Health inspection·November 6, 2020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility shall support that each resident must receive, and the facility must provide the necessary care plan and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g. palliative approaches in the end of life situation, coordination with the Hospice plan of care. 2. Daily Updates to Care Plans a. Daily updates to care plans are added by each member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 2 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 11/3/20 at 9:30 a.m. Resident #45's room was approached and he was observed in his bed with an over the bed table positioned over his lap. He was observed with his left arm and hand positioned on his lower stomach area, under the over the bed table. His right hand and arm were positioned on the surface of the table. Further observations revealed a soft hand splint positioned on a box of personal items, near his bedside window. He was not observed wearing a splint on either of his hands. Additionally that day at 11:00 a.m., 12:56 p.m. and at 2:20 p.m. the resident was again observed in his room, while seated in his wheelchair and neither of his hands were observed with a splint applied. Further, the soft hand splint was observed placed in a box of personal items, near the bedside window. On 11/4/20 at 7:20 a.m., Resident #45 was observed in his room and in bed and not wearing a hand splint on either hand. Resident #45 was observed in his room at 8:01 a.m., seated in his wheelchair with the over the bed table placed in front of him. He was observed eating his breakfast meal and only using his right hand. His left hand and arm were observed positioned on his lap with no movement. His left hand was observed to contracted. The soft splint was again observed in the same previously observed spot, on a box of personal items near the bedside window. Various staff, to include his assigned CNA, Staff D and the unit nurse, Staff A, Registered Nurse (RN) had been observed in the room talking and communicating with the resident. None of the staff were observed to offer Resident #45 the left hand splint. On 11/4/20 at 9:10 a.m. Resident #45 was observed in a wheelchair and self-propelling up and down the hallway and using his right foot and right hand to propel the wheelchair. His left foot was resting on a foot pedal and his left hand and arm resting on the left wheelchair padded bolster. He was again observed not wearing a left hand splint. On 11/4/20 at 10:03 a.m. Resident #45 was observed in his room and seated in a wheelchair. His left arm was resting on the left armrest with the padded bolster. His left hand was hanging down towards his lap. He was noted not wearing his left hand splint. The splint was observed placed on a box of personal property near the window. The splint had been observed in the same place since 11/3/2020. On 11/4/20 at 11:45 a.m. Resident #45 was observed in his room and received a lunch meal tray. He was observed to eat with his right hand and with his left hand and arm resting on the bolstered arm rest. He was not moving his left hand and or arm. Further, the left hand splint was still not on resident's hand and was still observed placed on a box of personal property. On 11/4/20 at 12:47 p.m. Resident #45 was observed self-propelling up and down the hallway very slowly using his right hand and right leg to self propel. He was observed still not wearing the left hand splint. The splint was again observed placed on a box of personal property. On 11/4/20 at 12:50 p.m. Resident #45 was observed in his room using his right hand to write with a pen to paper. He was asked about the use of his left hand and he said, I can't really move it. He was asked if he wears anything on his left hand and he pointed over to the hand splint, that was placed on a box of his personal items. Resident #45 was asked if he wore it. He said that he did and needs help putting it on. He was asked when was the last time he wore it. Resident #45 replied,I don't know, it's been awhile and they don't help me with it. He said that he could wear it and it makes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 3 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0688 his hand feel better, but after awhile it hurts and he has to take it off. Level of Harm - Minimal harm or potential for actual harm On 11//6/20 at 7:50 a.m. Staff B, CNA was observed to assist Resident #45 while he was seated in his wheelchair to the 400 hall dining room to be weighed. He was observed wearing his left hand splint. He was asked about his splint and he said, Yeah they helped me with it today, probably because you (state) is here. He further indicated that he was not helped to put it on for awhile that he could remember. He also confirmed that he appreciates having the splint on today and it makes his hand feel better. He said he has not had problems with wearing the splint and had no