Health inspection·July 13, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few happened to Resident #4. The note added the resident was not assisted from the floor. The resident was noted to be able to transfer from the floor with the assistance of a mechanical lift. The last time the resident was toileted: 7/5/23 8:00 AM. Please note the following intervention or interventions initiated: Low Bed. A review of records showed the care plan was never updated to add the low bed intervention after the fall on 7/4/23. A progress note was entered on 7/7/23 at 11:01 a.m. by the Director of Nursing (DON.) The note showed the IDT (Interdisciplinary Team) met to discuss resident being observed on the floor on 7/2/23 and 7/4/23. Interventions include bolsters to air mattress for positioning due to poor trunk control. As of the record review on 7/13/23, Resident #4's care plan did not include Low Bed. The resident was observed in her bed multiple times throughout the day on 7/13/23 with her bed at a normal height, not in a low position. An interview was completed on 7/13/23 at 12:15 p.m. with Resident #4's family member. He stated the resident had fallen out of bed twice. He said he was with the resident when she fell the second time. He said he was sitting on one side of the bed and the resident slipped off the other side. He said he was unable to get to her before she fell. He said he felt like the mattress was part of the problem. An interview was conducted on 7/13/23 at 3:53 a.m. with the DON. The DON said bolsters were added to Resident #4's bed on 7/5/23. She confirmed low bed was listed as an intervention that was supposed to be put in place after the fall on 7/2/23 and 7/4/23. The DON reviewed the care plan and confirmed it was not listed and it should have been added to the care plan by the nurse after the first fall on 7/2/23. The DON said when a resident falls on the weekend, the nurse notified the nurse manager on call and discussed the fall and interventions with them. The nurse could then update the care plan accordingly. She said when the IDT met to discuss the falls, they must not have noticed low bed was not in the care plan. A facility policy titled Fall and Injury Reduction Policy, dated March 2023, was reviewed. The policy stated the following: Overview: The facility has designated and implemented processes, which strive to reduce the risk for falls and injuries. Status post witnessed/unwitnessed fall or observed on floor event. Serious Injury 1. If there are signs/symptoms of serious injury, provide first aide if needed. 2. Ask the resident and/or witnesses what happened. 3. Obtain vital signs and document in the medication record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 2 of 8 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 07/13/2023 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 0657 7. Notify the resident representative of the fall, new interventions, and/or care given or location transferred. Level of Harm - Minimal harm or potential for actual harm 8. Update the care plan with new interventions, communicate to the care staff to the oncoming nurses and CNA's during shift-to shift report. Residents Affected - Few 11. Document the event in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 3 of 8 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 07/13/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to maintain complete and accurate documentation for two residents (Resident #7 and #2) out of seven sampled residents. Findings included: A review of Records showed Resident #7 was admitted on [DATE] with diagnoses including muscle wasting and atrophy, lack of coordination, dementia, and Alzheimer's disease. A review of the admission Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns showed the resident had a Brief Interview for Mental Status (BIMS) score of 99, meaning the interview was unable to be completed. Section G, Functional Status, showed the resident required limited assistance with 1-person physical assist with walking. A review of the facility's incident log showed Resident #7 had a fall on [DATE] at 10:31 a.m. A review of progress notes revealed the following: [DATE] 10:35 a.m.: PT lose [sic] the balance fell and hit the floor hard with his head. Dose not move from the floor, the MD is called, he orders transfer to ER family notify. 911 is called. [DATE] 2:21 p.m.: Patient returns and does not present any new orders family and MD is notify. [DATE] 9:01 a.m.: IDT met to discuss resident's fall on [DATE]. Resident was in the facility less than 24 hrs and not yet familiar with surroundings. [Resident #7] has dx of Alzheimer's and dementia. New interventions to include medication review with psych. NP and RP aware and agree with plan of care. [DATE] 10:22 p.m.: Patient returned form hospital approx. 