Health inspection·March 13, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to provide Advance Beneficiary notice of non-coverage in a timely manner for 2 of 3 residents reviewed for beneficiary notification, Resident #36 and #172. Residents Affected - Some Findings include: Review of Resident #36's Notice of Medicare non-coverage showed Medicare coverage of current skilled nursing services would end on 3/01/2025. Review of Resident #36's Advance Beneficiary Notice of Non-coverage (ABN) was signed by Resident #36 on 3/07/2025. Review of Resident #172's Notice of Medicare non-coverage showed Medicare coverage of current skilled nursing services would end on 12/24/2024 Review of Resident #172's Advance Beneficiary Notice of Non-coverage (ABN) was signed by Resident #36 on 12/30/2024. During an interview on 03/12/2025 at 10:15 AM with the Quality Improvement Manager stated, [Resident #36's name] Advanced Beneficiary Notice of Non-Coverage (ABN) should have been given before 3/1/2025 which was her last cover day for Part A services. [Resident #36's name] ABN was given on 3/7/2025. [Resident #172's name] ABN was given on 12/30/2024 passed the last cover day of her Part A services of 12/24/2024. [Resident #172's name] ABN should have been given before that date. An ABN should be given two calendar days before the last day of coverage. Review of the policy and procedure titled Advanced Beneficiary Notice (ABN) and Notice of Non-Coverage (NOMNC) with a last review date of 12/16/2024 read, Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Page 1 of 9 106066 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of minimum data set assessments for 2 of 5 residents, Residents #9 and #46. Residents Affected - Few Findings include: 1) Review of Resident #9's physician order with a start date of 8/30/2024 read, Risperidone oral tablet 0.5 mg give 1 tablet by mouth one time a day for bipolar disorder. Review of Resident #9's Minimum Data Set (MDS) titled Quarterly dated 12/8/2024 read, Section N Medication: Antipsychotic: No. Review of Resident #9's Medication Administration Record (MAR) for the month of December 2024 documented the administration of Risperidone oral tablet daily. During an interview on 3/12/2025 at 12:48 PM with the MDS Coordinator stated, [Resident #9's name] Section N has a data entry error he was on antipsychotic medication. During an interview on 3/12/2025 at 12:58 AM with the Director of Nursing (DON) stated, We follow the Resident Assessment Instrument (RAI) manual. 2) Review of Resident #46's physician order dated 2/13/2025 read, Quetiapine Fumarate oral tablet 400 mg. Give 1 tablet by mouth one time a day for severe depression refractory with psych features. Review of Resident #46's MAR for February 2025 documented the resident was administered Quetiapine Fumarate starting on 2/13/2025, which is prior to the initiation of the Admission/5-Day Minimum Data Set (MDS) assessment. Review of Resident #46's admission MDS dated [DATE] did not document the resident was receiving antipsychotic medication under Section N0415, High Risk Drug Classes. During an interview on 3/12/2025 at 12:30 PM, the MDS Coordinator stated, It was obviously a data entry error. During an interview on 3/12/2025 at 12:30 PM, the MDS Coordinator related that there was no facility policy for Minimum Data Set completion. We use the RAI [Resident Assessment Instrument]. 3) Review of Resident #14's admission Minimum Data Set (MDS) dated [DATE] documented the resident had adequate hearing without hearing devices under Section B. Sensory. Review of Resident #14's care plan 12/22/2024 documented a focus for the resident being hard of hearing and requiring a right hearing aid. During an interview on 3/12/2025 at 12:30 PM, the MDS Coordinator stated, I guess he wasn't wearing it when I did his MDS. 106066 Page 2 of 9 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide dialysis services consistent with professional standards related to the assessment of the resident's condition and monitoring for 1 of 2 residents reviewed for dialysis, Resident #57. Residents Affected - Few Findings include: Review of Resident #57's physician order dated 2/11/2025 read, Pre/Post Dialysis Evaluation Assessment after resident returns from dialysis. Review of Resident #57's physician order dated 3/4/2025 read, Pre/Post Dialysis Evaluation Assessment after resident returns from dialysis every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for Dialysis. Review of Resident #57's assessments did not contain documentation of pre or post dialysis assessments on the following dates 2/19/2025 no pre-dialysis assessment, on 2/21/2025 no post dialysis assessment, on 2/26/2025 no post dialysis assessment, on 2/28/2025 no pre or post dialysis assessment, and on 3/7/2025 no post dialysis assessment. During an interview on 3/31/2025 at 2:40 PM with the Director of Nursing (DON) stated, We put in the order to tell staff what needs to be done. We want them to check on the resident when they get back from dialysis. Staff is expected to follow the order and do a pre and post dialysis assessment for [Resident #57's name]. Review of the facility policy and procedure tiled Dialysis Resident with a last review date of 12/16/2024 read, Policy: Care of the dialysis resident will be coordinated with the dialysis center. 106066 Page 3 of 9 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

