Health inspection·August 13, 2021

F 0550 identify how staff were to refer to residents in regards to the assistance required during the meal service. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 2 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to honor resident's rights related to their choice of food preferences for five (Residents #37, #122, #160, #171, #193) of 59 sampled residents. Findings included An interview on 8/13/21 at 12:48 p.m., with Resident #160 revealed that she was on a regular diet and loved hot dogs and missed eating hot dogs. She reported that she did not know why she could not have a hot dog. She reported that the facility said that it was a safety hazard. She said, her mother brought her some hotdogs thinking that the facility would cook them but they would not, she was told that she could buy ready cooked hotdogs from outside the facility. Review of Resident #160's record revealed that she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed that she had a Brief Interview for Mental Status (BIMS) score of 13 (Cognitively intact), did not require her food to be mechanically altered, and had no difficulty chewing. Review of Resident #160's Nutrition Evaluation dated 7/6/21, revealed that the resident had no difficulty chewing or swallowing. During a meeting of four alert and oriented Residents (#37, #122, #171, #193) on 8/12/21 at 10:30 a.m., the group reported that they were told that due to a child choking on a hotdog at a day care center, they are not allowed to have hot dogs. The group reported that they do not understand why those who are not capable of handling a hot dog should be addressed on an individual bases and allow those residents who could and want hot dogs to have them. The group reported that this rule affects hot dogs, kielbasa, and link sausages. The group reported that this was not fair. Review of resident #37's record revealed that he was admitted to the facility on [DATE] . Review of the MDS dated [DATE], revealed that he had a BIMS score of 11 (Moderate impairment), Did not require her food to be mechanically altered and had no difficulty chewing. Review of Resident #37's Nutrition Evaluation dated 5/13/21, revealed that the resident had no difficulty chewing or swallowing. Review of Resident #122's record revealed that she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed that she had a BIMS score of 15 (Cognitively intact), did not require her food to be mechanically altered, was not on a therapeutic diet and had no difficulty chewing. Review of Resident #122's Nutrition Evaluation dated 6/23/21, revealed that the resident had no difficulty chewing or swallowing. Review of Resident #171's record revealed that she was re-admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed that she had a BIMS score of 15 (Cognitively intact), did not require her food to be mechanically altered, was not on a therapeutic diet and had no difficulty chewing. Review of Resident #171's Nutrition Evaluation dated 7/15/21, revealed that the resident had no difficulty chewing or swallowing. Review of Resident #193's record revealed that she was re-admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed that she had a BIMS score of 15 (Cognitively intact), did not require her food to be mechanically altered and had no difficulty chewing. Review of Resident #193's Nutrition Evaluation dated 7/19/21, revealed that the resident had no difficulty chewing or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 3 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0561 swallowing. Level of Harm - Minimal harm or potential for actual harm An interview on 8/13/21 at 12:11 p.m., with the Nursing Home Administrator (NHA) revealed that it was the rule of the facility that hotdogs and other sausages could not be served. He reported that this rule had been put in writing in the form of an email from the Director of Nutrition Services dated February 10, 2021, and this was what he went by. He reported that the facility did not have a policy related to serving hotdogs/sausages. Residents Affected - Some An interview on 8/13/21 at 12:35 p.m., with the Registered Dietician (RD) revealed that about one year ago all cylindrical meats were removed from the purchase guide and menus for the safety of the residents. She reported that no assessments were completed on any resident as to their ability to consume hotdogs safely. She reported that the first time she heard of a concern about hotdogs was this week when a resident consulted with her and wanted hotdogs. A phone interview on 8/13/21 at 1:27 p.m., with the Director of Nutrition Services revealed that cylindrical meats were not on the menu and not on the order guides. She reported that the order guides accommodate only meals that were in the order guide. She reported that she had been with the company for about one year and ordering outside of the order guide had never been done. She reported that typically residents were not assessed as to their ability to consume certain foods unless there was an issue. She reported that all residents had the ability to request resident choice meals, but could only get the item if it was on the order guide. She reported that there was no policy related to not serving cylindrical meats. A review of an email dated February 10, 2021, from the Director of Nutrition Services revealed that this email included the following: Just a reminder that we do not serve any cylindrical meats at our facilities (no hot dogs, no cylindrical sausages). These are not on our order guide and also should not be purchased from outside vendors. Review of the facility policy titled Resident Rights with an effective date of January 2017 revealed the following: The facility