1700 (5:00 p.m.) No new orders. Patient is a fall risk. One on one in place. Bed at lowest positions. Will continue to monitor. An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at 10:30 a.m. He stated Resident #7 fell on [DATE] and was sent to the hospital. He said they provided care to the resident, and he came back to the facility the same day with no new orders. He said the resident had been in the facility less than 24 hours before he fell. An additional interview was conducted on [DATE] at 1:00 p.m. with the NHA and the Director of Nursing (DON.) They both agreed when Resident #7 fell on [DATE] he returned to the facility the same day. They said this was his only fall. The DON also confirmed the Interdisciplinary Team (IDT) reviewed the fall on the morning of [DATE]. The DON and NHA did not know why there was a progress note in the record stating the resident came back from the hospital on [DATE]. They both stated they were going to look into it. At 2:15 p.m. the DON reviewed the record and was shown an Emergency Medical Services report from [DATE] and an emergency room After Visit Summary from [DATE]. She confirmed there is no additional information in the record about why the resident went to the emergency room on [DATE]. She stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 4 of 8 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 07/13/2023 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 0842 was unaware of anything happening. Level of Harm - Minimal harm or potential for actual harm At 3:35 p.m. the DON stated she spoke with the nurse caring for Resident #7 on [DATE]. The nurse said she sent the resident to the hospital after he fell. The DON said the nurse did not document anything about the fall or report the fall to the supervisors. The DON said there was nothing completed under Risk Management either. She stated the nurse should have notified the DON, done a risk report, documented what happened, notified the doctor and the family. The DON said the resident had medications reviewed on [DATE] after the fall and labs were ordered, but the resident refused. The DON confirmed there was not IDT review or interventions put in place after the fall on [DATE] because they were unaware it happened. Residents Affected - Few A review of admission records showed Resident #2 was admitted on [DATE] with diagnosis including major depressive disorder, malignant neoplasm of cervix, anxiety, altered mental status, muscle wasting and atrophy, senile degeneration of brain. A review of progress notes showed the following: [DATE] 12:36 a.m.: Dr. ordered Venous Doppler for edema. [DATE] 8:47 p.m.: COVID positive note. Resident placed on droplet precautions. There was no additional notes or evaluations in the record until [DATE] at 3:18 p.m. that stated, Hospice aid came in assisted with total care. On [DATE] at 6:40 p.m. a note showed, The resident is observed to by hypoactive. Vital signs are taken, reflecting and pulse and low saturation, the hospice is notified, who order 2 liters cannula oxygen, the family member who come [sic] here is notified. Hospide [sic] nurse come to assess resident. A review of the electronic and closed record did not show any hospice notes past [DATE]. An interview was conducted on [DATE] at 4:30 p.m. with the DON. The DON was asked why there was no documentation of care for Resident #2 from [DATE], when she tested positive for COVID, until [DATE] stating hospice provided care. She stated they implemented enhanced monitoring for the resident on [DATE], which includes vitals and observing for signs and symptoms of COVID. She said they are basically doing the charting on their monitoring. She said the resident had been declining but she did not remember how many days before her death on [DATE] she began to decline. The DON said the hospice notes should be in the record. She reviewed the residents record and was unable to find notes after [DATE]. Documentation was provided showing Resident #2's temperature and oxygen saturation were checked daily. Her heart rate and blood pressure were documented on [DATE] and [DATE]. A facility policy titled Charting and Documentation, revised [DATE], was reviewed. The policy stated the following: Services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 5 of 8 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 07/13/2023 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 0842 Guideline: Level of Harm - Minimal harm or potential for actual harm 1. Guidelines for implementation entries may only be recorded in the resident's record by licensed personal (e.g. RN LPN/LVN, physicians, therapist, etc.) in accordance with state law and facility policy. Residents Affected - Few 2. Incidents, accidents, or changes in the resident's condition must be recorded. 3. For skilled residents, documentation will occur at least daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 6 of 8 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 07/13/2023 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 residents had access to call lights that were functional for two (Residents #5 and #4) of four residents. Residents Affected - Few Findings included: 1. On 07/13/23 at 10:48 a.m., Resident #5 was observed sitting on her bed. She stated sometimes it took staff a long time to respond to her call light. The resident did not know if there was problem with the call light or not. The Nursing Home Administrator (NHA) asked Resident #5 to activate her call light. The light outside the resident's room did not light up. The NHA stated they would replace the bulb and audit all call lights. The NHA confirmed if a staff was not at the nurse's station at the time the resident was calling, they would not know the resident needed help. The NHA stated the nursing staff conduct frequent rounds. A review of Resident #5's record revealed the resident was admitted to the facility on [DATE] with diagnosis of benign neoplasm of cerebral meninges, Epilepsy, hyperlipidemia, Type 2 diabetes with autonomic neuropathy, muscle wasting and atrophy. A minimum Data Set (MDS) for Resident #5 showed in Section C a Brief Interview for Mental Status (BIMS) score of 04, indicating severe impairment. Section G showed the resident is dependent on staff for toilet use and hygiene and requires limited assistance of one staff member. 