Inspection·July 2, 2025

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some document any mental illness. 4) Review of the PASRR for Resident #9 dated 6/9/2025 read, Resident #9 did not have or was not suspected of having any mental illness.Review of Residents #9's medical record documented a diagnosis of anxiety disorder.Review of Resident #9 physician order dated 6/29/2025 read, Xanax 0.25 mg, give one tablet by mouth every 8 hours as needed for anxiety for 14 days.5) Review of the (PASRR dated 4/17/2025 read, Resident #15 did not have or was not suspected of having any mental illness.Review of Resident #15's psychiatry subsequent note dated 6/17/2025 read, I saw the patient for medication management as the patient has active psychiatric diagnosis, is on psych med, is in the facility setting .Review of Resident #15's physician order dated 6/13/2025 read, Remeron 30 mg, give one tablet by mouth at bedtime for major depressive disorderReview of Resident #15's physician order dated 6/14/2025 read, Risperdal 1 mg, give one tablet by mouth two times a day for behavior disorder.Review of Resident #15's physician order dated 6/15/2025 read, Clonazepam 2 mg, give one tablet by mouth three times a day for anxiety.6) Review of the PASRR dated 5/17/2024 read, Resident #28 was only suspected to have depression as the only mental illness the Resident is diagnosed with. Review of Resident #28's psychiatry subsequent note dated 6/3/2025 read, This is a [AGE] year old patient with an past psychiatric history of depression and anxiety.Review of Review #28's physician order dated 5/16/2025 read, Duloxetine 60 mg, give one capsule by mouth at bedtime for depression.Review of Resident #28's physician order dated 6/1/2025 read, Lorazepam 0.5 mg, give one tablet by mouth every 3 hours as needed for anxiety, restlessness.7) Review of PASRR dated 3/4/2024 read Resident #59 was only suspected to have depression and anxiety as the only mental illness the Resident is diagnosed with. Review of Resident #59's medical diagnosis related to mental illness read generalized anxiety disorder, major depressive disorder and adjustment disorder.Review of Resident #59's physician order dated 1/22/2025 read, Sertraline 100 milligrams, give one tablet by mouth one time a day for depression.Review of Resident #59's physician order dated 1/22/2025 read, Buspirone 5 mg, give one tablet by mouth two times a day for anxiety. Review of Resident #59's physician order dated 2/5/2025 read, Trazodone 50 mg, give one tablet by mouth at bed time for major depressive disorder. Review of Resident #59's physician order dated 4/8/2025 read, Alprazolam 0.25 mg, give one tablet by mouth every eight hours for anxiety.During an interview on 7/1/2025 at 3:30 PM the Administrator stated, The PASRRs are incorrect. My expectations would be that the PASRRs be correct.During an on 7/1/2025 at 3:30 PM the Administrator stated, The PASRRs are incorrect. My expectations would be that the PASRRs be correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 2 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 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 treatment and care was provided for intravenous (IV) dressing changes for 2 of 4 residents, Residents #195 and #444, reviewed for IV catheters and infusions, and failed to ensure medication management for 1 of 6 residents, Resident #55, reviewed for medications.Findings include:1) During an observation on 06/29/25 at 10:17 AM Resident #195 had a double lumen PICC (peripherally inserted central catheter) line inserted in his left upper arm. The dressing covering the insertion site was dated 6/17/2025. Review of Resident #195's physician order dated 5/23/2025 read, Change catheter site dressing every week and prn [as needed] with a transparent dressing every shift every Tue [Tuesday] for IV therapy.During an interview on 7/1/2025 at 1:11PM Staff E, Licensed Practical Nurse stated, IV dressing changes should be done every week or as needed. I don't know what happened I thought I had changed the dressing.During an interview won 7/2/2025 at 9:45 AM the Director of Nursing (DON) stated, Central line dressing should be [changed] every seven days and peripheral lines every three day. [Resident #195's name] should have been changed on 6/24/2025.2) Review of Resident #55's physician order dated 3/30/2025 read, Carvedilol Oral Tablet 3.125 mg [milligrams] give 1 tablet by mouth every 12 hours for htn [hypertension] hold medication for SBP <135 [systolic blood pressure less than 135].Review of Resident #55's Medication Administration Record (MAR) for the month of June 2025 documented Carvedilol 3.125 mg was administered outside of the physician ordered parameters at 0900 [9:00AM] on 6/2/2025 SBP was 106, 6/3/2025 SBP was 113, 6/4/2025 SBP was 110, 6/5/2025 SBP was 112, 6/6/2025 SBP was 122, 6/7/2025 SBP was 129, 6/8/2025 SBP was 128, 6/9/2025 SBP was 115, 6/10/2025 SBP was 111, 6/11/2025 SBP was 120, 6/12/2025 SBP was 124, 6/13/2025 SBP was 118, 6/16/2025 SBP was 108, 6/17/2025 SBP was 115, 6/18/2025 SBP was 111, 6/19/2025 SBP was 111, 6/20/2025 SBP was 113, 6/21/2025 SBP was 105, 6/22/2025 SBP was 116, 6/23/2025 SBP was 115, 6/24/2025 SBP was 107, 6/25/2025 SBP was 117, 6/26/2025 SBP was 132, 6/29/2025 SBP was 123, 6/30/2025 SBP was 126. At 2100 [9:00PM] on 6/1/2025 SBP 106, 6/2/2025 SBP was 113, 6/3/2025 SBP was 117, 6/4/2025 SBP was 110, 6/6/2025 SBP was 129, 6/7/2025 SBP was 122, 6/8/2025 SBP was 120, 6/9/2025 SBP was 116, 6/10/2025 SBP was 111, 6/11/2025 SBP was 108, 6/12/2025 SBP was 124, 6/13/2025 SBP was 113, 6/14/2025 SBP was 129, 6/15/2025 SBP was 108, 6/16/2025 SBP was 108, 6/17/2025 SBP was 118, 6/18/2025 SBP was 111, 6/21/2025 SBP was 108, 6/22/2025 SBP was 118, 6/23/2025 SBP was 107, 6/24/2025 SBP was 117, 6/25/2025 SBP was 120, 6/26/2025 SBP was108, 6/29/2025 SBP was 126, and on 6/30/2025 SBP was 126.During an interview on 7/2/2025 at 9:51 AM the DON stated, The nurses were administering medications out of parameters. The staff are expected to follow the physician orders and make the physician aware. I believe it might have been confusion with the less than sign. I always encourage the staff to write out the words instead of using the symbols.During an interview on 7/2/2025 at 10:22 AM Staff E, LPN stated, I always look at the parameters. I know the sign is for less than and you hold the medication. If the entry has a check mark it means it was given. I don't know what happened there, I don't recall. I would always document a progress note if I contacted the provider for any questions regarding medication.During an interview on 7/2/2025 at 2:30 PM Medical Doctor #1 stated, [Resident #55's name] has an extensive cardiac history. I was going to change her parameters. It's a betablocker and she needs the drug. If medication has parameters it should be followed. Review of the policy and procedure titled Medication Administration with a last review date of 12/30/2024 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. Residents Affected - Few 3) Review of Resident #444's physician orders dated 6/23/2025 read, Change catheter site dressing every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 3 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 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 week and PRN with a transparent dressing.During an observation on 6/30/2025 at 09:11 AM Resident #444 was lying in the bed and was noted to have a peripherally inserted central catheter (PICC) in the upper right arm. The transparent dressing covering the PICC was dated 6/22/2025. During an observation on 06/30/2025 at 9:45 AM with Staff B, Licensed Practical Nurse, Resident #444's PICC line dressing was observed. (Photographic evidence obtained) Residents Affected - Few During an interview on 06/30/2025 at 9:45 AM Staff B, Licensed Practical Nurse stated, The dressing is dated on 6/22/2025. Dressing changes are to be done every seven days. It should have been changed yesterday 7/29. During an interview on 6/30/2025 at 1:20 PM the Director of Nursing stated, The dressing should be changed at least every seven days.Review of the policy and procedure titled PICC (peripherally inserted central catheter/MIDLINE/CVAD(central venous access device) Dressing Change dated 12/30/2024 read, It is the policy of this facility to change peripherally inserted central catheter (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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 4 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 medications were securely stored when unattended and failed to date and label intravenous (IV) medication infusion bags and tubing. Findings include: 1) During an observation on 6/29/2025 at 11:32 AM Resident #499 was lying in bed. Next to the bed was an