Inspection·October 31, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - A focus of DISCHARGE PLANNING: The resident wishes/or Responsible Party wishes to:[ MISSING LOCATION] Date Initiated: 08/20/2024. With interventions including Discuss with resident/family/representative discharge planning process Date Initiated: 08/20/2024 RMGMT, and Referral to Local Contact Agency prn Date Initiated: 08/20/2024. With a goal of Safely Discharge to a lower level of care (Home, Home with HHA, ALF, ILF, other): Date Initiated: 08/20/2024 Revision on: 09/16/2024 Target Date: 12/05/2024. An interview was conducted on 10/30/24 at 12:40 PM with Resident #141. He stated he would like to discharge to a facility in [name of city], Florida, closer to his girlfriend to minimize her travel time and be able to see her more often. He stated he had told staff but unable to recall names of who he told. An interview conducted on 10/31/24 at 9:50 AM with Staff B, MDS coordinator. She stated she oversaw all the residents' care plans. She stated she created and updated the care plans as necessary. She stated a dialysis care plan would include the appointment time, dialysis center location, contact information for the dialysis center. She stated if a dialysis resident had a physician order for fluid restriction it would need to be reflected in the hemodialysis section of the care plan. She stated Resident #141's hemodialysis section of the care plan was incorrect as fluid restriction was marked no and should have been marked yes as Resident #141 had a physician order in place for fluid restriction. She stated his care plan needed to be corrected. An interview was conducted with Staff A, Social Services Director (SSD) on 10/30/24 at 10:00 AM. She stated discharge planning was discussed with the resident and or the resident representative at admission, during quarterly care plan meetings and as needed, or per resident/resident representative request. A Psychosocial history and Assessment evaluation was completed at admission and readmission for each resident. She stated the discharge location should be listed in the evaluation and in the care plan. She stated the care plan would be updated if the discharge location changed. She stated the discharge planning section of Resident #141 care plan was incomplete as it did not state his desired discharge location. She stated it needed to be corrected, and Resident #141's discharge location should be added to his care plan. A review of the facility policy titled Care Plan-Interdisciplinary Plan of Care from Interim to Meeting with effective date February 2024. It revealed in section Policy: 1. Managing risk factors to the extent possible or indicating the limits of such interventions. 2. Part I Social Services showed that discharge planning is to be discussed as part care plan process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 2 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 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 observation, record review, and interviews, the facility did not ensure accuracy of Preadmission Screening and Resident Review (PASRR) for two (#67 and #75) of 16 sampled residents. Residents Affected - Few Findings include: 1. Review of Resident #67's medical record showed an initial admission to facility on 09/22/2022 and readmission on [DATE] with diagnoses including unspecified dementia, other specified depressive episodes, schizophrenia and unspecified psychosis. Review of care plan dated 02/27/24 revealed: - A focus of BEHAVIORAL: The resident has been noted with the following behaviors: throwing things at staff, refusing care and services at times, combative at times, noncompliant with safety suggestions, refuses weights Date Initiated: 03/12/2024 Revision on: 05/29/2024. With interventions including Report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician) Date Initiated: 03/12/2024 Observe/document for side effects and effectiveness. Date Initiated: 03/12/2024. - A focus of PSYCHOTROPIC MED: The resident uses psychotropic medications r/t Anticonvulsant to manage: Seizures. Date Initiated: 02/27/2024 Revision on: 02/27/2024. With interventions including Obtain and review lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 02/27/2024, Psychotropic Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes Date Initiated: 02/27/2024. Administer medications as ordered. Observe/document for side effects and effectiveness. Date Initiated: 02/27/2024, and Psychiatry Services per order\PRN\protocol Date Initiated: 02/27/2024. Review of Minimum Data Set, dated [DATE] revealed: - Section C brief interview for mental status (BIMS) score of 13 indicating no cognitive impairment. - Section I marked yes for Non-Alzheimer's Dementia, Depression, Psychotic Disorder, and Schizophrenia. - Section N showed high risk drug class marked yes for antianxiety. Review of psych notes revealed resident seen by psych services on 10/29, 10/11, and 09/23. Psychology planned for continued monitoring. Review of Level I PASRR showed No marked for need of LEVEL II to be completed with patient having a secondary diagnosis of Dementia and 4 Mental Illness (MI) marked on page 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 3 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 10/31/2024 at 10:00 AM with Staff A. She stated the process for PASRR, is when a resident came in from the hospital, she would review the PASRR for accuracy. She stated if it was not correct, she would complete a new PASRR. She stated she confirmed if a Level I PASRR needed to be submitted for a level II PASRR. She stated if a resident had a primary or secondary diagnosis of dementia, and a diagnosis of a mental illness she would submit for a Level II PASRR. She stated Resident #67 was not submitted for a Level II PASARR and that was incorrect. She stated Resident #67 should have had a Level II PASRR submitted as he had diagnoses of dementia and schizophrenia. 