Health inspection·January 25, 2024

F 0641 Section A, Part F: Discharge, Return not Anticipated. Level of Harm - Minimal harm or potential for actual harm Section A, Part A2000: discharge date - [DATE]. Section A, Part A2105: Discharge Status - Home/Community. Residents Affected - Some On [DATE] at 9:32am, an interview was conducted with Staff A, Licensed Practical Nurse (LPN), MDS Coordinator. The above MDS assessments were reviewed with Staff A, who confirmed: -Resident #127 was discharged to an ALF and the Discharge MDS assessment, which listed the discharge disposition to a hospital, was incorrect. -Resident #128 was discharged to a hospital and the Discharge MDS assessment, which listed the discharge disposition to Home/Community, was incorrect. Staff A reviewed the MDS assessment and clinical records for Resident #126. She confirmed the resident was discharged to the hospital and the discharge disposition on the MDS Discharge assessment was listed as 'death in facility.' Staff A stated the resident expired in the Emergency Department (ED) of the hospital and as the resident was not admitted to the hospital, the discharge disposition was listed as 'death in facility.' On [DATE] at 9:49am, an interview was conducted with Staff B, LPN, MDS Coordinator. Staff B stated she was taught to use 'death in facility' when a resident expired in the ED of the hospital. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated [DATE], Chapter 2, Assessments for the RAI, Page 2-10 revealed: Death in facility refers to when the resident dies in the facility or dies while on leave of absence (LOA) . On [DATE] at 10:14am, an interview was conducted with the Director of Nursing (DON). The DON confirmed he signs all MDS assessments. He confirmed he does that as the MDS coordinators are LPNs. The DON said he does not always check the MDS assessment, stating, I trust them. Review of a facility-provided policy titled MDS 3.0 Completion and dated [DATE] revealed: 2i. Death Tracking: i. Complete when a resident expires in the facility or when on LOA no later than discharge (death) date + 7 calendar days. 4b. Coding of Assessment: i. All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105248 If continuation sheet Page 2 of 6 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 105248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure one resident (41) out of thirty-five sampled was care planned for behaviors. Findings included: On 01/22/24 at 2:30 p.m., an observation was made of two residents arguing in their room. Resident #41 was sitting on the edge of her bed with pieces of her landline phone in her hand. Resident #379 seated in a wheelchair, stated her roommate, Resident #41, was coming on her side and taking her stuff from her nightstand. Resident #41 stated her son was coming to pick up her phone and to repair it. Resident #41 then placed the phone down on the bed and reached over to Resident #379's nightstand and grabbed an item. Resident #379 yelled out, that's my bible, leave it alone, put it back, she keeps taking my things. Resident #379 stated not only does she keep taking her things but Resident #41 has struck her twice since Resident #379 has been newly admitted to this room stating, she's hit me twice since I've been with her but I don't strike back. Resident #379 stated she returned from the hospital recently and was placed in this room with her roommate. Immediate assistance from staff members was sought with a speech therapist outside hallway arrived to intervene. The Director of Nursing (DON) was sought out and updated immediately on events. On 01/23/24 at 10:45 a.m., an observation was made of Resident #379 in a new location with a new roommate. Resident #379 stated she was fine with the new move and her roommate stated, I heard what happened to her and I will protect her, she is safe with me. A review of Resident #41 admission has an admission date of 12/13/23 with a primary diagnosis of Urinary Tract Infection (UTI) as well as dementia, anxiety, depression. A review of the admission Minimum Date Set (MDS) dated [DATE] Section C-Cognitive Patterns has Resident #41 with a Brief Interview for Mental Status (BIMS) of 05 suggesting severe cognitive impairment. A review of the progress notes dated 12/27/23 at 12:09 p.m. for Behavior describes resident as, continuing to have periodic episodes of increased anxiety and aggression and is not easily directed. Resident in wheelchair, calling out for her son, grabbing at personal items belonging to other residents. Resident was scheduled to have diagnostic testing; however, refused. Non-pharmacological interventions were noted as soothing conversation, redirection from unsafe areas/situation, therapeutic activity of interest, offering of snack/hydration. A review of the progress note dated 1/10/24 at 7:01 a.m. for Behavior describes resident following CNA [certified nursing assistant] as they were trying to complete rounds during evening shift. Several attempts were made to try and enter other resident's room. She was redirected each time, becoming verbally aggressive towards staff each time. Compliant with HS [evening] meds after 3 attempts. Resident noted to be sleeping between 11pm and 4:30 am. At 04:50, resident started coming down the hall, attempting to go into resident's room. When attempts were made to redirect, resident became verbally and physically aggressive with nurse. Refused to take medications several times then when she agreed, she spit them out. Resident then remained in her room, refusing to allow nurse and CNA to enter the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105248 If continuation sheet Page 3 of 6 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 105248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #41's Care Plan with a completion date of 12/31/23 showed no Behavior focused care plan. On 1/25/24 at 10:45 a.m. an interview was conducted with Staff J, Registered Nurse (RN). Staff J, RN stated resident #41 is confused sometimes but easily directed. Resident is no longer a 1:1 and had a visit from [a family member] yesterday that may have triggered resident in becoming slightly agitated by stating she wanted to go home but that she was able to calm resident down by offering a book to read. Staff J stated the Interdisciplinary Team (IDT) meets daily to discuss the facility's residents. When asked if Resident #41 should have been care planned for behavior Staff J stated, she should be. A review of the policy entitled, Comprehensive Care Plans revised 01/05/24, revealed, it is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally- competent and trauma -informed. 