Health inspection·April 13, 2023

F 0578 until 4/11/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #174's admission record documented Resident #174 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications and pruritus. Residents Affected - Some Record review of Resident #174's Advance Directives Policy and Record on 4/12/2023 documented Resident #174 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #222's admission record documented Resident #222 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, [NAME] macroglobulinemia, and hypo-osmolality and hyponatremia. Record review of Resident #222's Advance Directives Policy and Record on 4/12/2023 documented Resident #222 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #224's admission record documented Resident #224 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of bone and articular cartilage, intrahepatic bile duct carcinoma, and essential hypertension. Record review of Resident #224's Advance Directives Policy and Record on 4/12/2023 documented Resident #224 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #325's record documented Resident #325 was admitted to the facility on [DATE] with diagnoses that included hypertensive crisis, dysphagia, heart failure, chronic kidney disease and atherosclerotic heart disease. Record review of Resident #325's Advance Directives Policy and Record on 4/12/2023 documented Resident #325 had not been provided information related to the right to formulate an advance directive until 4/11/2023. During an interview on 4/12/2023 at 11:02 AM, the Administrator confirmed the facility had not consistently provided residents with information related to the right to formulate advance directives upon admission. Record review of the facility policy titled Advance Directives, last reviewed 2/28/2023, read 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 2 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure care and services were provided for a PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 (Resident #222) of 7 residents reviewed. Photographic evidence obtained. Residents Affected - Few Findings include: During an observation on 4/10/2023 at 11:36 AM Resident #222 was sitting in a bed side chair, PICC observed on left upper arm. A transparent dressing was over top of gauze securing the PICC. The dressing was dated 3/30/2023. During an interview on 4/10/2023 at 11:36 AM Resident #222 stated that he came into the facility with the catheter and the dressing has not been changed since he was admitted . During an observation on 4/10/2023 at 1:18 PM Resident #222 a PICC was on left upper arm with a transparent dressing was over top of gauze securing the PICC. The dressing was dated 3/30/2023. During an interview on 4/10/2023 at 2:52 PM Staff B, Licensed Practical Nurse (LPN), confirmed that the dressing was dated 3/30/2023 and should have been changed within 7 days. Review of the admission record for Resident #222 documented the resident was admitted on [DATE] with diagnosis that included but not limited to osteomyelitis of ankle and foot. Review of physician orders for Resident #222, dated 4/3/2023, read: Change PICC dressing and end caps every day shift every 7 days for infectional [sic] control and as needed for soiled or not intact. During an interview on 4/11/2023 at 8:17 AM the Director of Nursing (DON) stated Dressing changes for PICC's are to be changed on admission if gauze is under the Tegaderm (clear dressing). If no gauze is under the Tegaderm and we can see the site and there is no issue, then the dressing on the PICC is changed in 7 days. Review of the policy titled Central Venous Catheter Dressing Changes, last reviewed 2/28/2023, read The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines. 4. After original insertion of CVAD ( Central Venous Catheter Dressing), the dressing will consist of gauze and TSM (Transparent semi-permeable membrane). This must be changed within 24 hours. 5. Change transparent semi-permeable membrane dressing at least every 5-7 days and PRN (as needed when wet, soiled, or not intact). 6. If gauze is used, it must be changed every 2 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 3 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided for 2 of 2 sampled residents out of 10 residents receiving respiratory services (Resident #22 and #223). Photographic evidence obtained. Residents Affected - Few Findings include: During an observation on 4/10/2023 at 10:19 AM, Resident #223 was sitting in a bedside recliner. The oxygen tubing was hanging on the regulator on the wall and the tubing was not dated. During an interview on 4/10/2023 at 10:19 AM, Resident #223 stated I only use oxygen when I have sinus issues and the oxygen will clear it up, the oxygen rate is 2 and I never change it. The tubing has not been changed since I've been here. During an observation on 4/10/2023 at 1:49 PM Resident #223's oxygen tubing was not dated. During an observation on 4/11/2023 at 8:37 AM Resident #223 was sitting in his bedside recliner with his nasal cannula lying over the bedside table. There was no water observed in the bottle for the humidifier. Review of the admission record for Resident #223 documented an admission date of 3/22/2023 with diagnosis that included but not limited to atherosclerosis heart disease, pleural effusion, hypoxia, and encounter for surgical aftercare following surgery on the circulatory system. Review of physician orders for Resident #233 dated 3/23/2023 read O2: Oxygen at 2 liters per nasal cannula as needed for shortness of breath, low