2. A review of Resident #75's admission Record showed Resident #75 was admitted to the facility on [DATE] with diagnoses to include mood disorder due to known physiological condition, dementia, schizophrenia, convulsions, anxiety disorder, depressive disorder and encephalopathy. Review of Resident #75's Level I PASRR, dated 9/30/24, Section I, mental illness (MI) or suspected mental illness showed anxiety disorder, depressive disorder, schizophrenia and mood disorder due to known physiological condition. Review of Section II's instruction showed A level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia . Review of Section IV PASRR screen completion showed the level 2 PASRR evaluation is not required. An interview was conducted on 10/31/24 at 9:55 A.M. with the Social Services Director (SSD) and Social Services Assistant (SSA). The SSD said Resident #75 required a PASRR Level II evaluation. A review of the facility's policy and procedure titled, PASRR requirements level I and level II, February Effective 2021 showed, .The screening is reviewed by Admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services . 2. Determine if a serious mental illness and our intellectual disability or a related condition exists while reviewing the PASRR form completed by the acute care facility (trigger for Level II completion.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 4 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0659 Provide care by qualified persons according to each resident's written plan of care. 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 did not ensure services provided/arranged by an individual had the skills, experience, knowledge and licensure to perform tasks for one resident (#142) out of eight residents observed. Residents Affected - Few Findings included: On 10/28/2024 at 10:45 a.m., an observation and interview was conducted in Resident #142's room. Resident #142 was in a private room with thick yellow sputum on his hospital gown from his tracheostomy. A young man was sitting in a chair in the corner of Resident #142's room. The young man (Sitter #1) identified himself as a private sitter hired by the family. Sitter #1 stated he would assist the nursing staff with Resident #142's ADL (Activity of Daily Living) care during the day. On 10/29/2024 at 8:28 a.m., an observation and interview was conducted with Resident #142's private sitter (Sitter #2). Sitter #2 stated she was familiar with Resident #142 and stated she had been taking care of the resident since he had been at this facility. Sitter #2 stated she would do all ADL care for Resident #142 during her twelve-hour shift. Sitter #2 stated she would sign in the visitor log but because they knew her, she was rarely handed a visitor badge. Sitter #2 stated she would turn Resident #142 every two hours and would provide toileting when needed. Resident #2 stated, when she was on duty, she would never see another Certified Nursing Assistant (CNA) enter his room. Sitter #2 stated the nurses would come into his room to give him his medications and his feedings. On 10/29/2024 at 11:50 a.m., an observation and interview was conducted in Resident #142's room with Sitter #2. Resident #142 was clean shaven, and hair groomed and wet. Sitter #2 stated she had finished his full ADL care and provided lotion to his body. Sitter #2 stated the family had hired 24 hours /7 days a week sitter service. On 10/30/2024 at 9:43 a.m., an observation was made of Sitter #3 and Staff I, CNA providing incontinence care for Resident #142. Both were appropriately wearing PPE (personal protective equipment) during ADL care. On 10/30/2024 at 1:00 p.m., an observation and interview were conducted with Sitter #3, Sitter #3 was wearing a mask, gown, and gloves sitting in a chair in the corner of Resident #142's room. Sitter #3 stated she was a CNA. Sitter #3 stated she had performed ROM (range of motion) and turned Resident #142 every two hours. Sitter #3 stated Resident #142 still had a pressure area to his right ear in which she would roll up a washcloth to offset pressure on the right side of his face. Sitter #3 stated she would sign in at the front desk and get a visitor pass for the day. Sitter #3 stated she had asked the staff for mouth swabs today to clean his mouth and the staff provided them for her. Sitter #3 stated no other CNAs had come into Resident 142's room since she provided ADL care with Staff I, CNA this morning. Sitter #3 stated she placed zinc oxide on