Health inspection·February 18, 2026

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 interview and record review, the facility failed to ensure treatment and care was provided to all facility residents for physician prescribed medications for 2 of 4 residents, Resident #1 and #4, reviewed for medication administration.Findings include:Review of Resident #1's admission data revealed the resident was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections and chronic kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double strength] oral tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645 [6:45 AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/18/2025 and 12/19/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/19/2025 at 1700 [5:00 PM]; D/C date 12/22/2025 at 1104 [11:04 AM].Review of the MAR documented dated 12/19/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/20/2025, 12/21/2025, and 12/22/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/20/2025 and 12/21/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 days. Start Date: 12/22/2025 at 1700; D/C date 12/23/2025 at 1654 [4:54 PM].Review of the MAR documented dated 12/22/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/23/2025 at 0600 was documented with a 9.Review of the Progress Notes dated 12/23/2025 did not provide for documentation for the 0600 note of 9.Review of Resident #1's physician orders read, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 Days, Start Date 12/23/2025 at 2100 (9:00 PM).Review of a Progress Note dated 12/24/2025 read, Nurse spoke with pharmacy in regards to Bactrim, pharmacy to stat out. Facility to use [name of medication dispensing system] supply until delivered. MD [Medical Doctor] and family notified.During an interview on 2/18/2026 at 1:35 PM the DON (Director of Nursing) said the nurses should be documenting on the MAR if they are unable to administer a medication, such as if it was not available from the pharmacy, and they should notify the provider. Bactrim was also available in the [name of the automated medication dispensing system] machine.Review of Resident #4's admission data documented the resident was admitted on [DATE] with medical diagnoses Residents Affected - Few Page 1 of 4 106145 106145 02/18/2026 Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to include primary generalized osteo arthritis; cerebellar ataxia in diseases classified elsewhere; pneumonia, unspecified organism; muscle weakness (generalized).Review of Resident #4's MDS (Minimum Data Set) assessment, an admission assessment dated [DATE], documented a BIMS score of 15 out of 15 = cognitively intact.Review of Resident #4's physician orders documented Cyanocobalamin [Vitamin B-12] Injection Kit 1000 mcg/ml [micrograms per milliliter] (Cyanocobalamin) Inject 1000 mcg intramuscularly [into the muscle] one time a day for neuropathy [damage to the nerves outside the brain and spinal cord] for 7 days. Start Date 02/11/2026 0900 [9:00 AM].Review of Resident #4's MAR for Cyanocobalamin administration documented on 02/12/2026 and 02/13/2026 at 0900 12 = Not Applicable. Dated 02/17/2026 at 0900 was documented with a 9 = Other/See Nurse Note.Review of Resident #4's Progress Notes did not contain documentation for 02/12/2026 and 02/13/2026 for the code of 12, or for 02/17/2026 for a code of 9.During an interview on 2/18/2026 at 4:20 PM Resident #4 said she was participating in therapy but some days it really wore her out. She didn't have as much energy as she usually did and thought it might be because she had not received all of the B-12 injections she was supposed to get. The facility was having some problems getting the shots. During an interview on 2/18/2026 at approximately 5:50 PM the DON said the pharmacy had sent Resident #4's B-12 injections in a kit and not all of the doses had arrived. The nurses should have contacted Resident #4's physician when the medication wasn't available and they should have checked with the pharmacy. Review of the policy and procedure titled, Medication Monitoring, read, Policy: this facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. Policy Explanation and Compliance Guidelines: 5. Licensed nurses, with periodic oversight by nurse managers, shall: Report refusals of medications, frequent holding of medications, or signs of adverse consequences of medications to the physician.Review of the policy and procedure titled, Medication Administration, read, Policy: medications are administered by licensed nurses, 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. Policy Explanation and Compliance Guidelines: 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager. 106145 Page 2 of 4 106145 02/18/2026 Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document unavailable medications and notification to physicians of missed doses of ordered medications for 2 (Resident #1 and Resident #4) of 4 residents reviewed for medication administration.Findings include:Review of Resident #1's admission data revealed the resident was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections and chronic kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double strength] oral tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645 [6:45 AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/18/2025 and 12/19/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/19/2025 at 1700 [5:00 PM]; D/C date 12/22/2025 at 1104 [11:04 AM].Review of the MAR documented dated 12/19/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/20/2025, 12/21/2025, and 12/22/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/20/2025 and 12/21/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 days. Start Date: 12/22/2025 at 1700; D/C date 12/23/2025 at 1654 [4:54 PM].Review of the MAR documented dated 12/22/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/23/2025 at 0600 was documented with a 9.Review of the Progress Notes dated 12/23/2025 did not provide for documentation for the 0600 note of 9.Review of Resident #1's physician orders read, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 Days, Start Date 12/23/2025 at 2100 (9:00 PM).Review of a Progress Note dated 12/24/2025 read, Nurse spoke with pharmacy in regards to Bactrim, pharmacy to stat out. Facility to use [name of medication dispensing system] supply until delivered. MD [Medical Doctor] and family notified.During an interview on 2/18/2026 at 1:35 PM the DON (Director of Nursing) said the nurses should be documenting on the MAR if they are unable to administer a medication, such as if it was not available from the pharmacy, and they should notify the provider. Bactrim was also available in the [name of the automated medication dispensing system] machine.Review of Resident #1's medical record for the period of 12/17/2025 through 12/31/2025 did not contain documentation the physician was notified when the Bactrim DS was not administered as order.Review of Resident #4's admission data documented the resident was admitted on [DATE] with medical diagnoses to include primary generalized osteo arthritis; cerebellar ataxia in diseases classified elsewhere; pneumonia, unspecified organism; muscle weakness (generalized).Review of Resident #4's MDS (Minimum Data Set) assessment, an admission assessment dated [DATE], documented a BIMS score of 15 out of 15 = cognitively intact.Review of Resident #4's physician orders documented Cyanocobalamin [Vitamin B-12] Injection Kit 1000 mcg/ml [micrograms per milliliter] (Cyanocobalamin) Inject 1000 mcg intramuscularly [into the muscle] one time a 106145 Page 3 of 4 106145 02/18/2026 Oak Hill Health & Rehabilitation 7371 Cortez Oaks Blvd Brooksville, FL 34613

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few day for neuropathy [damage to the nerves outside the brain and spinal cord] for 7 days. Start Date 02/11/2026 0900 [9:00 AM].Review of Resident #4's MAR for Cyanocobalamin administration documented on 02/12/2026 and 02/13/2026 at 0900 12 = Not Applicable. Dated 02/17/2026 at 0900 was documented with a 9 = Other/See Nurse Note.Review of Resident #4's Progress Notes did not contain documentation for 02/12/2026 and 02/13/2026 for the code of 12, or for 02/17/2026 for a code of 9.During an interview on 2/18/2026 at 4:20 PM Resident #4 said she was participating in therapy but some days it really wore her out. She didn't have as much energy as she usually did and thought it might be because she had not received all of the B-12 injections she was supposed to get. The facility was having some problems getting the shots. During an interview on 2/18/2026 at approximately 5:50 PM the DON said the pharmacy had sent Resident #4's B-12 injections in a kit and not all of the doses had arrived. The nurses should have contacted Resident #4's physician when the medication wasn't available and they should have checked with the pharmacy. Review of Resident #4's medical record for the period of 02/11/2026 through 02/18/2026 did not contain documentation the physician was notified the medication was not administered as ordered.Review of the policy and procedure titled, Medication Monitoring, read, Policy: this facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. Policy Explanation and Compliance Guidelines: 5. Licensed nurses, with periodic oversight by nurse managers, shall: Report refusals of medications, frequent holding of medications, or signs of adverse consequences of medications to the physician.Review of the policy and procedure titled, Medication Administration, read, Policy: medications are administered by licensed nurses, 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. Policy Explanation and Compliance Guidelines: 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager. 106145 Page 4 of 4