again, it's in a locked room, in a locked fridge, so I think it is stored correctly. At about 11:40 a.m., Staff N informed the surveyor that there was a second thermometer in the C-Wing refrigerator, which was the accurate thermometer in the fridge. It had fallen under some of the antibiotic bags and was not seen by the surveyor the first time. Approximately one half-hour later, at 12:10 p.m., Staff G, the Nursing Manager on the C-Wing unit, unlocked the C-wing medication room, unlocked the refrigerator, and a second observation of the temperature was conducted. Staff G pulled the accurate thermometer from the refrigerator and showed it to the surveyor. Staff G said, Yes, this was under the antibiotic bags, but it's the one we use for the temperature. The thermometer read 58 degrees Fahrenheit, and Staff G confirmed the reading. She returned the thermometer to the fridge, and the surveyor observed that all medications had been removed. Staff G said, Yes I know. It's still high. We pulled everything out. Those medications will not be used. An interview was conducted with the Director of Nursing (DON) on 1/24/20 at 7 a.m. The DON stated that she was not aware of any regulation requiring the storage of Schedule II to V Controlled Substances in a permanently affixed compartment. The DON stated I thought the controlled medications just (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 11 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 had to be stored under 2 locks. The medication room is locked, and there is a lock on the refrigerator. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes, and Needles revised on 1/1/13, revealed: Applicability: This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. Procedure: 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Facility staff should monitor the temperature of vaccines twice a day. 11.2. Refrigeration: 36-46 degrees Fahrenheit or 2-8 degrees Celsius. 12. Controlled Substances Storage: 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area .in all cases in accordance with Applicable Law. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 12 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 observations, interviews, policy review and CDC guidelines, the facility did not ensure contact precautions were maintained during resident contact for one (#90) of two residents on contact precautions. Residents Affected - Few Findings included: Resident #90 was admitted to the facility with a diagnosis of Methicillin resistant Staphylococcus Aureus (MRSA) infection according to the face sheet in the admission record. On 1/21/20 at 9:21 a.m., Staff A, a Certified Nursing Assistant (CNA), was observed in Resident #90's room with gloves on. She was not wearing a gown. There was an isolation kit outside the door in the hallway. Staff A, CNA exited the room wearing the gloves, opened a drawer in the kit and removed a gown. Staff A, CNA put the gown on after removing the gloves. Then Staff A, CNA put on a new pair of gloves, and returned to Resident #90's room. There was also signage observed on top of the isolation kit indicating see nurse before entering. On 1/23/20 at 1:25 p.m., Staff B, an Occupational Therapist (OT) was observed in Resident #90's room, standing at the bedside wearing a pair of gloves. She was not wearing a gown. There was an isolation kit outside the door and signage indicating see nurse before entering. On 1/23/20 at 1:30 p.m., the Director of Nursing, stated the policy was staff must wear a gown and gloves if they are in the room. A review of the physician's orders in the medical record dated 1/1/20 showed an order for Vanco trough needed 30 minutes before 6 am dose. Please schedule lab collection at 5:30 am on 1/4/20. Fax results to MD and pharmacy ASAP one time only for MRSA until 1/4/20 06:00. Further review of the medical record for Resident #90 showed a physician's order dated 1/15/20 for Daptomycin Solution reconstituted use 400 mg intravenously (IV) one time a day for MRSA in prosthetic joint for 6 weeks. A review of the care plan dated 12/25/19 revealed Resident #90 has infection (MRSA in right hip incision). Interventions included contact isolation. Contact precautions: utilize appropriate personal protective equipment (PPE) as required to complete task. On 1/24/20 at 10:24 a.m., the C wing Unit Manager stated staff must wear a gown and gloves for every encounter. The policy, Isolation Precautions, revised 7/2015, revealed standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission based precautions shall be used when caring for residents requiring infection control measures above and beyond standard precautions, as deemed necessary by the infection control nurse or designee. The community will make every effort to use the least restrictive approach to managing individuals with a potential or active communicable disease, based upon the resident's clinical condition. Transmission based precautions shall only be used when transmission cannot be reasonably prevented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 13 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 by less restrictive measures. Policy Detail: A new or current resident suspected of, or identified as, having a communicable infectious disease will receive appropriate infection control precautions, based upon the resident's clinical signs and symptoms of infection, and as deemed necessary by the director of clinical services or designee, and the resident's healthcare provider as prescribed. Residents Affected - Few A. Transmission-Based Precautions The centers for disease control (CDC) approach to reducing the risk of transmission of an infectious agent from documented (e.g., culture positive for an infectious agent) or suspected (e.g., culture result unknown or culture not taken) infection or colonization with a highly transmissible or epistemologically important infectious agent (e.g., MRSA, VRE, etc.). These precautions include three sub categories (1) contact precautions, (2) droplet precautions, and (3) airborne precautions. For some diseases (e.g., severe acute respiratory syndrome (SARS)), multiple routes of transmission have been identified and more than one category may be required (e.g.: contact plus airborne precautions). 