his bottom and groin due to chafing. A record review of Resident #142's admission Record showed an initial admit date of 4/25/2024 with a readmission date of 7/18/2024. A review of Resident #142's Minimal Data Set (MDS) dated [DATE] Section GG- Functional Abilities and Goals, GG0130-Self-care showed Resident #142 dependent for oral hygiene, toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 5 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dependent is defined as - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to compete the activity. Section GG- Functional Abilities and Goals, GG0170-Mobility showed Resident #142 dependent for roll left to right. A review of Resident #142's care plan dated 7/18/2024 showed a focus area of Enhance Barrier Precautions related to wounds, gastrostomy tube, tracheostomy and Candida aureus with interventions to include but not limited to: Gloves and gowns to be worn when providing high touch resident care. A focus area of ADL: The resident has an ADL self-care performance deficit related to weakness, anemia, history of Transient Ischemic Attack (TIA), Chronic Kidney Disease (CKD), tracheostomy, diabetes mellitus type 2, dementia, seizure, cardiomegaly, cerebral infarction, and Alzheimer's. Interventions include but are not limited: Resident is total dependent upon staff for ADL's. Bed mobility dependent assistant of two to turn and/or reposition. Total toileting use dependent assist of two persons bathing the resident requires assist of two. On 10/30/2024 at 3:31 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing, and the Assistant Nursing Home Administrator. The NHA stated he was unaware of the extent Resident #142's care was provided by the privately hired sitters. A review of the facility's policy titled Visitation Designated Essential Caregiver, effective November 2022 showed the following: as mentioned earlier in the policy, the essential caregiver or visitor will be screened, educated regarding infection control practices, personal protective equipment, remaining in the resident's room and/or minimal movement throughout the facility and any other protocols recommended by the department of health, CDC or other agency at the time of visitation when visiting residents were signs or symptoms of respiratory illness or infectious disease. The essential caregiver is not required to provide necessary care to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 6 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 10/29/2024 at 10:15 a.m. and 4:00 p.m., Resident # 472 was observed lying down in bed throughout the day without being provided activities. When she was asked questions, she was only able to speak in Creole. She was observed with her television on an English- speaking program all throughout the day Residents Affected - Few During an observation 10/30/24 at 9:45 a.m., 2:00 p.m., and 4:00 p.m., Resident # 472 was observed lying down in bed throughout the day without being provided with activities. She was observed again with her television on an English-speaking program. Review of Resident # 472's admission Record dated 10/31/2024, showed she was originally admitted on [DATE] with diagnoses to include but not limited to Other Cerebral Infarction Due to Occlusion or Stenosis of Small Artery, Need for Assistance with Personal Care and History of Falling. Review of Resident # 472's Minimum Data Set (MDS) dated [DATE], showed a Brief Interview Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Review of Resident # 472's care plan focus for Activities revealed Resident # 472 required assistance with involvement of Activities related to may not staying for the entire activity. Cognitive deficits, Requires physical assistance to and from activities. Date Initiated: 10/25/2022, date revised: 8/16/2023. The goal of this care plan stated, Resident 472 will participate in activities of choice/ will participate in activities. Date initiated 10/25/2024, date revised on 7/15/2024, target Date 1/12/2025. The Intervention of this care plan stated, encourage to participate with activities of choice. Date initiated 10/25/2022 On 10/31/2024 at 9:00 am., an interview was conducted with the Activities Director. She stated that she did one to one room visits three times a week. During her room visits she discussed with residents about their activity preferences and provided them with puzzles or games of their choice. She stated if a resident spoke Spanish, she would get someone to assist with translating their questions to find out the resident's activity preference. If a resident spoke Creole, she would have to use a translator, but she had never had to experience working with a Creole speaking resident. She stated she was not even aware that the facility had a resident that spoke Creole. She stated she did not have a process in place to show that she conducted room visits and she had not looked at the resident's care plans to see if their activity intervention was being followed out. On 10/31/2024 at 11:00 a.m., an interview was conducted with Resident # 472 representative. He stated that his mom could only understand Creole and did not understand English or speak English. He stated he would like to see his