will protect and promote the rights of each resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 4 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure that each resident was afforded the right to personal privacy for one (Resident #168) of 59 sampled residents. Residents Affected - Few Findings include: Observations of Resident #168's room on 8/10/21 at 11:28 a.m., revealed the resident lived in a 4 bed room and occupied the bed next to the window. It was noted that there were multiple broken and bent blinds at the window not allowing for privacy. Observations on 8/11/21 at 10:18 a.m., revealed that the window blinds next to Resident #168 bed were bent, broken, and not allowing for privacy. Observations on 8/12/21 at 9:27 a.m., revealed that Resident #168 was asleep in her bed and the window blinds on the window next to her bed were bent, broken, and not allowing for privacy Observations on 8/13/21 at 7:47 a.m., revealed Resident #168 lying in bed sleeping in her bed next to the window. The window blinds were bent, broken, and not allowing for privacy. Review of Resident #168's quarterly Minimum Data Set (MDS) dated [DATE], revealed that this resident had a Brief Interview For Mental Status (BIMS) score of 03 (Severe Cognitive Impairment), and required extensive physical assistance of 2 persons for dressing and personal hygiene. Review of the Resident #168's care plan dated 5/7/16, revealed that the resident was unable to complete activities of daily living (ADL) tasks independently and required individualized interventions. An interview on 8/13/21 at 7:50 a.m., with Staff B, RN Unit manager revealed that the window blinds should not be like that. He reported that the window looked out to a courtyard and with other windows across on the other side of courtyard, it was possible for someone to see into the room. He reported that he was not aware of the condition of the window blinds and that this resident required total care. He said the aides who provide care daily to the resident should have reported the blinds. An interview on 8/13/21 at 8:00 a.m., with the Maintenance Director revealed that the system in place was that if staff notice a concern they should complete a work request and place it in the wall file located on each unit. He reported that every day he collected the work requests from the wall files on each unit, but had not seen anything related to the window blinds in this room. He reported in addition to the staff making work request, he did a daily walk-through and must have missed the window blinds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 5 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide a complete written notification of a Transfer & Discharge notice to the Resident representative and the Ombudsman for one (Resident #81) of five residents sampled for discharge. Findings included: Resident #81 was admitted to the facility on [DATE] according to the admission Record. On 8/11/21 at 10:11 a.m., Resident #81 was observed lying in bed. The resident was unable to speak or answer any questions related to care and was bed bound. A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was unable to be conducted due to Resident #81 being rarely/never understood. A review of the progress notes, dated 6/1/21 at 11:15 a.m., revealed Resident #81 had episodes of vomiting projectile coffee ground emesis times 4. The physician was notified, and the Advanced Registered Nurse Practitioner (ARNP) ordered the nurse to send the resident to the emergency room for evaluation and treatment. A follow up note from nursing, dated 6/1/21 at 11:15 p.m., indicated Resident #81 was admitted with a diagnosis of gastrointestinal bleeding. A review of the order summary for Resident #81 revealed a physician's order to transfer the resident to the emergency room for nausea, vomiting and coffee ground emesis dated 6/1/21. According to the admission record, the resident returned to the facility on 6/4/21. A review of the nursing home transfer/discharge notice form provided by facility revealed the front of the form to be typewritten and indicated the resident's needs could not be met at the facility. The back of the form was only signed by a nurse and dated 6/1/21. There was no signature from the resident/resident representative on the form, and no indication of notice to the Ombudsman was on the form. A review of the monthly transfer/discharge list for the facility did not indicate Resident #81 had been transferred to the hospital on 6/1/21. On 8/13/21 at 1:49 p.m., an interview was conducted with the Medical Records Manager and the Regional Registered Nurse (RN). The Manager stated she was not aware that transfer/discharge notices had to go out in writing to the resident representative. The Regional RN stated she was aware of the process, but she was not able to verify the transfer/discharge notice, and ombudsmen notification had been sent to the Resident Representative for Resident #81. The Manager stated the process had been for the nurse to initiate the documents and send the record to the medical records department where the paperwork was checked for accuracy and provided the notification. The Manager verified this process was now in place and they, medical records, would be sending the notifications out as required in the future. On 8/13/21 at 1:55 p.m., an interview was conducted by telephone with the Resident Representative for Resident #81. The Representative stated she did receive a phone call from the facility when the resident was sent out for care, and did not recall receiving any documents in the mail related to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 6 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transfer. The Representative