Inspection·September 6, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 residents who were diagnosed with possible serious mental disorder were referred for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 3 residents reviewed for PASARR, Resident #38. Residents Affected - Few Findings include: Review of Resident #38's admission record showed the resident was initially admitted on [DATE] with diagnoses that included other bipolar disorder (onset date 1/2/2024). Review of Resident #38's Level I PASARR dated 12/28/2023 showed no entries in Section I- PASRR Screen Decision-Making under mental illness or suspected mental illness. Review of Resident #38's clinical records failed to show documentation Resident #38 had been referred for a Level II PASARR evaluation following the diagnosis of other bipolar disorder on 1/2/2024. During an interview on 9/6/2024 at 8:09 AM, the Director of Nursing confirmed that Resident #38 had not been referred for a Level II PASARR after she was identified with a newly evident or possible serious mental disorder. Review of the facility policy and procedure titled Behavioral Health Services implemented on 3/5/2024 read, Policy: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning . Policy Explanation and Compliance Guidelines . 7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will: a. Complete PASARR screening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106115 If continuation sheet Page 2 of 8 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 106115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewater Park Health & Rehabilitation Center 9280 South West 81st CT Ocala, FL 34481 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 Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for PICC (Peripherally Inserted Central Catheter) access devices for 2 of 6 residents reviewed with a central venous access device (CVAD), Resident #212 and Resident #215, and for 1 of 3 residents reviewed for pain management, Resident #92. Residents Affected - Few Findings include: 1) During an observation on 9/3/2024 at 9:18 AM, Resident #212's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible (Photograph evidence obtained). During an observation on 9/3/2024 at 12:02 PM, Resident #215's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible During an observation on 9/4/2024 at 12:40 PM, Resident #215's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible During an observation on 9/4/2024 at 3:45 PM, Resident #212's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible. Review of Resident# 212's physician order with the start date of 8/26/2024 read, Change Catheter Site Dressing every week and PRN [as needed] with transparent dressing every day shift every 7 day(s) for IV [Intravenous] therapy. Review of Resident# 215's physician order with the start date of 8/23/2024 read, Change Catheter Site Dressing every week and PRN with transparent dressing every day shift every 7 day(s) for IV therapy. During an interview on 9/4/2024 at 3:45 PM, Staff A, Licensed Practical Nurse (LPN), stated, The PICC dressing kit comes with the gauze. I didn't know the dressing should be changed within 24 hours since gauze was used under the transparent dressing. During an interview on 9/4/2024 at 4:00 PM, the Infection Prevention Officer confirmed PICC line transparent dressing noted over gauze and dated 9/1/2024 and stated, The PICC line dressing should have been changed within 24 hours. Gauze cannot be left under the transparent dressing we use bio patches [antibiotic patch] so we can see the site and monitor for signs and symptoms of infection. During an interview on 9/4/2024 at 4:30 PM, the Director of Nursing stated, Our policy does not say that gauze cannot be placed on the IV site under the transparent dressing. I am not aware that the transparent dressing has to be changed again within 24 hours. Review of the facility policy and procedure titled PICC/Midline/CVAD Dressing Change dated 11/28/2023 read, Policy: It is the policy of this facility to change peripherally inserted central catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106115 If continuation sheet Page 3 of 8 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 106115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewater Park Health & Rehabilitation Center 9280 South West 81st CT Ocala, FL 34481 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes . Policy Explanation and Compliance Guidelines . 6. Inspect the catheter-skin junction and surrounding area, palpating through the intact dressing for redness, tenderness, swelling and drainage. Be attentive to any reports of pain, paresthesias, numbness, or tingling . 18. Apply a transparent semipermeable dressing to the insertion site. Review of Omnicare guidelines titled Central Vascular Access Device (CVAD) Dressing Change revised on January 15, 2004 read, Guidance . 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed . 2.2 Every two days . 3. Sterile gauze dressings must be occlusive and are changed . 3.2 Every two days. 2) Review of Resident #92's physician order dated 7/2/2024 read, Acetaminophen Tablet 325 MG [milligram] Give 2 tablets by mouth every 4 hours as needed for pain 1-3 do not exceeded 4 gm [grams] (4000 mg) in 24 hours and give 2 tablets by mouth every 4 hours as needed for elevated temp > 100.2 [temperature higher than 100.2]. Review of Resident #92's Medication Administration Record (MAR) for August 2024 showed the resident received Acetaminophen 325 mg on 8/1/2024 at 3:24 AM for pain level of 6, 8/2/2024 at 9:49 PM for pain level 4, 8/10/2024 at 2:39 AM for pain level of 4, 8/12/2024 at 1:23 AM for pain level of 6 and at 5:36 AM for pain level of 5, 8/13/2024 at 1:32 AM for pain level of 4 and at 4:50 PM for pain level of 4, 8/15/2024 at 5:36 AM for pain level of 7 and at 11:20 PM for pain level of 4, 8/17/2024 at 12:38 AM for pain level of 4 and at 1:35 PM for pain level of 4, 8/18/2024 at 5:25 AM for pain level of 6, 8/20/2024 at 11:47 PM for pain level of 4, 8/21/2024 at 6:11 AM for pain level of 5, 8/22/2024 at 1:00 AM for pain level of 6, 8/23/2024 at 5:43 AM for pain level of 5, 8/25/2024 at 1:31 AM for pain level of 6, 8/26/2024 at 11:50 PM for pain level of 4, 8/29/2024 at 12:51 AM for pain level of 6, and 8/30/2024 at 4:57 AM for pain level of 5. Review of Resident #92's MAR for September 2024 showed the resident received Acetaminophen 325 mg on 9/4/2024 at 1:36 AM for pain level of 4. During an interview on 9/5/2024 at 3:00 PM, the Director of Nursing stated, [Resident #92's name] medication was given out of parameters. Staff are expected to follow the parameters and if pain is higher, they should contact the physician for orders. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/11/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106115 If continuation sheet Page 4 of 8 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 106115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewater Park Health & Rehabilitation Center 9280 South West 81st CT Ocala, FL 34481 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. 6) During an observation on 9/3/2024 at 9:35 AM, there were three pills in a medication cup on the bedside table in Resident #75's room. During an interview on 9/3/2024 at 9:35 AM, Resident #75 stated, It is aspirin, my probiotic and iron pill. I cannot take it on an empty stomach, so I take it after breakfast. During an interview on 9/5/2024 at 8:43 AM, with the Director of Nursing stated, Medication should not be at resident's bedside. Residents need an order for self administration of medication and an assessment of their capability. Medication would need to be stored in the first drawer which has a lock to secure medication kept in the resident's room. Review of the facility policy and procedure titled Medication Storage with the last review date of 1/11/2024 read, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Policy Explanation and Compliance Guidelines. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . c. During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles (Photographic evidence obtained). Findings include: 1) During an observation on 9/3/2024 at 9:28 AM, Resident #264 was lying in bed. There was one bottle of lubricant eye drops on the resident's night stand. During an interview on 9/3/2024 at 9:28 AM, Resident #264 stated, I use these eye drops every day for my eyes because they will get dry. During an interview on 9/3/2024 at 10:40 AM, Staff B, Licensed Practical Nurse (LPN), stated, [Resident #264's name] does not have orders in the system for eye drops. I will take them from her and let the physician know in order for us to provide her with the eye drops she needs. The eye drops should not be in her room. 2) During an observation on 9/3/2024 at 9:33 AM, Resident #92 was eating breakfast. There was one large light yellow circular tablet near her plate. During an interview on 9/3/2024 at 9:33 AM, Resident #92 stated, The nurse brought the [antacid brand name] so that I can drink it after breakfast. I had almost forgotten I had it there. During an interview on 9/3/2024 at 10:42 AM, Staff B, LPN, stated, Yes, I gave [Resident #92's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106115 If continuation sheet Page 5 of 8 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 106115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewater Park Health & Rehabilitation Center 9280 South West 81st CT Ocala, FL 34481 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 name] two [antacid brand name] one before breakfast and left one, so she would take the [antacid brand name] after breakfast. [Resident #92's name] does not have orders to self-administer medications. 3) During an observation on 9/3/2024 at 9:55 AM, Resident #266 was sitting in his wheelchair in his room. On top of his drawer, there was a vial of Albuterol next to his nebulizer machine. Residents Affected - Few During an interview on 9/3/2024 at 9:55 AM, Resident #266 stated, I do breathing treatments since before coming here. The nurse will set up the machine and I will give myself the treatment. During an interview on 9/3/2024 at 10:33 AM, Staff B, LPN, stated, Yes, this is a vial of Albuterol. I came into the room and [Resident #266's name] was on the phone. I left the breathing treatment here in the room with the intention to come back and give it to him. 4) During an observation on 9/3/2024 at 9:05 AM, there was one Albuterol inhaler on bedside table in Resident #212's room. During an interview on 9/3/2024 at 9:05 AM, Resident #212 stated, I use the inhaler whenever I need it maybe once or twice a day. During and observation on 9/4/2024 at 12:55 PM, there was one Albuterol inhaler on bedside table in Resident #212's room. During an observation on 9/4/2024 at 4:10 PM with the Infection Control Officer, there was one Albuterol inhaler on bedside table in Resident #212's room. During an interview on 9/4/2024 at 4:10 PM, the Infection Control Officer confirmed Resident #212's albuterol Inhaler was unsecured at the bedside. 