mom out of her bed more and involved in activities in the facility. The staff had not called him about finding out what type of activities his mother was interested in participating in. On 10/31/2024 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON). She stated her expectation was for all residents to participate in activities or at least be offered the opportunity to participate. If the resident refused to participate in an activity, it was their right, but they should still be offered the opportunity. The Activities Director should document the resident refusal and then follow up with the resident to see what we could do to get them involved in some type of activity. She stated she would work with the Activities Director to see what they could do for Resident # 472 because the resident spoke Creole. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 7 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled, Activities Overview, Effective dated October 2021 showed Policy: Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The Activity Programs will reflect individual needs and provide/ promote the following: Stimulation or solace, physical, cognitive, and/or emotional health, enhancement, to the extent practicable, of each resident is physical and mental status, resident self-respect by providing activities that support self-expression, social and personal responsibility, and choice. Based on observation, staff interview, and record review, the facility failed to provide an ongoing activity program that provided one on one activities as scheduled and met the individual interests and needs to enhance the quality of life for two (#154 and #472) of two sampled residents. Findings Included: During an interview on 10/28/24 at 11:00 A.M., Resident #154 said he preferred to stay in bed, he felt weak due to recent cancer treatments. He wanted to participate in activities but the facility staff had not offered or provided bedside activities. Review of Resident #154's admission record, showed admission date of 6/28/24. Review of Resident #154's order summary report active orders as of 10/28/24, showed monitor and record pain every shift, restorative nursing as needed, Tramadol 50 mg every 6 hours as needed for pain. Review of Resident #154's care plan focus on pain, initiated 7/1/24, showed resident has pain or a potential for pain related to chronic knee pain and other comorbidities [and] muscle spasms. The care plan goals included Resident #154 will participate in activities of choice. Care plan interventions to included 1) report to nurse any change in usual activity attendance patterns . 2) Invite, encourage, remind and escort to preferred activities . Review of care plan focus titled, activities, initiated 7/1/24 showed the resident requires staff assistant with involvement of activities .The interventions included encouraged to participate with activities of choice, provide the resident with materials for individual activities. Review of Resident #154's Documentation Survey Report V2, dated October 2024, did not show participation in group or individual activities throughout the month. Review of Resident #154's Activity Assessment, signed 7/5/24, showed Resident #154 preferred activities in the afternoon and required physical assistance to and from activities. Resident #154 preferences included one-to-one and in-room activities. The activities Resident #154 enjoyed included word puzzles, one-on-one daily chronicle social and listening to music. Resident #154 enjoyed participating in self-directed activities and activity supplies items chosen by the resident. Review of Resident #154's admission Minimum Data Set (MDS) dated [DATE], Section C, cognitive patterns showed a Brief Interview for Mental Status (BIMS) score 15/15, which indicated intact cognition. Section GG, Functional Abilities and Goals, showed Resident #154 mobility devices were a walker or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 8 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0679 wheelchair. Level of Harm - Minimal harm or potential for actual harm Review of the facility activity calendar dated; November 2024 showed 3:00 P.M daily 1:1 room visits were scheduled. Residents Affected - Few During an interview on 10/31/24 at 9:00 A.M., the Activities Director (AD) said, during one-to-one room visits staff read, sang, provided cross word puzzles and coloring books for the residents. The AD said now she had an assistant; they would split the one-to-one room activities assignment. The AD said one-on-one activities were not documented in the resident's medical record, a logbook is used. During an interview on 10/31/24 at 9:12 A.M., the AD provided the facility's Weekly Activity log. A review of the weekly activity log dates week of 10/28/24, section titled 3:00 P.M. Activity did not include Resident #154's name. In the section of the log titled extra added activities showed all residents receive one to one room visits while delivering weekly menu During an interview on 10/31/24 at 2:43 P.M. the Director of Nursing (DON) said she expected staff to assist residents with activities. It was important to have all residents involved in activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 