stated she was not aware that she was to receive any documents in writing at the time of a transfer or discharge. The Representative stated she was the only designated person responsible for the care of Resident #81. A review of the policy entitled Bed hold and in-house transfer- Florida with a revised date of February 2021, revealed the following : Policy: In-house transfer: Residents that are transferred, planned or unplanned will receive the Nursing Home Transfer and Discharge Notice AHCA Form 3120. Purpose: 5. In cases of emergency transfer, notice at the time of transfer means the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. Emergency transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also still be sent to the ombudsman, but may be sent when practicable, such as in a list of residents on a monthly basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 7 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide written notification of the facility Bed Hold Policy to the Resident representative for one (Resident #81) of five residents sampled for discharge. Findings included: A review of the facility bed hold policy (dated 6/1/21) revealed a stamp on the document stating a copy was sent with Resident #1 and a copy was mailed to the patient representative. Unable to sign was written on the document and dated by nursing on 6/1/21. A review of the policy entitled Bed hold and in-house transfer- Florida with a revised dated of February 2021, revealed the following: Policy: The facility provides the resident/resident representative notice of bed-hold in advance of transfer. An additional notice, which specifies the duration of the bed-hold, will be provided upon transfer to the hospital or prior to the therapeutic leave. The bed hold form provided at the time of discharge or therapeutic leave will be written and shall specify the duration for the bed-hold. Resident hospitalization or therapeutic leave days that exceed the bed-hold period under the State's plan, 8 days for hospitalization and 16 days for therapeutic leave, will be readmitted to the facility upon the first availability of the bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services A review of the monthly transfer/discharge list for the facility did not indicate Resident #81 had been transferred to the hospital on 6/1/21. On 8/13/21 at 1:49 p.m., an interview was conducted with the Medical Records Manager and the Regional Registered Nurse (RN). The Manager stated she was not aware that transfer/discharge notices and bed hold policies had to go out in writing to the resident representative. The Regional RN stated she was aware of the process, but she was not able to verify the bed hold policy had been sent to the Resident Representative for Resident #81. The Manager stated the process had been for the nurse to initiate the documents and send the record to the medical records department where the paperwork was checked for accuracy and provide the notification. The Manager stated that this process was now in place and they, medical records, would be sending the bed holds out as required in the future. On 8/13/21 at 1:55 p.m., an interview was conducted by telephone with the Resident Representative for Resident #81. The Representative stated she received a phone call from the facility when the resident was sent out for care, did not recall receiving any documents in the mail related to the transfer. The Representative stated she was not aware that she was to receive any documents in writing at the time of a transfer or discharge. The Representative stated she was the only designated person responsible for the care of Resident #81. Resident #81 was admitted to the facility on [DATE] according to the admission Record. On 8/11/21 at 10:11 a.m., Resident #81 was observed lying in bed. The resident was unable to speak or answer any questions related to care. The resident was bed bound. A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 8 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0625 Status (BIMS) was unable to be conducted due to Resident #81 being rarely/never understood. Level of Harm - Minimal harm or potential for actual harm A review of the order summary for Resident #81 revealed a physician's order to transfer the resident to the emergency room for nausea, vomiting and coffee ground emesis dated 6/1/21. According to the admission record, the resident returned to the facility on 6/4/21. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 9 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0641 Ensure each resident receives an accurate assessment. 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 ensure that resident assessments reflected the resident's status accurately for two (#29, #32) of 59 sampled residents. Residents Affected - Few Findings included: 1. Observations on 8/10/21 at 11:55 a.m., revealed that Resident #29 was noted with his lower mouth sunken in. The resident opened his mouth to show his upper dentures in place and reported that his lower dentures were in the night stand top draw and that staff assist him in putting it in daily but no one had done it today. Observations of Resident #29 on 8/11/21 at 12:15 p.m., revealed the resident with his midday meal. It was noted that he did not have in his lower dentures. Observations on 8/12/21 at 9:24 a.m., revealed Resident #29 seated in the hallway by a window looking out. He reported that he had his breakfast already but that his dentures were still in his room in the drawer. He reported that he did not get any assistance with getting his dentures put in for his meal. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had no dental concerns. Review of the annual MDS dated [DATE], revealed that the resident had no dental concerns. The assessment indicated that this resident required extensive assistance of one person to complete personal hygiene Review of the Nursing quarterly and PRN Data collection dated 7/29/21, indicated that the resident has natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 4/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 1/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 10/29/20, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 7/29/20, indicated that the resident had natural teeth and did not have dentures. An interview with Resident #29 on 8/12/21 at 12:35 p.m., revealed that he did not get assistance with his lower dentures. He said that he would like to wear them but they did not fit, and had not fit for a long time. Interview on 8/12/21 at 12:36 p.m., with Staff A, CNA revealed that the resident did have dentures and that she asked him daily if he wanted them in and he refused. When asked if the dentures fit, she replied that she was unsure but that could be why he refused them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 10 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 8/12/21 at 12:46 p.m., with Staff B, Unit 4 manager, he reported that he was not aware of a problem with Resident #29's dentures. He was not aware that they were not being worn. He reported that he would contact Social Services and get the resident on the list to be seen by dental services. 2. Resident #32 was admitted to the facility on [DATE] and had diagnoses that included Parkinson's Disease; Contracture of Right Hand; Contracture of Left Hand; Osteoarthritis, unspecified site. Observations of Resident #32 on 8/10/21 at 11:08 a.m., revealed the resident lying in her bed with bilateral palm splints in place. Observations on 8/10/21 at 11:11 a.m., revealed the resident lying in bed. She was noted to be wearing bilateral hand splints. Observations on 8/10/21 at 1:52 p.m., revealed the resident with bilateral hand splints. Observations of Resident #32 on 8/11/21 at 10:54 a.m., revealed the resident wearing bilateral hand splints. Observations on 8/12/21 at 11:55 a.m., revealed the resident with bilateral hand splints on. Observations on 8/13/21 at 7:46 a.m., revealed the resident lying in bed, she was noted to not be wearing bilateral hand splints. An interview on 8/13/21 at 7:50 a.m., with Staff B, RN revealed that the resident needed total care and that she had some contractures of both her hands and used bilateral hand splints. Review of the Nursing Quarterly and PRN data collection dated 6/6/21 revealed that the resident did not have contractures of the right and left upper extremities, but did have contractures of right and left lower extremity. Review of the Nursing Quarterly and PRN data collection dated 3/6/21 revealed that the resident did not have contractures of the right and left upper and lower extremities. Interview on 8/13/21 at 1:59 p.m. with the Director of Nursing (DON) confirmed that Resident #32 did have contracture's of her right and left upper extremities. She reported that nursing completes the nursing assessments which should be accurate. 3. A policy was requested from the facility related to the accuracy of assessments. This policy was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 11 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 observations, record review, and interviews, the facility failed to revise the care plan for one (#153) out of fifty-nine sampled residents in related to the implementation of positioning devices while the resident was in bed. Findings included: Resident #153 was observed, on 8/11/21 at 9:25 a.m., lying in bed with the head of the bed raised and bilateral floor mats. During the observation, the mattress appeared to have bilateral bolsters on each side of the resident. On 8/12/21 at 4:10 p.m., the resident was observed lying in bed with bilateral mattress bolsters and no side rails were attached to the bed frame. On 8/12/21 at 5:28 p.m., an observation of Resident #153 was conducted with the Director of Nursing (DON) and the Assistant DON (ADON). The DON confirmed that the blue wedge on the left-side of the bed was removable from the mattress and not attached to the bed frames and that the rectangular bolster on the right-side of the bed was not attached to either the mattress or bed frame. On 8/13/21 at 10:00 a.m., an observation of the resident indicated that the resident was lying in bed with both the rectangular and wedge bolster on either side of the resident. The admission Record of Resident #153 indicated that the resident was admitted on [DATE]. The record included diagnoses not limited to other seizures, unspecified extrapyramidal and movement disorder, and dementia in other disease classified elsewhere without behavioral disturbance. A review of Resident #153's care plan indicated that the resident had a Focus for a seizure disorder, with an initial date of 10/04/16. The interventions related to the resident's seizure disorder did not indicate any safety devices were used for the resident. The care plan had a Focus that the resident was at risk for falls, with an initial date of 10/04/16. The interventions indicated that floor mats and a low/platform bed were to be used while the resident was in bed but did not indicate that bolsters were in use. The interventions of Resident #153's care plan did not identify that bilateral positioning devices were utilized for the resident. A review of Resident #153's physician orders, active as of 8/12/21, did not include an order for the use of any positioning devices while the resident was in bed. On 8/13/21 at 2:15 p.m., Staff Member H, Certified Nursing Assistant (CNA), stated Resident #153 had the wedges (bolsters) on the mattress for about one week. The staff member identified that the Registered Nurse/Unit Manager (RN/UM) had put the devices on the resident's bed. On 8/13/21 at 2:25 p.m., Staff Member G, Registered Nurse/Unit Manager (RN/UM), confirmed that she had placed the positioning devices on Resident #153's bed one or two weeks ago. She stated she had meant to implement a care plan but had not. She stated that the responsible party had been notified. She reviewed the progress notes and stated that she had not documented that the responsible party was notified. She stated that the resident had extrapyramidal movements and had the tendency to turn in the bed and its not safe. The RN/UM reviewed the clinical record and confirmed that therapy had not been notified to evaluate the resident for positioning devices. She stated she normally did refer to therapy and had meant to send the referral. The Unit Manager reported that the procedure for placing devices next to the resident was to have a therapist evaluate the resident then let the doctor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 12 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 know of therapy recommendations. She confirmed that the last Therapy Referral on 7/7/21 was not for an evaluation of positioning devices. The Director of Nursing (DON) stated, on 8/12/21 at 5:17 p.m., staff did not need a physician order for the bolsters but the bolsters should be care planned. She stated that the resident utilized the bolsters for positioning. The DON reviewed the care plan for Resident #153 and confirmed that it did not identify bolsters were utilized. On 8/13/21 at 8:54 a.m., the DON stated that the wedges were placed by nursing this week as a nursing judgement. On 8/13/21 at 1:31 p.m., the Clinical Reimbursement Coordinator stated that changes to the care plan were done as things change for the residents. The Clinical Reimbursement department was notified of changes during morning meetings, and the unit managers and nurses notify them of changes daily. The policy and procedure, Care Plan Interdisciplinary Plan of Care from Interim to Meeting, effective March 2017, indicated that The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. The policy indicated that Daily updates to care plans are added by a member of the Interdisciplinary Team (IDT) at the time of the change is implemented, the interventions needed, or other care plan revision in 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: 105299 If continuation sheet Page 13 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0791 Provide or obtain dental services for each resident. 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 prompt dental service when a residents dentures do not fit appropriately for one (Resident #29) of 59 sampled residents. Residents Affected - Few Findings included: Observations on 8/10/21 at 11:55 a.m., revealed that Resident #29 was noted with his lower mouth sunken in. The resident opened his mouth to show his upper dentures in place and reported that his lower dentures were in the night stand top draw and that staff assist him in putting it in daily but no one had done it today. Observations of Resident #29 on 8/11/21 at 12:15 p.m., revealed the resident with his midday meal. It was noted that he did not have in his lower dentures. Observations on 8/12/21 at 9:24 a.m., revealed Resident #29 seated in the hallway by a window looking out. He reported that he had his breakfast already but that his dentures were still in his room in the drawer. He reported that he did not get any assistance with getting his dentures put in for his meal. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had no dental concerns. Review of the annual MDS dated [DATE], revealed that the resident had no dental concerns. The assessment indicated that this resident required extensive assistance of one person to complete personal hygiene Review of the Nursing quarterly and PRN Data collection dated 7/29/21, indicated that the resident has natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 4/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 1/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 10/29/20, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 7/29/20, indicated that the resident had natural teeth and did not have dentures. An interview with Resident #29 on 8/12/21 at 12:35 p.m., revealed that he did not get assistance with his lower dentures. He said that he would like to wear them but they did not fit, and had not fit for a long time. Interview on 8/12/21 at 12:36 p.m., with Staff A, CNA revealed that the resident did have dentures and that she asked him daily if he wanted them in and he refused. When asked if the dentures fit, she replied that she was unsure but that could be why he refused them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 14 of 15 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 105299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Oaks 1514 E Chelsea St Tampa, FL 33610 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete In an interview on 8/12/21 at 12:46 p.m., with Staff B, Unit 4 manager, he reported that he was not aware of a problem with Resident #29's dentures. He was not aware that they were not being worn. He reported that he would contact Social Services and get the resident on the list to be seen by dental services. Review of the facility policy titled Dental Services with an effective date of February 2021 revealed that The facility will assist residents in obtaining routine care, 24-hour emergency dental care and denture replacement in the case of loss, damage, or ill-fitting dentures. Event ID: Facility ID: 105299 If continuation sheet Page 15 of 15