intravenous (IV) pole. Hanging on the pole was a Zosyn IV infusion bag. The infusion bag and the tubing were not dated or timed. re was no date or time on the IV infusion bag or tubing. (photographic evidence obtained)2) During an observation on 6/30/2025 at 10:19 AM of Resident #27's room there was CeraVe eczema relief cream on top of the bedside table. (Photographic evidence obtained) 3) During an observation on 7/1/2025 at 8:22 AM Resident #195's IV medication was hanging from an IV pole. The infusion bag and the IV tubing was not labeled with the date and time. Observed on top of Resident #195 bedside table was a Germa Ubre Plus topical analgesic ointment (is a medicated ointment used to relieve minor aches and pains in muscle and joints). During an interview on 7/1/2025 at 8:47 AM Resident #195 stated, I use the ointment if I have a tooth ache. I normally will apply it outside on the side of the mouth area and when I wake up the next morning it feels better.During an interview on 7/1/2025 at 8:50 AM Staff C, Licensed Practical Nurse (LPN), stated, The IV medication should be labeled with the time and date it was hung. I do not see this one [IV medication bag and tubing] has a date and time. I do not see a doctor's approval for Resident #195 to have medication at bedside.During an interview on 7/1/2025 at 9:15 AM the Director of Nursing stated, The residents need to have a medication self-administration assessment and be educated on medication self-administration. Also, the physician would be notified, and the medication should be secured when not in use. The intravenous tubing should be labeled with the time and date when first used.Review of the facility policy and procedure titled Intravenous Therapy with a last review date of 12/30/2024 read, Policy: The facility will adhere to accepted standards of practice regarding infusion practices. Compliance Guidelines: 5. All IV tubing is to be labeled with date, time and initials.Review of the facility policy and procedure titled, Labeling of Medications and Biologicals with a last review date of 12/30/2025 read, Policy: All medications and biologicals used in the facility will be labeled in accordance with current stated and federal regulations to facilitate consideration of precautions and safe administration of medication. 5. Labels for medications prepared or compounded for intravenous infusion must include: f. Initials of compounder and person administering medications if different than compounder. Event ID: Facility ID: 106145 If continuation sheet Page 5 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure foods and drinks were served at a safe and appetizing temperature.Findings include: During an interview on 6/29/25 at 10:03 AM Resident #493 stated, My food is always cold.During an interview on 6/29/25 at 10:20 AM Resident #495 stated, My food is sometimes cold. During an interview on 6/29/25 at 10:32 AM Resident #498 stated, The food is lukewarm.During an observation on 7/1/25 beginning at 7:00 AM, a test tray investigation on the 100 hallway was conducted related to resident complaints. At 7:19 AM the last tray/test tray was plated and placed on an enclosed meal delivery cart. At 7:20 AM the meal delivery cart exited the kitchen and headed towards the 100 hallway. At 7:35 AM the test tray/last tray was removed from the insulated meal delivery cart. The CDM (Certified Dietary Manager) tested the temperature of the scrambled eggs with a finding of 101 degrees Fahrenheit, the link sausages with a finding of 120 degrees Fahrenheit, and a glass of orange juice with a finding of 48 degrees Fahrenheit. During an interview on 7/1/25 at 7:40 AM the CDM stated, The hot foods [scrambled eggs and sausage] temp should be higher than 140 [degrees Fahrenheit] for hot foods. Cold foods/drinks should be below 41 [degrees Fahrenheit].Review of the policy and procedure titled, Food Safety Requirements, with a review date of 4/9/24 read, 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. 5. Foods and beverages shall be distributed to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone [where bacteria can multiply rapidly, potentially causing foodborne illnesses]. Review of Room Test Tray Evaluation Form read, Acceptable delivery Temperatures: include Entree: cold 40-55* [degrees Fahrenheit] hot foods 135-160.* Cold beverages 40-55.