9 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a process was in place for smoking safety for three (#8, #29, #164) out of 19 residents sampled. Findings Included: 1. During an interview on 10/28/2024 at 10:00 a.m., Resident #8 was observed lying in bed dressed for the day. To the right of her bed was a bedside table with a green and white box of cigarettes. Next to the box was a lighter. Resident #8 stated she was a smoker but only smoked occasionally when she was having a bad day. She stated she usually signed out at the front desk and went in front of the building to smoke. She stated she did not use the facilities smoking section because the smoking area was disgusting and the times available were not convenient for her. She stated, no one cleans the smoking area, and it smells out there. She stated she bought cigarettes from the store in front of the building and two packs last her up to six months. She stated all of the other residents in the facility knew they could come and see her, and she would give them a few cigarettes. She stated she had even bought lighters for other residents in the building. She stated she kept her smoking materials with her in her room. The facility provided a Smoker List upon request during the Entrance Conference conducted on 10/28/2024. Of the residents named on this list, Resident #8's name did not appear on the list of active smokers in the facility. Resident #8 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) was done on 09/17/2024. This MDS documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. 2. During an observation on 10/31/2024 at 10:10 a.m., Resident #29 was observed sitting in her wheelchair dressed for the day and clean in appearance. Resident #29 was observed with a green lighter, while waiting for the aide to let her into the smoking patio. On 10/31/2024 at 2:00 p.m., a second observation of Resident #29 was attempted during the scheduled smoking time and no residents or staff were on the smoking patio. Resident #29 was re-admitted to the facility on [DATE] and initial admission on [DATE]. An admission Minimum Data Set (MDS) was done on 07/30/2024. This MDS documented Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she had intact cognition. 3. During an observation on 10/31/2024 at 10:12 a.m., Resident #164 was observed sitting in his wheelchair dressed for the day and clean in appearance. Resident #164 was observed with a lit cigarette in his hand on the smoking patio. On 10/31/2024 at 2:00 p.m., a second observation of Resident #164 was attempted during the scheduled smoking time and no residents or staff were in the smoking patio. Resident #164 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) was done on 10/03/2024. This MDS documented Resident #164 had a Brief Interview for Mental Status (BIMS) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 10 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0689 score of 14, which indicated he had intact cognition. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/31/2024 at 9:45 a.m., with Staff K, Restorative Certified Nurse Assistant (RCNA), she stated she went out with residents for smoking at 10:00 a.m. and 2:30 p.m. After 3 p.m., it was the Certified Nurse Assistant (CNA) on the floor's responsibility to bring out any residents who smoke. She stated she and the medical records custodian go out with the residents at 2:30 p.m. She stated the medical records custodian was also a RCNA. She stated at this time they did not require a smoking apron for any residents. She stated they had a book with the resident's picture, and it told her if the resident needed an apron while smoking. There was also a log where she could include counts of how many cigarettes the residents' smoked and how many was left in their pack. Each pack of cigarettes was labeled with the resident's names, so she knew who belonged to who. She was not sure of the process for assessing the residents to know if they required smoking aprons or any other safety items. She stated that when residents first came into the facility, they came to the smoking section and then tend to not come after being in the facility for a while. She stated I think they quit smoking so that was why they no longer came to the smoking section. She stated it was usually the same three residents that came out during the smoking sessions Residents Affected - Some During an interview on 10/31/2024 at 10:10 a.m., Staff L, CNA stated she helped supervise the residents during smoking times. She stated she also did the transportation and helped the residents go to outside appointments. She stated the residents who were in the smoking area were residents who could not go out for leave of absence (LOA) because they were careless with their cigarettes, meaning they drop it, or they were flicking ashes on themselves. She was not sure how the residents were assessed for needing supervision during smoking. She stated residents could not keep their smoking materials, so they kept them in a lock box and provided them with a lighter when they were outside. She stated the residents who signed out for Leave of Absence (LOA) got their smoking materials from the receptionist. During