discomfort at that time. Residents Affected - Few On 11/6/20 at 8:00 a.m. an interview was conducted with Resident #45's CNA, Staff D. Staff D confirmed that Resident #45 utilizes a hand splint. She confirmed that she did not put it on today, and didn't know who put it on. She did not believe Resident #45 has ever refused the splint and has seen him wear it at times. She did not know who's responsibility it was to apply the splint to his hand on a daily basis. On 11/6/20 at 8:45 a.m. an interview with the Restorative Aide, Staff B revealed she does the restorative program with residents and confirmed Resident #45 wears a left hand splint. She was unsure what the order was; if he was to wear it at night or during the day. She said residents who wear the splints all have different times to wear them. She did say that Resident #45 was already up this morning and had the left hand splint on when she went to get him for monthly weights. She was unsure who got him up for the day and applied the left hand splint. On 11/6/20 at 9:10 a.m. an interview with the 300 unit nurse, Staff C, RN. She confirmed that Resident #45 wears a left hand splint. She was asked if Resident #45 has ever presented with any behaviors of refusing to wear the left hand splint. Staff C revealed that she does not think Resident #45 has ever refused wearing the splint. She indicated that it is the responsibility of all nursing staff to assist with applying splints to residents. She did not know who applied Resident #45's splint this morning. On 11/6/2020 at 10:10 a.m. an interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and MDS Coordinator was conducted and it related to Resident #45's left hand splint and who's responsibility it was to ensure it is offered and assisted with on a daily basis. The DON explained that in Resident #45's case, he is to have the left hand splint on daily, but as tolerated. The MDS Coordinator, the ADON and the DON could not confirm there had been any behaviors, or refusals by Resident #45 with reference to wearing the splint. They looked through the record and could not find any evidence he had ever refused the splint. The DON and ADON confirmed that usually the CNA would be responsible for putting on and taking off the splint, and if a resident were to refuse, that they should notify the nurse, so the behavior could be documented. The MDS Coordinator revealed that the resident was documented with behavioral care plans, but nothing related to refusing wearing the left hand splint. A review of Resident #45's medical record revealed he was admitted to the facility on [DATE] for long term care and resided in the secured dementia unit. Review of the diagnoses sheet revealed diagnoses to include: hemiplegia, contracture multiple sites, lack of coordination, stiffness elbow shoulder (L), and muscle wasting. Review of the current Physician Order Summary dated for the month of 11/2020 revealed: Enabler to right side of bed which is medically appropriate due to promotion of bed mobility; half lap tray to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 4 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair while out of bed; Left hand splint daily per tolerance. Remove and check skin each shift (original order date 2/24/2020). Review of the last Occupational Therapy certification period assessment 8/5/2020 to 10/6/2020 revealed that Resident #45 had an onset diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Precautions included: Fall risk, Left sided weakness. Left wrist/hand contracture with Left hand splint on daily as tolerated. Review of the current care plans with the next review date of 11/11/2020 revealed the following areas: - ADL self care deficit and with impaired mobility Left side deficit, communication deficit and cognition deficit with interventions in place to include: Left hand splint on daily per md tolerance, Remove and check skin every shift, Left padded armrest bolster in wheelchair, offer to cut up food - Range of Motion (ROM) resident is at risk for developing and or has an impairment in functional joint mobility because of actual impairment Left hand, with interventions to include: Apply hand splint to Left upper extremity per therapy recommendations, splint to Left hand, Splint application: Left grip splint to be worn daily as tolerated. Based on observation, interview, and record review, the facility failed to ensure therapy devices (splints) were applied to contracted limbs to maintain, and prevent, a decrease in range of motion for two residents (#57 and #45) of thirteen residents sampled as evidenced by: 1) For Resident #57, the facility did not ensure the right-hand splint was available for use by direct care staff and applied per therapy discharge orders to prevent further wrist and hand contracture. Additionally, the facility did not evaluate and update Resident #57's care plan to determine if the ordered ankle foot orthoses was required to prevent decreased