2. On 7/13/23 at 12:15 p.m., an interview was conducted with Resident #4's family member. He stated he was concerned about her ADL (Activities of Daily Living) care. He said, It takes a while for staff to answer call bells. I document when she pushes the button and why. I don't know if [Resident #4] is capable of using the call bell if she needed to get staff attention. The family member stated when he would visit, he was the one that had to push it for her. He said, She also has a sacral wound that she got at another facility., but they do not reposition her at all. He said he had been at the facility since 9:00 a.m. and she had been in the same position. He stated when he was concerned that [Resident #4] did not have the ability to call staff for assistance and they were not checking on her. A review of Resident #4's record showed the resident was admitted to the facility on [DATE] with a diagnoses to include Hemiplegia and Hemiparesis, morbid severe obesity, narcolepsy, muscle wasting, cognitive communication deficit, atherosclerotic heart disease and presence of cardiac pacemaker. An MDS for Resident #4 dated June 5, 2023, showed a BIMS score of 03, indicating severe impairment. Section G showed the resident was totally dependent on staff for toilet use and personal hygiene, requiring 2 person's physical assistance. On 07/13/23 at 12:35 p.m., an interview was conducted with Staff A, Occupational Therapist (OT) who was in Resident #4's room assisting her with eating. Staff A was asked to confirm this resident's ability to use the call light. The call light was noted with a cylinder type hand-holder with a button on top. The resident would have to hold the cylinder on top and use her thumb to press the call button for assistance. Staff A asked the resident if she knew how to use the call bell and the resident said no. Staff A got the resident to put the call light in her hand and asked the resident to push the button. The resident was observed trying multiple times with one or two hands and was unable to push the call light button. The resident held the call light in one hand and attempted to push the button with the same hand and was unable. She then attempted to push the button with the second had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 7 of 8 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 07/13/2023 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and was unable to coordinate both hands to hold the call light and push the button. Staff A stated she had only worked with this resident a couple of times. She stated she would speak with the nurse and see about getting the resident a different style call light. Staff A confirmed the resident was not able to push the button on the call light. A review of a facility's document titled, Grievance/Concern log, dated April 2023 showed Resident #4's family member had filed grievances on 04/07/23 and 04/10/23. A review of the grievance log dated 04/07/23 showed the family member expressed concerns about the duration of unanswered call lights and the resident's inability to make her needs known. On 04/07/23 at 12:48 p.m., an interview was conducted with the Social Services Director (SSD). She stated the family member had expressed concerns related to excessive delays in answering call lights as he watched, and [Resident #4's] inability to manipulate the call light due to physical limitations. The SSD said, his main focus was the call light he stated she could not turn it on, and no one was checking on her. The SSD stated her response was to the CNAs. She stated they said sometimes they were busy assisting other residents and that was why there was a delay. She stated the nurse educated all CNAs. The NHA stated they did not assess the resident's ability to use the call light and they did not conduct any audits. The NHA stated they had just initiated the audits. On 07/13/23 at 2:16 p.m., an interview was conducted with Staff B, OT and Staff C, ST (Speech Therapist). They stated therapy had assessed Resident #4 clinically, to determine if the resident had fine motor skills and the ability to manipulate utensils which carries over to using a call light. Staff B stated their assessment had determined the resident was able to feed herself but needed cueing for attention to the task. She stated the resident had severe dementia. She stated the resident would need cuing to train the brain for use of a call light. Staff B stated they did not assess the resident's ability to use the call light. She confirmed a resident should have an equipment they are able to use. On 07/13/23 at 2:32 p.m., an interview was conducted with the NHA. He stated the Director of Maintenance (DOM) had conducted a full house call light audit. He stated Resident #4 had received a different style of call light that she can operate. He stated during their audit they switched out some call lights for residents who were not able to manipulate the call light button to one that they just squeeze the button. He stated they had found two call lights that were not working, one in the memory care shower room and one in the family room in the memory care unit. The NHA stated they conduct call light audits monthly but will move to weekly audits. On 07/13/23 at 4:15 p.m., Surveyor requested the facility's policy on call lights. The NHA stated they did not have one. Review of a facility policy titled, Safety and Supervision of Resident, dated 05/31/18 showed staff shall make routine resident checks to help maintain resident safety and well-being. Residents safety, supervision, and assistance, to prevent accidents are facility wide priorities. (3) Routine resident checks by nursing staff involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105280 If continuation sheet Page 8 of 8