an interview on 10/31/2024 at 10:15 a.m. with Staff M, Receptionist, she stated residents came to her to sign out for LOA. She had a list she looked at to see who was allowed to sign out LOA. She then documented on the resident's sign out sheets of what time they signed out and would document when they signed back in. She stated if they had cigarettes in the lock box, she would provide them to them and they were supposed to turn them back in when they came back. She stated she took the smoking materials back from residents unless she was unaware that they had smoking materials. She was not able to find the lockbox where the residents smoking materials were kept at the time of the interview and stated they must have it on the smoking patio. During an interview on 10/31/2024 at 1:55 p.m., Staff G, Registered Nurse (RN), stated when new residents arrive, an admission assessment was completed. The facility protocols were explained to the residents including the smoking policy. An inventory of the residents' belongings were done with the CNA's and if the residents' said they were a smoker they let the residents' know their smoking materials would be in the lock box. She stated there was part of their admission assessment that had a spot where they answered if the resident was a smoker and when they mark yes it allowed them to answer more questions about the resident. She reviewed an admission assessment for Resident #24 was not able to locate the document she was referring to. During an interview on 10/31/2024 at 2:05 p.m., Staff N, RN, stated when a new admission came in, they get information about the resident. When the resident arrived, you complete the head-to-toe assessment, every system. If the resident was a current smoker, residents signed the education sheet, and they answered the smoking questions under the admission assessment. Staff N reviewed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 11 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some electronic medical record for Resident #8 and located the question on the initial assessment where it asked if the resident was a smoker and indicated he would mark yes instead of no in that section, and it would prompt him to answer more questions about the resident. During an interview on 10/31/2024 at 2:30 p.m., the Director of Nursing (DON), stated when residents were admitted to the facility, they completed admission assessments, vital signs, and they asked questions to confirm how alert and oriented the resident was. The next day the Interdisciplinary Team (IDT) confirmed the residents' diagnosis and looked at antibiotics. On admission they asked if the resident had cigarettes or lighters, and they took them and put them in the lock box. She stated when residents first arrived, she watched the residents during their first smoking session and assessed the resident at that time and watched if the residents flicks their cigarette without getting ashes on them. She stated if a resident got ashes on them then that would indicate the resident needed an apron. She stated she educated staff before they could supervise residents during smoking times. She stated that she did not document this information anywhere. She stated she visited the smoking area to confirm residents were safe and that the aids were out there to supervise residents during smoking times. She stated she did not document these observations anywhere. She stated when the nurses did the assessment, they asked questions to determine if the resident was safe to smoke. She stated the nurses did not observe the residents smoking. She stated the facility did not have a smoking assessment and all they had was the form (resident family and visitor smoking safety education and acknowledgement) for residents to sign. She stated residents who smoked were care planned for smoking. She stated they did have residents who signed out LOA to go smoke. She stated residents that signed out LOA she could not control. She stated If staff observed a resident with a lighter or any other smoking materials it should be removed from the resident and added to the lock box. She stated residents should not be in possession of any smoking materials while in the building. On 10/30/2024 at 4:45 p.m., the (DON) was asked for Resident #8 and Resident #24's smoking assessments. The DON provided the surveyor a form labeled Resident family and visitor smoking safety education and acknowledgement and stated this was the facilities smoking assessment. Review of the Resident family and visitor smoking safety education and acknowledgement form revealed: State law prohibits smoking within the facility. It is the facility policy that smoking be directly supervised by staff members. This is to protect both the individual smoking and the entire resident population and staff. The facility has established appropriate smoking areas and smoking times that while not interfere with the care of other residents. Guidelines: 1. Smoking or tobacco material should be labeled with the resident's name and will be maintained in a secure location. Residents may not keep any smoking or tobacco materials in their room, or on their person, to include but may not be limited to lighters matches cigarettes pipes cigars E cigarettes or any other smoking materials. Facility staff will provide materials and assist each resident as needed during the posted smoking times in the designated area. 5. Residents families or visitors should not provide assistance with or distribute smoking material to any residents wishing to smoke. 