2. The comprehensive care plan will describe, at a minimum, the following: a) the services that are to be furnished to attain or maintain the residence highest practicable physical, mental and psychosocial well-being. b) Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her rights to refuse treatment. c) Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d) The resident's goal for admission, desired outcomes, and preferences for future discharge. e) Discharge plans as appropriate. 6. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105248 If continuation sheet Page 4 of 6 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 105248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews and facility file review, the facility failed to ensure an effective pest control program to include one of one kitchen space, and during two of four days observed (1/22/2024 and 1/24/2024). Residents Affected - Many Findings included: On 1/22/2024 at 10:34 a.m. during an initial kitchen tour there were seven to eight black in color small flying insects observed flying around the area. The flying insects were observed flying around the sink wall, around and near the parked meal tray carts, around and near the S plastic water drain pipe under the sink, as well as at, near and under the dish washing machine, specifically near the floor drain. Immediately following the observation an interview was conducted with the Dietary Aide Staff E, who confirmed the small flying insects at and under the dishwashing machine. She confirmed the insects have been in the area on and off for a few weeks but did not know when they first appeared. Further interview with the Certified Dietary Manager, who was in the area, also confirmed the small flying insects at and around the dish washing machine, surrounding parked meal tray carts as well as at and near the hand washing sink. She too was not able to remember when the small flying insects first appeared, but they have been noticing them on and off for the past few weeks. She added the facility does have a pest control company who comes out and they have treated the kitchen for pests to include the small flying insects. The Certified Dietary Manager confirmed she was not sure where the flying insects were coming from but it could be possible from a floor drain or two. On 1/22/2024 at 12:10 during a second tour of the kitchen, and with the Certified Dietary Manager and the Nursing Home Administrator, it was again observed many small flying objects surrounding the dish washing machine area, parked meal tray carts and at and near the hand washing sink. The Certified Dietary Manager again confirmed the small flying insects and she did point out as they were receiving dish washer maintenance, there were some flying insects near the floor drain under the machine. She was not sure if the small flying insects were coming from that area, but would speak to maintenance about de clogging the floor drain. On 1/24/2024 during a third kitchen tour at 10:50 a.m. and after walking up to the hand washing sink; the sink area was observed with over five small black in color flying insects. The insects were noted to fly around the meal tray carts, the hand washing sink, one to two feet from the meal service station, and at and near the dish washing machine. The Certified Dietary Manager, and the head [NAME] Staff G also confirmed the flying insects and again confirmed they have been around the kitchen for some time and that Pest Control services treat but it seems the insects keep coming back. On 1/25/2024 at 8:00 a.m. the Nursing Home Administrator provided the facility's Pest Control program service contract and policy and procedure for review. Review of the Pest Control Agreement revealed a beginning service date of 4/1/2021 and is still current. The contract revealed Roaches, Ants, Silverfish and Rodents were the pests to be routinely controlled. The contract revealed services will be conducted on a monthly basis. Further review of the monthly pest control log revealed routine service visits on 8, 9, 10, 11, 12/2023 as well as 1/2024. The log also revealed request visits during the same timespan reviewed. Months 10/2023 revealed flying ants in the Administration office. There was no other documentation to support treatment for other flying insects, and specifically in the kitchen. The Nursing Home Administrator provided evidence of the type of product that was used to treat the surfaces, walls and ceilings, in order to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105248 If continuation sheet Page 5 of 6 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 105248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774 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 0925 further outbreaks of flying insects. The date of that treatment was noted on 1/25/2024. Level of Harm - Minimal harm or potential for actual harm Review of the pest control policy and procedure with a revision date of 1/5/2024 revealed; It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Residents Affected - Many The definition explained; an Effective pest control program is defined as measures to eradicate and contain common household pest (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). The policy continued; 1. Facility will maintained a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. 2. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health. 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pests services and treat as indicated. 4. Facility will utilize a variety of methods in controlling certain seasonal pests i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pests service and state and federal regulations. 5. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures, i.e. dumpster area, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105248 If continuation sheet Page 6 of 6