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 the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principle for 1 of 1 resident receiving intravenous therapy, Resident #41 and 1 of 3 hallways reviewed for unattended medication. Findings include: 1) During an observation on 3/10/2025 at 9:46 AM, Resident #9 was sitting in his room. On top of his bedside table there was a clear medication cup containing a white circular pill. During an interview on 3/10/2025 at 9:46 AM with Resident #9 stated, I do not know why a nurse would leave a pill on the table. I do not have any idea at what hour it was given. This should be restricted; this is no way to give a medication. It has never happened before, but I was shocked to see it on my table. Review of Resident #9 physician orders did not show documentation of medication self-administration orders. During an observation on 3/10/2025 at 10:36 AM, Resident #42's room was empty. There was a medication cup with a white powdered substance on top of the drawer. During an observation on 3/10/2025 at 11:05 AM Resident #42 was sitting in his wheelchair in his room. There was a medication cup with a white powdered substance on top of the drawer. During an interview on 3/10/2025 at 11:05 AM Resident #42 stated, The nurses will apply the powder to the chaffing in my groin area. Review of Resident #42's physician orders did not show documentation of medication self-administration orders. During an interview on 3/13/2025 at 9:08 AM the Director of Nursing (DON), stated, We do an assessment and let the doctor know. We will do a self-administration assessment. Medication should not be left unattended in the room if they do not have a self-administration assessment. If they were able to self-administer the bedside dresser has a lock drawer and a key is provided. [Resident #9's name] or [Resident #42's name] do not have a self-administration assessment evaluations or self-administration orders. Review of the facility policy and procedure titled Medication Storage with a last review date of 12/16/2024 read, Policy: It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy, medication rooms, and/or on medication carts according to the manufacturer's recommendations, ensuring proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Procedures: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments under proper temperature controls. b. only authorized personnel or resident approved for self administration of drugs will have access to the keys to locked compartments. 106066 Page 4 of 9 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0761 Level of Harm - Minimal harm or potential for actual harm 2) During an observation on 3/10/2025 at 10:23 AM, Resident #41 had intravenous fluids (IV) running into a catheter on his upper right arm. The fluid bag was labeled by the manufacturer as 0.9% Sodium Chloride. The rate on the medication pump was 100 milliliters per hour (ml/hr). Resident #41's catheter dressing on his right upper arm was dated 3/9/2025. There was no label on the IV tubing and there was no label on the fluids indicating when the bag and tubing were hung. Residents Affected - Few During an observation on 3/11/2025 at 9:04 AM, Resident #41 had 0.9% Sodium Chloride running at a rate of 100 ml/hr. The bag of fluids did not have a date or time when it was hung by the nurse. The tubing was labeled 3/11/2025, 8:00 AM. During an interview on 3/13/2025 at 11:57 AM, Staff B, Licensed Practical Nurse (LPN) stated, When hanging IV tubing and fluids, they are to be labeled with date and time that they were hung. During an interview on 3/13/2025 at 12:30 PM, the Director of Nursing (DON), stated, Tubing and fluids should be labeled and dated with the date and time when they are administered. Review of Resident #41's physician order dated 1/24/2025 showed that Resident #41 is ordered to have Sodium Chloride Intravenous solution 0.9% with instructions reading, Use 1 liter of fluid intravenously one time a day every Monday, Tuesday for AKI (acute kidney injury) run at 100 ml/hr. Review of the facility's policy and procedure titled IV administration set (tubing) change last reviewed on 12/16/2024 showed it read, Explanation and Implementation Guidelines . Label the administration set and solution container with the date of initiation, as directed by your facility. 106066 Page 5 of 9 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to obtain laboratory services to meet the needs for 1 of 5 residents reviewed for medication administration, Resident #41. Residents Affected - Few Findings include: Review of Resident #41's physician order dated 6/20/2024 read, Check BMP [basic metabolic panel] every other week. Review of Resident #41's laboratory results for BMP showed a BMP was drawn on 2/4/2025 and 3/6/2025. Review of Resident #41's Treatment Administration Record (TAR) for February 2025 did not contain documentation of a BMP being drawn on 2/19/2025 as ordered by the physician. During an interview on 3/13/2025 at 9:37 AM, the DON (Director of Nursing) stated, I reviewed the resident's chart, and the BMP was not drawn according to the physician order. During an interview with on 3/12/2025 at 11:09 AM, the Medical Doctor #1 stated that her expectations would be that if she ordered a lab to be drawn every other week, the facility would draw the lab as ordered. Record review of the facility's policy titled, Laboratory Services last reviewed on 12/16/2024, stated: Policy: The facility must provide or obtain laboratory services to meet the needs of its residents and is responsible for the quality and timeliness of the services. 106066 Page 6 of 9 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food items were stored according to professional standard of practice, failed to serve foods at safe temperatures, and failed to ensure staff prepared food in accordance with professional standards to prevent the possible spread of food borne illness. (Photographic evidence obtained). Findings include: During an observation on 3/10/2025 at 9:15 AM with the Culinary Services Manager in the Main Dining Room, there were two packages of a food item that were not in the original packaging in the freezer with no identifying label. In refrigerator 1 there was a bag containing a white liquid with no identifying label or date. During an interview on 3/10/2025 at 9:19 AM, the Culinary Service Manager identified the food item in the bag stored in the refrigerator as yogurt and the two packages in the freezer as food molds of purred