6. Staff will ensure the availability of stop and watch tools or report changes and condition to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 12 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0689 nursing personnel. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Smoking/Tobacco Use dated August 2024 revealed: Policy Residents Affected - Some The facility permits smoking and the use of tobacco products in accordance with state specific regulations. Each facility will identify specific, well-ventilated areas and designate the area(s) as approved smoking area(s). Smoking will not be permitted in any other location(s) Suspicion of non-compliance If necessary, and with resident consent or physician order in case of safety concerns, physical inspection of resident/storage areas will be performed by staff, including following contact with visitors who may be suspected of providing the resident with smoking materials and or associated articles. Smoking restrictions will not be assessed against residents for the convenience of the staff, but for the safety and well-being of the residents, staff and visitors. The smoking agreement will be provided to the resident slash resident representative to review and resign. Procedure: 1. The NHA and facility interdisciplinary team will determine the needs of the residents and established smoking times that will not interfere with the care and services of non-smoking facility residence . 2. Initiate and complete an admission data collection and initial plan of care or quarterly or as needed (PRN) data collection form if the resident requests smoking privileges. 3. Explain the smoking policy and request the resident or resident representative signed the smoking safety policy. A. File the signed original acknowledgement in the financial file B. Provide a copy to the resident or resident representative C. Place a copy of the resident medical record 4. Smoking/tobacco materials should be labeled with a resident's name and maintained in a secure location. Residents may not keep combustible smoking materials in their room. Residents are not to retain lighters, matches, cigarettes, e-cigarettes, ignitable tobacco products, or other smoking materials in their personal possession. Smoking Safety 1. Obtain the resident smoking material from the designated secure area. 9. Return the smoking supplies to the designated secure area. Education Guidance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 13 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 0689 Residents/Resident Representatives Level of Harm - Minimal harm or potential for actual harm 1. Residents that smoke, or their representatives, are provided with the smoking safety outline for signature. 2. Smoking materials are secured by staff for safekeeping. Residents Affected - Some 3. Residents leaving independently for a leave of absence will return smoking materials and any new items to nursing staff upon return. 4. Family members or friends bringing in smoking materials will give such items to staff for safe storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 14 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide emergency tracheostomy supplies for three residents (#142, #25, and #156) of three residents observed. Residents Affected - Few Findings included: 1. On 10/28/2024 at 1:48 p.m., an observation and interview was conducted in Resident #142's room with Staff E, Registered Nurse/Unit Manager (RN/UM). Resident #142 did not have the same size and a smaller size tracheostomy set in his room. Staff H, RN/UM agreed resident did not have this equipment. A record review of Resident #142's admission Record showed an initial admit date of 4/25/2024 with a readmission date of 7/18/2024. Resident #142 has a diagnosis of chronic respiratory failure unspecified whether with hypoxia or hypercapnia and tracheostomy status. A review of Resident #142's Minimal Data Set (MDS) dated [DATE] Section O- Special Treatments, Procedures and Programs, area under Respiratory Treatments C1 -Oxygen therapy, D1-Suctioning and E1Tracheostomy care was each checked off as present. A review of Resident #142's physician orders have an order dated 7/18/2024 to maintain ambu (resuscitation) bag at bedside and replacement trach of equal size and one size down maintained at bedside every sift for Preventative Measure. A review of Resident #142's care plan dated 7/18/2024 showed a focus area of Tracheostomy with interventions/tasks include but not limited to: Maintain ambu bag and replacement trach at bedside per order 2. On 10/30/2024 at 4:00 p.m., an observation and interview was conducted in Resident #25's room with Staff O, RN. Resident 's #25's humidifier bottle was dry and dated 10/27/24. Staff O, RN was unable to locate suction catheters in Resident #25's room. Oxygen was set at three liters per minute. Photographic evidence obtained. A review of Resident #25's admission Record showed an admit date of 7/27/2024 with a diagnosis of chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. A review of Resident #25's physician orders dated 7/29/2024 showed an order for humidified oxygen per trach continuously two liters every shift for shortness of breath. A review of Resident #25's care plan dated 7/27/2024 showed a focus area of Tracheostomy with interventions/tasks to include but not limited to: Give humidified oxygen as prescribed. 