oxygen saturation. Review of physician orders for Resident #233 dated 3/29/2023 read O2 (oxygen): Change oxygen tubing and date with securement bag . Every night shift every Wed (Wednesday). During an observation on 4/10/2023 at 9:47 AM Resident #22 was sitting in a recliner beside her bed. Resident #22's oxygen tubing was not dated and the plastic bag hanging on the regulator was dated 3/22. During an interview on 4/10/2023 at 9:47 AM Resident #22 stated I use oxygen at night. During an observation on 4/10/2023 at 1:34 PM Resident #22 was lying in bed. Resident #22's oxygen tubing was not dated. During an interview on 4/11/2023 at 8:27 AM the Director of Nursing confirmed that Resident #22's oxygen tubing was not dated prior to her having the night shift go in and date the tubing the previous night. All tubing is supposed to be dated and changed on Wednesday nights, it was not changed and dated as ordered. Review of the physician orders for Resident #22 dated 3/15/2023 read O2: Oxygen tubing (must be dated) every night shift every Wed [Wednesday] for infection control. Review of the facility policy title Oxygen Administration, last reviewed 2/28/2023, read Purpose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 4 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the Procedure. 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 5 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a drug regimen review recommendation from the pharmacist was acted upon for 1 resident (Resident #6) of 5 residents reviewed. Findings include: Review of the admission record for Resident #6 documented the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to heart failure, muscle weakness, and abnormalities of gait and mobility. Review of physician orders for Resident #6 dated 11/1/2022 read: Voltaren Gel 1 % (Diclofenac Sodium) Apply to Bilat shoulders topically every 8 hours as needed (PRN) for shoulder pain. Review of physician orders for Resident #6 dated 12/31/2022 read: Diclofenac Sodium Gel 1% Apply to Both shoulders topically every 12 hours as needed for shoulder pain. Review of pharmacist consultation report dated 12/08/2022 read Recommendation: Please update the direction for topical diclofenac 1% gel to 'Apply 2 grams to bilateral shoulders every 8 hours as needed.' Physician Response: Diclofenac 1% gel Apply 1 gm to both shoulders every 12 hours prn for pain. Physician dated document 12/29/2023. Review of pharmacist consultation report dated 1/20/2023 read Recommendation: Please update the directions for topical diclofenac 1% gel to Apply 2 grams to bilateral shoulders every 8 hours as needed. (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written. Physician dated document 2/8/2023. Review of pharmacist consultation report dated 3/13/2023 read Recommendation: Please update the directions for topical diclofenac 1% gel to 'Apply 2 grams to bilateral shoulders every 8 hours as needed.' (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written. Physician dated document 3/23/23. Review of Resident #6's clinical records failed to document the facility acted upon the pharmacist recommendations. During an interview on 4/12/2023 at 1:44 PM, the Director of Nursing stated that the physician had agreed with the pharmacists' recommendation but the recommendations had not been acted upon. Review of policy titled Interim Medication Regimen Review (MMR), last reviewed 2/28/2023, showed the policy read: The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician / Prescriber to either accept and act upon the recommendations contained within the MRR ( Medication Regimen Review) or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 6 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 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. 3). An observation on 04/10/2023 at 10:05 AM, Resident #326 was observed at bedside taking medications from a medication cup. Two pills remained in the med cup. During an interview on 4/10/23 at 10:05 AM Resident #326 stated, I'm not even sure what the meds are but one taste like iron or something. During an interview on 4/11/23 at 10:52 AM Staff A, Registered Nurse (RN) stated that the nurse on the medication cart should prepare the medications for a resident, take it to the resident, administer the medications and then chart that the medications were given. Medications should not be left at bedside. When asked why Resident #326 had medication at bedside, Staff A stated, Oh no, I guess I forgot to go back when I went to get him something to drink. During an interview on 4/11/23 at 11:15 AM the DON stated that the nurse on the medication cart should follow the protocol when passing medications. The DON confirmed that Staff A, RN was the nurse on the medication cart for Resident #326. Based on observation and interview the facility failed to ensure that all drugs and biologicals used in the facility were properly labeled and stored in accordance with professional standards in 2 of 4 medications carts and two resident's rooms, Resident # 222 and Resident #326. Photographic evidence obtained. Findings include: 1). During an observation on 4/10/2023 at 2:52 PM of the west wing medication cart #2 with Staff B, Licensed Practical Nurse (LPN), two opened insulin pens, Toujeo Solostar and Insulin Glargine, were not dated with date opened. During an interview on 4/10/2023 at 2:55 PM, Staff B, LPN, confirmed the insulin pens in the west wing medication cart #2 were not dated with an open date or expiration date when removed from the refrigerator. Staff B stated, When insulin pens are