* Food and drinks cannot be held in the Danger Zone 40*- 140* no more than 4 hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 6 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards in the kitchen walk-in cooler and walk-in freezer and in the second floor nourishment freezer. Findings include:During the initial observation of the kitchen on 6/30/25 beginning at 9:07 AM in the walk-in freezer, there was a clear plastic bag of tater tots sitting on a shelf. The bag was not labeled or dated. In the walk-in cooler, were two trays of uncovered slices of pie on a rolling cart.During an interview on 6/29/25 at 9:08 AM Staff G, Head [NAME] stated, It [plastic bag of tater tots] should be labeled and dated. The dessert [pie] should be covered. During the interview on 7/2/25 at 12:37PM the Dietary Manager states, Food should be labeled and dated and the desserts [pie] should have been covered.During observation on 6/29/25 at 9:40 AM of the nourishment refrigerator/freezer located on the second floor inside the life enrichment room, there was an ice bucket in the freezer with an ice scooper laying on the ice.During an interview on 6/29/25 at 9:42AM Staff F, Dietary Aide stated, That should not be like that [the scooper laying on the ice]. During an interview on 7/2/25 at 12:38 PM the Dietary Manager stated, I don't know where that scooper came from. Review of policy and procedure titled, Food Safety Requirements, with a review date of 4/9/24 read, 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. Compliance guidelines: 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to, leftovers, so it is used by its use-by date, or frozen (when applicable) discarded; and v. Keeping food covered or in tight containers. Event ID: Facility ID: 106145 If continuation sheet Page 7 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to maintain complete and accurately documented medical records for 1 of 4 residents, Resident #195, reviewed for central catheters and 2 of 6 residents, Resident #5 and #13, reviewed for medication management.Findings include:1) During an observation on 06/29/25 at 10:17 AM Resident #195 was sitting in wheelchair. Resident #195 was observed to have a peripherally inserted central catheter (PICC) line double lumen inserted in the left upper arm. The site was covered with a dressing that was dated 6/17/2025.Review of Resident #195’s physician order dated 5/23/2025 read, Change catheter site dressing every week and prn [as needed] with transparent dressing every shift every Tue [Tuesday] for IV [intravenous] therapy.Review of Resident #195’s Treatment Administration Record (TAR) for the month of June 2025, documented the PICC line dressing change was completed on 6/24/2025.During an interview on 7/1/2025 at 1:11 PM Staff E, Licensed Practical Nurse (LPN) stated, IV dressing changes should be done every week or as needed. I cannot recall what happened on 6/24/20245 or why the dressing was dated as 6/17/2025.2) Review of Resident #5’s physician order dated 11/7/2024 read, Insulin Glargine Solution 100unit/ml [milliliters] inject 10 units subcutaneously at bedtime for diabetes.Review of Resident #5’s physician order dated 11/8/2024 read, Novolog Injection Solution 100 unit/ml (Insulin Aspart) inject as per sliding scale.Review of Resident #5 Medication Administration Record (MAR) for the month of June 2025 for Insulin Glargine Solution documented on 6/10/2025 at 2100 [9:00PM] coded 10 [No sliding scale required].Review of Resident #5 Medication Administration Record (MAR) for the month of June 2025 for Novolog there was a blank entry on 6/20/2025 at 0600 [6:00AM].During an interview on 7/2/2025 at 9:49 AM the Director of Nursing (DON) stated, The nurses should be documenting accurately the services provided. If there is contact with the provided, they need to document the communication in a progress note.During an interview on 7/2/2025 at 11:11 AM with Staff J, Registered Nurse (RN), stated, I know I called the doctor and asked about the insulin. I normally will call the provider with any concerns and act upon the orders provided.During an interview on 7/2/2025 at 2:03 PM Medical Doctor #2 stated, I oversee many patients and it’s hard to recall all. I think it was communicated to me in person and a lot of things are communicated in person. I remember with her [Resident #5] she had a morning she refused the insulin.Review of the facility policy and procedure titled Documentation in