3. On 10/30/2024 at 4:10 p.m., an observation and interview was conducted in Resident #156's room with Staff P, RN. An observation was made of a dark pink, light red liquid ¾ of the way full in the resident's suction canister. Staff O, RN stated the canister should be changed but was unable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 15 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 Residents Affected - Few to locate a new canister in the resident's room. Staff O, RN stated he would go downstairs immediately to central supply on the first floor to obtain a new canister. Photographic evidence obtained. On 10/20/2024 at 4:20 p.m., an observation and interview was conducted with Staff H, RN/UM. Staff H, RN/UM stated Staff P, RN did not have to go downstairs to central supply and stated each floor had its own supply closet for respiratory supplies. In the supply closet, Staff H, RN/UM was unable to locate extra canisters for suction collection nor suction catheters. Staff H, RN/UM stated Staff O, RN was in here recently for suction catheters and must have removed them. A record review of Resident #156's admission Record showed an initial admit date of 8/07/2024 with a readmission date of 10/14/2024. Review of admission Record showed Resident # 156 with a diagnosis of chronic respiratory failure unspecified whether with hypoxia or hypercapnia and tracheostomy status. A review of Resident #156's Minimal Data Set (MDS) dated [DATE] Section O- Special Treatments, Procedures and Programs, area under Respiratory Treatments C1 -Oxygen therapy, D1-Suctioning and E1Tracheostomy care was each checked off as present. A review of Resident #156's physician orders dated 10/15/2024 showed the following orders: To change suction canister every 72 hours and /or when ¾ full as needed. Trach suction: trach pre-record lung sounds, HR, and respirations as needed for suction as needed (prn) Trach suction: trach post record amount of secretions characteristic of secretions: (color, odor, viscosity) lung sounds, HR, respirations and tolerance as needed for suction prn. Acetylcysteine inhalation solution 10% four milliliters via trach four times a day for abnormal mucous secretions. 10/16/2024 Ipratropium-Albuterol solution 0.5-2.5 three milligrams /three milliliters via trach every six hours for shortness of breath. Pre-evaluation: describe lung sounds (Cl-clear, D-diminished, R-rales, Rh-rhonchi, W-wheezing). A review of Resident #156's care plan dated 10/14/2024 showed a focus area of Tracheostomy with interventions/tasks include but not limited to: Maintain ambu bag and replacement trach at bedside per order Give humidified oxygen as prescribed Suction as needed. On 10/31/2024 at 1:09 p.m., an interview was conducted with the Director of Nursing (DON). The DON was aware of findings and stated the concerns will be rectified. A review of the facility's policy titled, Ventilation effective date of December 2022 showed a policy statement: The nurse will perform an emergency tracheostomy tube change in the event that a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 16 of 17 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 105234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation and Healthcare Center of Tampa 4411 N Habana Ave Tampa, FL 33614 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 tracheostomy tube becomes displace or dislodged. Level of Harm - Minimal harm or potential for actual harm Equipment needed include the following but not limited to: Resuscitation bag Residents Affected - Few Oxygen source Tracheostomy tubes-one the same size and one a size smaller Suction kit (water soluble lubricant, gloves). Suction machine A review of the facility's policy titled Tracheal bronchial suctioning no effective or revised date showed the following purpose statement: Tracheal bronchial suctioning is an effective way to maintain a clear airway and to aid in the removal of secretions for patients who are unable to clear their secretions when coughing. The indications for tracheal bronchial suctioning include: Accumulation of secretions in the airway Obstruction of the airway due to secretions Inability to swallow and Ventilation through an artificial airway with interference of normal clearance mechanism The Procedure for tracheal bronchial suctioning includes but not limited to: . 4. Gather the necessary equipment a. Suction machine: i. Suction canister ii. Suction tubing b. Suction catheter kit: i. Sterile gloves ii. APPROPRIATELY sized suction catheter (see clinical considerations) iii. Container for holding sterile water/saline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105234 If continuation sheet Page 17 of 17