mobility in the right lower extremity, and 2) For Resident #45, the facility failed to ensure direct care staff assisted with the application of the left-hand splint to maintain range of motion. Findings included: 1) Resident #57's admission Record revealed an initial admission date of 01/11/19 with admitting medical diagnoses of phlebitis and thrombophlebitis of other deep vessels of right lower extremity, altered mental status, personal history of traumatic brain injury, other reduced mobility, and stiffness of right hand, not elsewhere classified. Additional medical diagnoses with an onset date of 06/22/20 showed contracture of the right wrist and right hand, muscle washing, and atrophy. Resident #57's Minimum Data Set, dated 09/18/20, Section C: Cognitive Patterns revealed a Brief Interview of Mental Status score of 4, indicating disorganized thinking with difficulty in recall. Section G: Functional Status revealed that Resident #57 requires extensive assistance with one-person assistance for dressing and bed mobility. Resident #57 has total dependence on direct care staff for assistance with transfer and locomotion on the unit. Resident #57's Active Orders for November 2020 revealed a physician order, order date of 03/17/20, to, Apply right hand/wrist splint daily per patient tolerance. Remove and check skin every shift every day and evening shift as tolerated. OFF at night. Further review revealed, a physician order dated 02/28/20, Apply Right AFO [Ankle Foot Orthoses] when out of bed daily per patient tolerance. Remove and check skin every shift every shift remove for skin checks every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 5 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #57's Care Plan, initiated on 01/28/20, revealed a focus of, ADL [Activities Daily Living]: The Resident has an ADL Self Care Performance Deficit as Evidence by: impaired mobility- right side . Interventions included, Apply Right AFO when out of bed or per patient tolerance . Right wrist/hand splint daily or per patient's tolerance. An observation on 11/04/20 at 12:00 p.m. revealed Resident #57 was sitting in a wheelchair inside of his room. His right hand was placed by his side and was contracted at the wrist with the fingers curled into a fist. The resident was not wearing a hand splint or a boot splint. An observation on 11/05/20 at 3:14 p.m. with an attempted interview with Resident #57 revealed a limited ability to communicate. The resident was lying in bed. He mainly responded to questions by shaking his head up and down for yes or side to side for no. When the resident was asked to open his right hand, he responded by smiling and lifting his left hand, opening and closing the fingers without assistance. An observation revealed the right hand tucked by the resident's side, contracted with no hand splint in place. An observation and interview on 11/06/20 at 7:05 a.m. revealed Resident #57 was lying in bed with the left hand on top of the bedsheets, and the right hand was underneath the bedsheets an unable to be seen from the hallway. When asked if he was wearing his hand splint, he squinted his eyes and shook his head no (from side to side). He lifted his left hand, opened and closed the fingers while smiling. He then slowly used his left hand to lift his right arm from underneath the covers to reveal the contracted right hand and wrist with no splint in place. A follow-up observation at 8:40 a.m. revealed Resident #57 was sitting in a wheelchair outside of his room without a foot or hand splint in place. Resident #57's OT [Occupational Therapy]-Therapist Progress & Discharge Summary, dated 07/25/20, page 2, section: Prosthetic/Orthotic Use revealed, The patient will tolerate R [Right] UE [Upper Extremity] wrist/hand orthosis for 6 to 8 hours and to tolerance without redness, swelling, or chaffing in order to properly position patients wrist/hand/digits due to contracture and hemiplegia End of Goal Status as of 07/25/2020 . the patient tolerates donning/doffing of R UE wrist/hand orthosis up to 6 hours without skin irritation or c/o [complaints] pain. Resident #57's PT [Physical Therapy]- Therapist Progress & Discharge Summary, dated 09/08/20, page 4, section: Precautions revealed, High fall risk. R [Right] sided spastic hemiplegia. Expressive aphasia. Single step commands. H/O TBI [History of Traumatic Brain Injury]. R arm trough on w/c [wheelchair] and R AFO when OOB [out of bed] . Record review revealed no instructions to discontinue the AFO boot. Resident #57's Splinting Program Form, with a start date of 3/24/19, revealed instructions to, R [Right] hand splint don/doff by CNA [Certified Nursing Assistant] staff daily on in AM (morning) ; off in PM (night), to tolerance. An interview on 11/06/20 at 9:11 a.m. with the Director of Rehabilitation (DOR) confirmed Resident #57 was discharged from PT on 09/08/20 and discharged from OT on 07/25/20. The discharge plans for PT and OT were