1. Contact Precautions In addition to standard precautions, contact precautions, a CDC approach intended to prevent the transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's contaminated environment. Examples include MRSA wound drainage and Clostridium difficile-associated diarrhea. Items to consider for residents in contact precautions, in addition to standard precautions: provide dedicated non-critical resident care equipment (stethoscope, thermometer, blood pressure cuff, etc.) to a single resident room for residents on contact precautions related to Clostridium difficile-associated diarrhea. Otherwise, dedicating non-critical resident care equipment is not required as long as equipment is disinfected between each resident and counter. Gloves to be worn upon entering the resident room. Wear a gown for all the interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. The following information was found at www.cdc.gov/hai/containment/PPE-Nursing-homes.html: Implementation of Personal Protective Equipment in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs) Implementation of Contact Precautions, as described in the CDC Guideline for Isolation Precautions (https://www.cdc.gov/infectioncontrol/guidelines/isolation/), is perceived to create challenges for nursing homes trying to balance the use of personal protective equipment (PPE) and room restriction to prevent MDRO transmission with residents' quality of life. Thus, current practice in many nursing homes is to implement Contact Precautions only when residents are infected with an MDRO and on treatment. Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months), and result in the silent spread of MDROs. With the need for an effective response to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 14 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 detection of serious antibiotic resistance threats, there is growing evidence that current implementation of Contact Precautions in nursing homes is not adequate for prevention of MDRO transmission. This document is intended to provide guidance for PPE use and room restriction in nursing homes for preventing transmission of novel or targeted MDROs, including as part of a public health containment response (https://www.cdc.gov/hai/containment/index.html). This guidance introduces a new approach called Enhanced Barrier Precautions, which falls between Standard and Contact Precautions, and requires gown and glove use for certain residents during specific high-contact resident care activities, that have been found to increase risk for MDRO transmission. This document is not intended for use in acute care or long-term acute care hospitals and does not replace existing guidance regarding use of Contact Precautions for other pathogens (e.g., Clostridioides difficile, norovirus) in nursing homes. Contact Precautions is one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions requires the use of gown and gloves on every entry into a resident's room. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and is placed into a private room. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be cohorted, or grouped together. Residents on Contact Precautions should be restricted to their rooms except for medically necessary care and restricted from participation in group activities. Because Contact Precautions require room restriction, they are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation. Description of New Precautions: Enhanced Barrier Precautions expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing 2,3. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: o Dressing o Bathing/showering o Transferring o Providing hygiene o Changing linens o Changing briefs or assisting with toileting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 15 of 16 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 106042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Square Health Care Center 10801 Johnson Blvd Seminole, FL 33772 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 o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Level of Harm - Minimal harm or potential for actual harm o Wound care: any skin opening requiring a dressing Residents Affected - Few Gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Implementation: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: o Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). o For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. See Enhanced Barrier Precautions - Example Sign [PDF - 1 page] (https://www.cdc.gov/hai/pdfs/containment/enhanced-barrier-precautions-sign-P.pdf) o Make PPE, including gowns and gloves available immediately outside of the resident room o Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room) o Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room o Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education o Provide education to residents and visitors Note: Prevention of MDRO transmission in nursing homes requires more than just proper use of PPE and room restriction. Guidance on implementing other recommended infection prevention practices (e.g., hand hygiene, environmental cleaning, proper handling of wounds, indwelling medical devices, and resident care equipment) are available in CDC's free online course - The Nursing Home Infection Preventionist Training (https://www.train.org/cdctrain/training_plan/3814). Nursing homes are encouraged to have staff review relevant modules and to use the resources provided in the training (e.g., policy and procedure templates, checklists) to assess and improve practices in their facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106042 If continuation sheet Page 16 of 16