removed from the refrigerator, we are supposed to date them with the open date and the expiration date. During the observation on 4/10/2023 at 3:18 PM of the west wing medication cart #2 with the east wing Nurse Manager, one Novolog insulin pen was lying in the cart, opened with no resident's name on the pen and one Lispro insulin pen with no opened date labeled on the pen. During an interview on 4/10/2023 at 3:18 PM the east wing Nurse Manager confirmed the Novolog insulin was opened with no resident's name on the pen and one Lispro insulin pen with no opened date labeled on the pen. During an interview on 4/10/2023 at 3:22 PM, the East Wing Nurse Manager confirmed the insulin pens were not dated when opened and no expiration dates were entered on Insulin pens. She stated, When the insulin pens are removed from the refrigerator the open date and the expiration date must be written on the insulin pen. These insulin pens expire within 28 days, but some insulin pens vary on the expiration days after opening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 7 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 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 2). An observation on 4/10/2023 at 8:30 AM of Residents #222's room revealed a syringe of Normal Saline and a syringe of Heparin lying on a bookshelf unsecured. An observation on 4/11/2023 at 7:51 AM of Residents #222's room revealed a syringe of Heparin lying on bookshelf unsecured. Residents Affected - Few During an interview on 4/11/2023 at 8:05 AM, Staff C, LPN, confirmed the Heparin syringe was lying on the bookshelf in Resident #222's room. Staff C confirmed that Heparin syringe was at the bedside and stated, this is to be locked up on the med cart, it should not be in here. During an interview on 4/10/2023 at 3:58 PM, the Director of Nursing (DON) stated that her expectation was that no medications were to be left at the bedside and that all insulin pens when removed from the refrigerator were dated with the date and an expiration date when the insulin pen was removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 8 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen coolers and freezers, and failed to ensure equipment was cleaned and sanitized before use (Photographic evidence obtained). Findings include: During an observation at the time of initial walk-through tour of the kitchen on 4/10/2023 at 9:16 AM with the Certified Dietary Manager (CDM), there were a large container with what appeared to be approximately 20 pieces of fresh raw chicken with red bloody fluids surrounding the bottom of the container in the walk-in cooler, a container of food that had a product with Fresh Sliced Mushrooms label by the [NAME], with no received or expiration date, and a partial box of frozen raw beef patties located on the bottom shelf with the lid open and the product exposed in the reach-in freezer. During an interview on 4/10/2023 at 9:45 AM, the CDM verified that the fresh raw chicken was stored in a container with blood pooling on the bottom of the container and should have been on an ice bed, that the fresh sliced mushrooms did not have a received, opened, or a use by date, and that the raw frozen beef patties should have been stored in a closed container that did not expose the product to freezer burn. The CDM stated that the products should be labeled according to the policy, and all products should be closed or covered when stored. Review of the facility policy and procedure titled Food Storage revised on 3/9/2020 and last reviewed on 2/28/2023, reads, Procedure . Raw Meat . 4. Hamburger and fresh chicken should be cooked within one to two days of purchase. Fresh Chicken should be stored on ice to maintain an optimal temperature of 28 to 32 degrees F [Fahrenheit] . Food Storage Frozen Meat/Poultry and Foods . 3. Storage: Store items promptly to 0 degrees F or less or at a temperature maintains the food frozen. Foods should be stored in their original containers if designed for freezing. Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items. During an observation at the time of follow-up tour of the kitchen on 4/11/2023 at 7:28 AM with the CDM, the can opener had a buildup of food residue and rust. The sanitation test strips being used had an expiration date of December 15, 2022. During an interview on 4/11/2023 at 7:28 AM, the CDM confirmed the can opener had food residue and that the test strips currently being used were expired. Review of the facility policy and procedure titled Can Opener, revised on 8/31/2018 and last reviewed on 2/28/2023, reads, Sanitation of Equipment. Frequency: After each meal; more frequently if needed. 1. Remove shank to pot and pan sink, or to the dish machine area. 2. Scrub shank, paying attention to blade and moving parts. Use sanitizing solution and brush, or run through dish machine. 4. Air dry on clean surface. Review of the facility policy and procedure titled Recording of Dish Machine Temperatures revised on 1/31/2023 and last reviewed on 2/28/2023 reads, 6. The concentration of the sanitary solution during the rinse cycle is 50-100 ppm with Chlorine sanitizer. This is used on low temperature dish (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 9 of 10 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 106083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159 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 machines. Assure that test strips are within the Use-By-date and not outdated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106083 If continuation sheet Page 10 of 10