beef. The Culinary Service Manager stated, The food items should be labeled and/or dated in the refrigerator and freezer. During an observation on 3/11/2025 at 11:50 AM, there was one opened pack of unsalted butter and two packs of ready-to eat turkey sandwiches not in the original packaging that were not labeled with an open date. During an interview on 3/11/2025 at 11:58 AM, the Morning [NAME] stated the butter and turkey sandwiches needed to be labeled. During an observation on 3/11/2025 starting at 12:05 PM of the Culinary Service Manager, and the Morning Cook, the Morning [NAME] took the temperature of the prepared gravy. The Morning [NAME] did not sanitize the temperature probe with an alcohol wipe after tempting the gravy and put the thermometer probe into the prepared tuna salad and took the temperature of the tuna salad. During an observation of the lunch meal distribution service on 3/11/2025 at 12:10 PM with the Culinary Service Manager, the Morning [NAME] placed a piece of salmon on a plate and moved the salmon to the center of the plate with his gloved right hand. The Morning [NAME] did not remove his glove, did not perform hand hygiene and opened the microwave oven door with his gloved right hand to remove a heated food item. The Morning [NAME] did not remove his glove, did not perform hand hygiene, returned to the steam table. The Morning [NAME] placed noodles on a plate and pushed the noodles to the center of the plate with his gloved right hand. The Morning [NAME] did not remove the glove, did not perform hand hygiene and removed beef tips out of a container that was on the steamtable with a ladle and placed the beef tips directly on the steamtable, without a barrier, and started cutting them. During an interview on 3/11/2025 at approximately 12:10 PM the Culinary Service Manager was interviewed regarding the observations. The Culinary Service Manager instructed the Morning [NAME] to throw away the beef tips. The Morning [NAME] did not remove his glove, did not perform hand hygiene, picked up a plate, scraped the beef tips with his gloved right hand unto the plate, and disposed of the beef tips by throwing them away in the trash can. The Morning [NAME] did not remove his glove, did perform hand hygiene, and went back to the steam table to continue serving the food. 106066 Page 7 of 9 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 3/11/2025 at approximately 12:10 PM, the Culinary Service Manager, who was present at the time of observations, confirmed the findings and stated that touching food items with gloved hands is not our practice and the Morning [NAME] should have changed the gloves after using the microwave oven and after throwing away the beef tips. Review of the facility policy and procedure titled Date labeling for Food Safety reviewed in January 2025 read, Policy The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food . Policy Explanation and Compliance Guidelines for Staffing . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. Review of the facility policy and procedure titled Food Safety Requirements reviewed in January 2025 read, Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions . Food Distribution means the process involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service or delivering meals to residents' rooms or dining areas, etc . Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident . 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. A. Staff shall wash hands according to facility procedures. b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas . 8. Additional strategies to prevent foodborne illness include, but are not limited to: a. Preventing cross-contamination of foods. 106066 Page 8 of 9 106066 03/13/2025 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

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 follow infection control standards for following enhanced barrier precautions to prevent the possible spread of infection for 1 of 3 residents for enteral nutrition, Resident #57. Residents Affected - Few Findings include: During an observation 3/10/2024 at 10:24 AM, Staff B, License Practical Nurse (LPN), entered Resident #57's room without donning a gown. Resident #57's room door has an enhanced barrier sign posted outside of the room. Staff B performed hand hygiene and don gloves but did not don a gown. Staff B stopped Resident #57 feeding pump and disconnected Resident #57's J-tube/G-tube [jejunostomy/gastrojejunostomy tube] from feeding. Staff B proceeded to flush Resident #57's J-tube with water. Staff B without donning a gown emptied Resident #57's J/G - tube drainage bag. Resident #57 physician order dated 3/4/2025 it read, Enhanced Barrier Precautions during high-contact resident activities: (dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care or assisting with toileting, medical device care, wound care) every shift for indwelling medical devices. Resident #57 physician order dated 3/4/2025 read, G-tube port of G/J tube connected to continuous drainage system. Empty drainage bag QS [every shift] and prn [as needed] every shift for Duodenal Adenocarcinoma. During an interview on 3/12/2025 at 12:04 PM Staff B, LPN, stated, I should have had a gown on but there were none in the room. During an interview on 3/13/2025 at 9:12 AM the Director of Nursing (DON) stated, The staff should wear a gown and gloves when they are preforming high touch activities. They have to wear a gown and gloves. During an interview on 3/13/2024 at 9:19 AM Staff C, Infection Preventionist LPN, stated, Staff are supposed to wear a gown and gloves when coming into contact with a gastric tube or emptying a drainage bag. Review of facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 12/16/2024 read, Policy: It is the policy of this facility to implement enhanced barrier precaution for the prevention of transmission of multidrug -resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) . 106066 Page 9 of 9