to provide caregiver training on proper techniques for safe transfers, assisting the resident on getting out of bed. Precautions included wearing the AFO boot when out of bed and wearing a right-hand splint. The DOR stated that CNAs are responsible for applying the splints. To assist with this process every unit has a splint book with a picture the resident's splint and how to apply it. The splints are preventative devices. The DOR stated Resident #57's resting hand splint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 6 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few maintains the space between the finger digits and the wrist in the proper position. Overtime if the wrist continues to have over-flexion, it can break. Resident splints are kept in the residents' room. The DOR confirmed that for Resident #57, the CNA would have to place the splints on, he would not be able to do it himself. An interview and observation was conducted on 11/06/20 at 9:31 a.m. Staff M, CNA stated he floats units, meaning he works various units in the building to assist where needed. Staff M, CNA has been assigned to Resident #57's hallway for the past week, and was assigned to provide direct care to Resident #57. Staff M stated Resident #57 is accepting of care and doesn't acknowledge any pain. The resident might grimace when the mechanical lift is used, but overall is able to tolerate it. Staff M stated he uses a rolled-up towel for Resident #57's hand contracture and that the boot is worn while in bed; splints are kept in the resident's room. Staff M proceeded to Resident #57's room to confirm the presence of the splints. Upon room investigation, Staff M produced a cone splint, which did not offer wrist support, and a padded foot support device. Staff M stated that the cone splint was the only splint available in the resident's room over the past week, and the splint with the wrist support has not been in the room. During a follow-up interview on 11/06/20 at 9:43 a.m. Staff M stated that Resident #57 could wear the AFO boot both in and out of the bed. Staff M confirmed that therapy provides education on how to apply the splints. Resident #57's Treatment Administration Record for November 2020 revealed treatments to apply the right hand/wrist splint daily and to apply the right AFO when out of bed daily. Review of 11/01/20, 11/02/20, 11/03/20, 11/05/20, and 11/06/20, revealed check marks for all treatment order times and days. Check marks indicated the treatment was administered. During an interview on 11/06/20 at 10:54 a.m. the DOR said, When it comes to the cone splints, or using a towel, is that, they do not address the wrist portion. So that would be okay with a resident that's wrist is not contracted or is straight. The DOR confirmed that the AFO boot should only be worn while out of bed, saying, It should not be worn in bed because it may cause skin break down . I know the note [Therapy Note] states that the boot should be worn out of bed. A follow-up interview on 11/06/20 at 1:26 p.m. with the DOR confirmed the padded foot support in Resident #57's room was not an AFO boot, but a device used to prevent pressure ulcer development. An interview on 11/06/20 at 11:00 a.m. with the Director of Nursing confirmed that the expectation would be to follow therapy instructions, the care plan, and physician orders in place for a resident. During an interview on 11/06/20 at 11:19 a.m. the DOR stated that Resident #57 arrived at the facility with the AFO boot, but never wore it. Resident #57 was being screened to determine if the AFO boot is necessary or if it can be discontinued. The DOR stated Resident #57's hand splint was found in the therapy room in a laundry bag. An interview was conducted on 11/06/20 at 1:05 p.m. The Regional Nurse stated since therapy is contracted, the facility does not have a policy on therapy, splints, or range of motion. The Regional Nurse provided Splitting Program Instructions, stating it discusses education that should be provided to CNAs regarding applying a splint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 7 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility policy titled, Splinting Program Instructions, no date, revealed, Complete the splinting program form. Include a picture of the splint showing how it is worn, complete all the sections, at time of discharge or the visit before discharge have charge nurse sign and CNA's . Have the in-service sheet completed for daily education that was performed leading up to discharge. Show multiple days of education and multiple shifts education . complete the therapy request for orders and have signed on the day of discharge . A review of the facility policy titled, Physician Orders, dated February 2020, revealed, At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit. Nurses, therapists and pharmacists may take verbal and/or telephone orders as permitted by their State licensure board Assigned nursing