Medical Record with a last review date of 12/30/2025 read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident’s progress through complete, accurate, and timely documentation.3) Review of Resident #13’s physician order dated 6/13/2025 read, Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 units/ml, inject subcutaneously before meals and at bedtime for diabetes mellitus, Inject as per sliding scale: if 150-200=1 unit, 201-250= 2 units, 251-300= 3 units, 301-350= 4 units, 351-400= 5 units, 401-999= 6 units, contact MD [Medical Doctor] and recheck every 1 hour until response or under 300, subcutaneously before meals and at bedtime for DM [Diabetes Miletus].Review of Resident #13's documented blood glucoses dated 6/14/2025 read, blood glucose reading at 6:17 AM of 145 milligrams/deciliters (mg/dl), 12:08 PM of 433 mg/dl, 4:50 PM of 139 mg/dl and 9:11 PM of 399 mg/dl.Review of Resident #13's documented blood glucose dated 6/19/2025 read, blood glucose reading at 11:11 AM of 190 milligrams/deciliters (mg/dl), 11:24 AM of 455 mg/dl, 1:45 PM of 489 mg/dl and 9:23 PM of 115 mg/dl.Review of Resident #13's medical record did not provide for document of notification to the medical doctor of the blood glucose readings greater than 400.During an interview on 7/2/2025 at 10:59 AM the DON stated, I spoke to the doctor and he stated that he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 8 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 notified of the follow-up glucose. I also spoke with the nurses who were responsible for the follow-up blood glucose checks but they did not document them. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 9 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 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 prevent the possible spread of infection when not following infection control standards to wear appropriate personal protective equipment for 3 of 5 residents, Resident #195, #444, and #499, reviewed for enhanced barrier precautions, and failed to store respiratory equipment when not in use for 1 of 2 residents, Resident #5, reviewed for respiratory services. Findings include: 1) During an observation on 7/1/2025 at 8:22 AM Staff C, Licensed Practical Nurse (LPN) entered Resident #195’s room. Outside on the door frame to Resident #195’s room there was an enhanced barrier sign posted. Staff C entered the room and performed hand hygiene. Staff C donned gloves but did not put on a gown. Resident #195’s IV (intravenous) pump was peeping. Staff C turned the pump off. Staff C walked outside of the room with the gloves on, returned to the medication cart, and grabbed a curos disinfecting cap [a single-use cap designed to disinfect and protect IV access points]. Staff C entered the room, removed her gloves, did not perform hand hygiene, and donned a new pair of gloves. Staff C disconnected the IV tubing and put the curos on the end of the needleless connector, removed her gloves, did not perform hand hygiene, and exited the room to verify the flush order. Staff C walked to the medication room, returned to the medication cart with two 3 milliliters (ml) heparin flush syringes and a 5 ml heparin flush syringe. Staff C did not perform hand hygiene and placed the two 3 ml heparin flushes in the medication cart and then entered Resident #195’s room. Staff C did not perform hand hygiene and donned a pair of gloves. Staff C did not don a gown. Staff C placed the flush on top of Resident#195’s bed. Staff C exited the room wearing the gloves, returned to the medication cart, grabbed alcohol wipes, entered Resident #195’s room, did not remove the gloves, did not perform hand hygiene, removed the green curos cap from the IV needless connector and placed it on top of the resident's bed. Staff C cleaned the needleless connector and flushed the IV tubing. Staff C grabbed the used, single use, green curos cap and placed it on the needleless connector. During an interview on 7/1/2025 at 8:47 AM with Staff C, LPN, stated, For enhanced barrier precaution I just wear gloves. The curos cap as long as you remove it and quickly put it back on is okay. I should have perform hand hygiene more often and in between changing my gloves. 