5) During an observation on 9/3/2024 at 10:00 AM, there was one nasal spray (Phenylephrine hydrochloride 1% nasal decongestant) lying on bedside table in Resident #213's room. During an interview on 9/3/2024 at 10:00 AM, Resident #213 stated, I've been addicted to nasal spray for years. I use the spray 2 to 4 times a day. During an observation on 9/4/2024 at 4:15 PM with the Infection Control Officer, there was one nasal spray (Phenylephrine hydrochloride 1% nasal decongestant) lying on bedside table in Resident #213's room. During an interview on 9/4/2024 at 4:15 PM, the Infection Control Officer stated, No medications should be at the bedside unless the resident has been assessed for self-administration and the doctor has ordered that the medication can be self-administered. Then, the resident's medication is secured in their bedside table. During an interview on 9/5/2024 at 4:30 PM, the Director of Nursing stated, Medications cannot be at the bedside unless the resident has been assessed for self-administration of medication. The doctor has to approve and write the order for self-administration of the medication. The medications are then locked in the resident's bedside table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106115 If continuation sheet Page 6 of 8 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 106115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewater Park Health & Rehabilitation Center 9280 South West 81st CT Ocala, FL 34481 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the walk-in and reach-in coolers in the areas of the main and satellite kitchens. Findings include: During an observation while conducting the initial walk-through tour of the kitchen on 9/3/2024 at 9:06 AM with the Kitchen Manager, there were bulk raw tomatoes with the tomatoes having a black and white areas, and one opened large partially covered container of boiled eggs in the walk-in cooler. There were one container of puree food without an identifying label or date, one container of ground beef patties with no identifying label or date, two open containers of whole milk without an open date, and one container of sour cream with a use by date of 9/1/24 in the reach-in cooler in the main kitchen. There were two flats of raw shell eggs stored directly over the whole milk individual containers without a protective barrier between the shelves in the satellite kitchen reach-in cooler. During an interview on 9/3/2024 at 9:20 AM, the Kitchen Manager stated that any bad tomatoes in the walk-in cooler should have been observed and removed and the boiled egg container should have been sealed properly when stored; the unidentified pureed product was pureed bread and that the pureed bread and ground beef patties were all in the reach-in cooler without an identifying label or date; and the opened whole milk containers should have had an opened date. The Kitchen Manager confirmed that raw shell eggs were located on a shelf directly over the individual milk cartons and stated the raw shell eggs should have been stored on the bottom shelves and not directly over ready to eat/drink products. Review of the facility policy and procedure titled Food Safety Requirements implemented on 4/9/2024 read, Definitions . Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness . Policy Explanation and Compliance Guidelines . 1 . b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms . 3 . c . iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded, and v. keeping foods covered or in tight containers. Review of the facility policy and procedure titled Leftovers last revised in February 2020 read, Procedure . 2. All foods stored for later shall be covered, labeled with the food name, and dated with the current date, as well as a use-by date, then stored appropriately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106115 If continuation sheet Page 7 of 8 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 106115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgewater Park Health & Rehabilitation Center 9280 South West 81st CT Ocala, FL 34481 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff used personal protective equipment (PPE) while providing services to 1 of 3 residents reviewed for isolation precautions, Resident #96, to prevent the possible spread of infection and communicable disease. Residents Affected - Few Findings include: During an observation on 9/5/2024 at 1:40 PM, Staff D, Dietary Aide, entered Resident #96's room with lunch tray in her hands without donning PPE. There were personal protective equipment and signage for transmission-based precaution-contact isolation posted on the door to Resident #96's room. During an interview on 9/5/2024 at 1:40 PM, Staff D, Dietary Aide, stated, I delivered tray to [Resident #96's name] room and I did not use PPE when entering the room. I should have followed the contact precaution signage. Review of Resident #96's physician order dated 8/5/2024, read, Contact precautions for c diff [Clostridioides difficile] every shift for C-Diff until 8/10/2024 23:59 [11:59 PM]. Review of Resident #96's physician order dated 8/30/2024 read, Obtain stool sample for C-Diff one time only for 2 days. Review of Resident #96's daily skilled note dated 8/31/2024, read, P. Other Information, 1. Comments . Patient to start precautions for c-diff and orders to start vancomycin 250 for 10 days. During an interview on 9/5/2024 at 3:15 PM, the Director of Nursing, stated, Staff should use the appropriate personal protection equipment required for transmission-based precautions. For Clostridium Difficile, staff should use gown, gloves, and mask. If wound care or risk for fluid contact, a face shield should be used. During an interview on 9/6/2024 at 10:10 AM, the Director of Nursing stated, If a resident is suspect for C Diff, we place resident in transmission-based precautions- Contact Precaution while awaiting stool culture results. [Resident #96's name] should have had contact precautions in the system. Review of the facility policy and procedure titled Management of C. Difficile Infection with the last review date of 1/11/2024 read, Policy: This facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C. Difficile) infections . Policy Explanation and Compliance Guidelines . 5. General principles related to contact precautions for C. difficile: a. All staff are to wear gloves and a gown upon entry into the resident's room and while providing care for resident with C. difficile infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106115 If continuation sheet Page 8 of 8