staff will complete a monthly review to ensure physicians orders are captured accurately on the monthly physician's orders. Identified errors or discrepancies should be clarified. This process should be completed 3 days before the end of the month. Reviewed to ensure scheduling of the medication, treatment, etc. entered correctly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 8 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the facility policy and plan of correction, the facility's Quality Assessment and Assurance committee failed to ensure that interventions for the plan of correction for splinting devices were comprehensively implemented by not ensuring the splinting devices were ordered, in place, or care planned for three residents (#1, #3 and #2) out of a total of six sampled residents. Findings included: A review of the facility's policy and procedure titled, Quality Assurance/Quality Improvement (QAPI), dated November 2019, revealed: The purpose of the Steering Committee is to review and analyze facility related data (See Agenda) and direct appropriate actions for the facility response. The appointment of a QAPI team may be necessary to explore the depth of the issue and identify the root cause so that interventions are appropriately resourced . Team members should be knowledgeable about the process/systems used that contribute to the assignment . The Steering Committee will provide the QAPI team the appointment and resources to review, inspect, validate and analyze concerns related to the assignment. A review of the facility's plan of correction revealed a completion date of 12/4/2020. The plan of correction stated, The Director of Nursing (DON)/Designee conducted an audit and observation of current residents with splinting devices and ensured devices are ordered, in place, and care planned. The facility audit was reviewed for splints with the criteria of, Recommendation in place and carried out for splint in [electronic medical record]. The audit did not reveal that splinting devices were ordered per the plan of correction as indicated. An interview was conducted at 2:29 p.m. with the Unit Manager that identified herself as a Registered Nurse (UMRN). She was asked about resident orders for splinting devices that were discontinued. She stated, Therapy are only recommendations. Like the standing orders for PT (physical therapy) to eval (evaluate) and treat. After the therapy department has finished with the resident, they only give recommendations for the splint. The recommendations are placed on the certified nursing assistant task list. She confirmed that certified nursing assistants can follow a recommendation, but they cannot perform a physician order. The UMRN went on to say, The MD [medical doctor/physician] orders were not consistent with the care plan. So, it would be easier to just delete the MD orders. An interview was conducted at 2:40 p.m. with the Nursing Home Administrator and she confirmed the therapy orders for splints were discontinued. She stated, Our corporate stated to discontinue the MD order. As they are only a therapy recommendation. An interview was conducted at 3:46 p.m. with the Director of Rehabilitation on their process for recommendations for a splinting device for a resident. She said, after it had been determined a resident needs a splint our process is to notify the physician and get an order. She was asked about the physician order as she stated, It's our protocol in therapy department to get a physician order. We can't just put a splint on them. We have to get a physician order. She went on to say after we receive the order, we hand it off to the nursing department. The nursing distributes the task to the staff that are available per day. The Director was asked about the facility discontinuing physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 9 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0867 orders for splints. She stated, I was not aware that the facility was deleting the physician orders for splints. Level of Harm - Minimal harm or potential for actual harm 1. On 12/21/2020 at 10:20 a.m. an interview was conducted with Staff B, Restorative Aide and she stated part of her job, . is to make sure residents are wearing their splints. She was asked if she had any recent training on splints and she stated, No. She was asked how she knows what residents are to wear what splints. Staff B said that she had been provided a list of residents that she monitors. She provided a copy of the list and it was titled, Tarpon Bayou Splint Program. The list had a column for the resident name, the device type, shift and wearing schedule. Staff B, Restorative Aide was asked about the column titled shift that documented times as 7-3 (7:00 a.m. - 3:00 p.m.), 11-7 (11:00 p.m. - 7:00 a.m.), 3-11 (3:00 p.m. to 11:00 p.m.), and PRN (as needed) and she stated, I don't know what that means. Residents Affected - Few A review of the Tarpon Bayou