2) During an observation on 7/1/2025 at 2:05 PM Staff D, LPN, entered Resident #499’s room who had an enhanced barrier precaution sign on the frame of the room door. Staff D performed hand hygiene and donned a pair of gloves but did not don a gown. Staff D primed the resident’s IV tubing, cleaned the needleless connector with a alcohol wipe, flushed the needleless connector with normal saline, and started the infusion. During an observation on 7/1/2025 at 2:35 PM Staff D entered Resident #499’s room and performed hand hygiene and donned a pair of gloves but did not don a gown. Staff D disconnected the IV tubing, cleansed the needleless connector with an alcohol wipe, flushed the tubing with normal saline followed by a heparin flush. During an interview on 7/1/2025 at 2:47 PM Staff D, LPN, stated, For enhanced barrier I wear gloves. I normally wear gloves only.During an interview on 7/2/2025 at 9:36 AM the Director of Nursing (DON) stated, The expectation is at least hand sanitizer goes on when nurses remove their gloves. When they come back from the medication room they should do hand hygiene. Reusing a curos cap is not a best practice it should be changed out. As far as EBP [enhanced barrier precautions] the staff if they will be in high contact with a patient they should wear gowns and gloves.During an interview on 7/2/2025 at 9:49 AM the Assistant Director of Nursing (ADON)/Infection Preventionist stated, EBP residents have signs posted on the door. Nurses are expected to follow the instructions on the signs and they should wear a gown and gloves.Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 12/30/2025 read, Policy: It is the policy of this facility to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 10 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613 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 implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ's targeted gown and gloves use during high contact resident care activities. 4. High-contact resident care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines midline catheters.Review of the facility policy and procedure titled Hand Hygiene with a last review date 12/30/2025 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Hand Hygiene Table: Before applying and after removing personal protective equipment (PPE), including gloves.3) During an observation on 6/29/2025 at 10:03 AM Resident #5 was lying in bed. Lying on the corner cabinet was a nebulizer mask that was not bagged. Review of Resident #5’s physician order dated 11/7/2024 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML [milligrams/milliliters] 3 ml inhale orally every 4 hours as needed for SOB [shortness of breath] or wheezing via nebulizer. Review of Resident #5’s Medication Administration Record for the month of June 2025 for Ipratropium Albuterol solution documented administered on 6/23/2025. During an interview on 7/2/2025 at 10:01 AM the DON stated, [Resident #5's name] nebulizer mask should be bagged when not in use. Review of the facility policy and procedure titled “Cleaning and Changing Respiratory Equipment with a last review date of 12/30/2024 read, Policy: It is the policy of this facility to ensure the safety of residents by cleaning and changing respiratory equipment using guidelines that adhere to infection control standards. Procedure: Handheld Nebulizers and mask (if applicable): c. The nebulizer will be kept in a plastic bag when not in use. 4) During an observation on 6/30/2025 at 09:11 AM Staff B, LPN prepared and administered medication and enteral feeding for Resident #444 without wearing the proper personal protective equipment (PPE gown, gloves and mask). Staff B, LPN administer enteral feeding via gastrostomy tube. Staff B, LPN completed an intravenous flush of Resident #444’s PICC access device.Review of Resident #444's physician orders dated 6/20/2025 read, Enhanced Barrier Precautions (EBP)During an observation of resident #444's door and the surrounding area there was no signage to notify staff of the need for EBP.During an interview on 7/1/2025 at 9:30 AM Staff B, LPN stated, Normally, I look at the door and there is a sign on the door that tells me what type of isolation the resident is on. There is no signage [for Resident #444]. I'm not sure what enhanced barrier precautions are or what I should be wearing.During an interview on 7/1/2025 at 12:20 PM the Director of Nursing stated, They [staff] should follow the orders and wear the appropriate PPE. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106145 If continuation sheet Page 11 of 11