Splint Program list showed that Resident #1 had a right elbow splint on the 11-7 shift and a right-hand splint on the 7-3 shift. The wearing schedule column indicated apply daily up to 8 hr (hours) or per pt tol. (patient tolerance). On 12/21/2020 at 10:45 a.m. Staff B was observed propelling Resident #1 in his wheelchair down the hallway. Resident #1 was wearing a right elbow splint and a brace/splint to his right lower extremity. A medical record review was conducted for Resident #1 and indicated on his admission Record documented that he had been at the facility for five years. The form included diagnoses information that contained the description of traumatic brain injury, muscle wasting and atrophy, stiffness of right elbow, and abnormalities of gait and mobility. Physician orders for December 2020 were reviewed and contained an order for check skin under splint every day shift, dated on 12/8/2020. It did not indicate were the splint was located. No current order was found in place for the right lower leg splint, right elbow splint nor the right-hand splint. Further record review was conducted that revealed the right elbow and right-hand splint were discontinued on 12/7/2020. Resident #1's care plan stated under the Focus for ROM [range of motion], initiated on 5/31/18 and revised on 10/16/18: The Resident is at risk for developing and/or has an impairment in functional joint mobility right upper extremity. The interventions included: Splint per therapy recommendation (initiated on 11/10/20 and revised on 12/8/20). On 12/21/2020 at 11:20 a.m. an interview was conducted with the Regional Nurse as she confirmed that she had been helping with the audits. She was asked about Resident #1 wearing a splint to his right lower leg. She said that she had not seen a splint on Resident #1's leg and stated, Some residents have preferences to when they wear the splints or not. She was asked why that had not been reflected in the resident's care plan. She did not respond. She was asked about Resident #1 not having physician orders for his splints, as the physician orders only reflected an order to check skin under splint every day shift, that was dated on 12/8/2020. She indicated that it is documented in the task section on the [NAME]. She was then asked how a nurse would know where to check skin under a splint every day when it did not reflect the splint location. She stated, They know to check the [NAME][certified nursing documentation]. The certified nursing documentation ([NAME]) was reviewed under the Task Reporting section. The section showed, Task: split application: R (right) elbow splint on daily for up to 8 hours or per patient tolerance 3-11 off 11-7, dated on 12/7/2020. The documentation was reviewed for the task section (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 10 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that revealed the resident right elbow splint was on 12/21/2020 at 1:20 a.m., on 12/20/2020 no documentation that it had been ever applied, on 12/19/2020 it was documented that it was on at 2:00 a.m., on 12/18 /2020 wearing at 12:06 a.m., on 12/16/2020 wearing at 12:20 a.m. , and on 12/15/2020 the resident was wearing the splint at 3:53 a.m. The Occupational Therapist (OT) -Therapist Progress & Discharge summary dated on 11/16/2020 was reviewed for Resident #1 and showed, Patient/ Caregiver Training since Last Report: Pt. [patient] caregiver training was provided regarding application, removal, skin monitoring, pt. removal, wearing R elbow orthosis daily as tolerated. FMP (Functional Maintenance Program) in place, education-in-service training record completed, and orders for wearing as tolerated in [electronic medical record], [NAME]. On 12/21/2020 at approximately 2:30 p.m. the Director of Therapy indicated that the right lower extremity brace that was observed on Resident #1 at 10:45 a.m. was called an ankle-foot orthosis (AFO). She provided a copy of a Physical Therapy Screening Form, dated 12/21/20. It stated that the reason for the screen was, pt. wearing BLE (Bilateral Lower Extremity) double upright AFOs without an order. After a short period of time the Regional Nurse and the Nursing Home Administrator said that an agency certified nursing assistant had cared for Resident #1 this morning. Apparently, she had found the right lower extremity splint in his closet and had placed it on him. 2. Resident #3 was observed at 2:06 p.m. sitting in his wheelchair outside of his room door with a splint placed on his left hand and wrist. He was asked about his splint at that time and he stated, It hurts. I don't know why am wearing it. He went on to say, I didn't have to wear it anymore and now they tell me I need to wear it. He was asked about the frequency of the splint use. Resident #3 stated, I don't wear it every day. Only when they tell me to. He began removing the hook and loop straps off the brace while stating it had been on for only 20 minutes now and it hurts too much. Resident #3 was asked if he wears the splint in the evening or at nighttime, he said only during the daytime. The medical record was reviewed for Resident #3. The admission Record indicated that he had been at the facility for over nine years. The form contained diagnoses information with the description of cerebral vascular disease, spastic hemiplegia affecting nondominant left hand, contracture of left wrist and hand and muscle wasting and atrophy. The December 2020 physician orders revealed no current order in place for the left-hand splint nor did the treatment administration record contain an order for a splint. An order was in place for check skin under splint daily every day shift, dated 12/8/2020. Further record review was conducted that revealed the left resting hand splint order was discontinued on 12/7/2020. A review of the Tarpon Bayou Splint Program list showed that Resident #3 had a left hand splint on 7-3 shift and the wearing schedule was to apply daily up to 8 hr or per pt tol. The Task Reporting section on the [NAME] showed, apply L [left] hand splint daily up to 8 hours per patient tolerance. The Task Reporting section on the [NAME] indicated the Task as hand splint daily up to 8 hours per patient tolerance. Review of recorded documentation in the task section revealed for 12/19/2020 at 6:38 p.m. the resident was wearing the splint, on 12/18/2020 at 5:28 p.m. the splint was in place, on 12/17/2020 at 4:48 p.m. the splint was in place, on 12/15/2020 at 10:59 p.m. the resident was wearing the splint, on 12/14/2020 at 8:14 p.m., 12/13/2020 at 6:41 p.m., and on 12/12/2020 at 8:56 p.m. The resident had indicated he wore the splint during the day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 11 of 12 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 105280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tarpon Bayou Center 515 Chesapeake Dr Tarpon Springs, FL 34689 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #3's care plan was reviewed and showed a Focus for Range of Motion, initiated on 4/19/16 and revised on 11/8/17, that documented, The Resident has actual limitations in Range of Motion as evidenced by: contracture of left hand r/t CVA (related to Cerebrovascular accident) with hemiparesis. Interventions included: Splints per therapy recommendation. (initiated on 4/20/16) 3. A review of the Tarpon Bayou Splint Program list showed that Resident #2 had a right-hand splint on the 3-11 shift and the wearing schedule was to apply daily up to 8 hr or per pt tol. On 12/21/2020 at 3:25 p.m. Resident #2 was observed lying in bed and it was observed that she did not have her right hand splint on. She stated, I haven't had it on for a while now. A medical record review was conducted for Resident #2. Her admission Record contained the description of her diagnoses to include Parkinson's disease, right shoulder stiffness, right elbow stiffness and muscle wasting and atrophy. The December 2020 physician orders were reviewed and were without an order for a current splint device. Upon review of discontinued orders for Resident #2, dated on 12/7/2020, the orders revealed: patient to wear right hand splint per patient tolerance. Removed and check skin every shift every evening, and night shift related to muscle wasting and atrophy. Resident #2's care plan was reviewed and showed a Focus for ADL [activities of daily living]: The Resident has an ADL Self Care Performance Deficit r/t Parkinson's, initiated on 8/23/19 and revised on 8/26/19. The intervention included, Splint per therapy recommendation. An interview at 3:30 p.m. was conducted with the Resident #2's Unit Manager, who identified herself as a Licensed Practical nurse (UMLPN). She stated that she had been on the unit for approximately three months. The UMLPN entered Resident #2's room and verified the splint was not in place. She said she would find out if the resident had an order for a splint. The UMLPN went to the nursing station and was observed reviewing Resident #2's physician orders. Which was not found at that time, as she started to review the resident's care plans. After she reviewed the care plans, she then turned stated, I will have to check with therapy if she has an order. UMLPN did not review Resident #2's [NAME] where the splint application was documented. While the UMLPN had been in Resident #2's room, Staff A, Certified Nursing Assistant (CNA) stated she worked full time at the facility and works with Resident #2 three or four nights a week. She was asked about the process for Resident #2's splint. She was unable to verbalize if Resident #2 had worn a splint or not. She stated she only works with the resident three to four times a week on the 3:00 p.m. to 11:00 p.m. shift. The UMLPN exited Resident #2's room and said she could not find a splint. Staff A then stated, I don't know where it's at maybe it got misplaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 12 of 12