Health inspection·August 24, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of any incident that occurred on 8/15/2023 with Resident # 113, it was just brought to her attention 8/22/2023. The DON said after she was notified about the incident, she conducted her investigation and found out Resident # 113 had an incident outside of the facility with his transport service. She said a nurse at [local hospital] reported to Staff M, the unit manager, that when Resident #113 arrived at his appointment with transportation service, she pulled the resident's covers off of him and noticed blood on his covers and skin tears on his legs and knees. During an interview on 8/23/2023 at 2:00 p.m., Staff M said she received a call from the nurse at [local hospital] on 8/15/2023 to inform the facility that Resident #113 was left in the front lobby by someone from the transportation service. She said the nurse reported she noticed blood on the resident's sheet when he arrived so she conducted an assessment on the resident and found big abrasions on his legs and arms. She said the nurse told her she immediately reported Resident #113's condition to her supervisor and was informed by her supervisor to notify the nursing facility. Staff M said the nurse reported to her that they offered to send Resident #113 to the emergency room (ER) but he refused to go. Staff M said, when the resident arrived back to the facility, they did not conduct an skin assessment on him. She was not aware of the skin tears on the resident's arms until later on. She said she did not report the information that was given to her by the nurse at [local hospital] to the Director of Nurses (DON) and the Risk Manager (RM), she only reported the information to the floor nurse who took care of the resident when he came back to the facility. Staff M said she knew she should have made sure that an skin assessment was done and that she should have reported the information to her supervisor/ DON. During an interview on 8/23/2023 at 1:30. p.m., the Nursing Home Administrator (NHA)/RM said she was not notified that Resident #113 had an incident on 8/15/2023 until [this writer] brought it to her attention. She said after she was notified, she conducted an investigation and found out by another resident that Resident #113 was dropped on the floor on 8/15/2023 by the transport service. The NHA/ RM said the resident across the hall reported to her he watched the transport service drop Resident #113 on the floor while trying to transfer him onto their stretcher. He also reported he watched them clean up the blood from the resident off the floor, then left the room with Resident #113 on their stretcher. The NHA/ RM said she reached out to the transportation services to further investigate the situation. The transportation service reported Resident #113 was sitting on the edge of his bed and fell off the bed and scraped his knee according to their driver. They reported when they asked the resident if he was okay, the resident replied, Yes, so they picked him up off the floor, placed him on their stretcher and left the facility to take the resident to his appointment without telling anyone at the facility what happened. The NHA/ RM said a nurse from [local hospital] called the unit manager to report to her the condition Resident #113 was in when he arrived at their facility. The unit manager followed up by notifying Resident #113's doctor to obtain an order for his left knee, but she did not notify the RM and the DON about Resident #113's condition. The NHA/ RM said the nurse did everything she was supposed to do. She felt like the only thing the nurse did not do was an event report, but all other protocols were followed. A review of the facility Risk Management Manual titled, Abuse Prevention Program, Change date, August 2022. Policy: The facility has designated and implemented processes, which strive to reduce that risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 2 of 21 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 08/24/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few education if staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Definition: Alleged Violations A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not been investigated and if verified, could be noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries or unknown, and misappropriation of resident property. Procedure: The facility has implemented the following procedures in an effort to provide residents, visitors, and staff with a safe and comfortable environment. The Administrator, DON, and/ or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, exploitation and misappropriation. Identification: Events of injuries of unknown origin/ source, such as suspicious bruising occurrences, patterns, & trends or other resident injury that may constitute abuse, neglect, or mistreatment are identified ad thoroughly investigated, with appropriate reporting as indicated. Event report is initiated upon identification of actual, suspected, and/ or abuse. Investigation: An event report is initiated. NHA or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. Reporting: The facility will follow Federal regulations and State specific reporting requirements. DCF will be notified promptly. The administrator of the facility and/ or designee will be notified immediately. Photographic evidence obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 3 of 21 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 08/24/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review (PASRR) and to correct the document for seven (Residents #172, #205, #28, #81, #82, #110 and #130) of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: 1. Review of Resident #172's admission Record identified an original admission date of 8/27/21 and a recent admit date of 8/9/22. The review of Resident #172's Pre-admission Screening and Resident Review (PASRR), dated 8/25/21, showed the diagnoses of bipolar disorder, psychotic disorder, and substance abuse. The PASRR revealed the resident had had the following characteristics of difficulty of interpersonal functioning, concentration, persistence, and pace, and adaptation to change, recent treatment for mental illness, and exhibited actions or behaviors that may make them a danger to themselves or others. The PASRR showed the resident may not be admitted to an [sic] Nursing Facility and that a Level II PASRR evaluation would have to be requested due to the diagnosis or a suspicion of a Serious Mental Illness. The admission Record for Resident #172 showed diagnoses not included on the residents PASRR: dementia in other disease classified elsewhere unspecified severity with other behavioral disturbance, unspecified schizophrenia, unspecified recurrent major depressive disorder, and unspecified mood (affective) disorder. A review of Resident #172's clinical record did not include a Level II PASRR determination. The facility did not provide the resident's Level II PASRR determination. On 8/24/23 at 2:13 p.m., Staff Q, Assistant Director of Nursing (ADON), reviewed the PASRR and confirmed Resident #172's PASRR should have been redone due to the addition of diagnoses. 2. Review of Resident #205's admission Record showed an admission date of 7/20/23 and included diagnoses of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified psychosis not due to a substance or known physiological condition, and generalized anxiety disorder. A review of Resident #205's Pre-admission Screening and Resident Review (PASRR) did not show the resident had any diagnosis of mental illness (MI) or suspected MI. On 8/24/23 at 2:09 p.m., an interview was conducted with the Admissions Coordinator and Staff Q. The Coordinator stated that Admissions department ensured the PASRR obtained prior to admission and was reviewed for accuracy, if inaccurate the Nursing Home Administrator (NHA) and Social Services (SS) review if the Level II was necessary then gets back in contact with the case manager (hospital). Staff Q stated that the SS and NHA have been auditing PASRR's for the last two weeks. 3. Review of Resident #81's face sheet showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The Face sheet indicated a list of secondary diagnoses that included the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 4 of 21 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 08/24/2023 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 0644 following: Level of Harm - Minimal harm or potential for actual harm -Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with onset date of 7/19/19 Residents Affected - Few -Major depressive disorder, Recurrent, with onset date of 6/5/18 -Schizophrenia, unspecified, with onset date of 5/16/14. Review of the PASRR Level I Screen completed, signed and dated by a facility nurse on 2/11/2020 showed the resident had mental illness identified as Depressive Disorder and Schizophrenia. Review of the resident record showed there was no level II PASRR available for review. In an interview on 08/24/23 at 02:00 p.m. with Staff Q, she stated the social worker reviewed the PASRR for accuracy and if it was warranted a request for a Level II screen would be made. She indicated for Resident #81 once new diagnoses of dementia and mental illnesses were identified a request for a level II PASRR should have been made. 4. Review of Resident #82's Level I PASRR dated 2/11/20, showed a mental illness diagnosis of Anxiety Disorder, Depressive Disorder, and Schizophrenia and indicated the resident did not have a primary or secondary diagnosis of dementia or related neurocognitive disorder. A review of Resident #82's diagnosis list in the electronic record showed a diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety dated 4/1/20 as a secondary diagnosis. A review of the residents care plan related to PASRR Level II Resident has or is suspected to have a Serious Mental Illness (SMI), Intellectual Disability (D) or other related conditions that require a a PASRR Level II, This plan was initiated on 5/11/21. A review of the quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had non-Alzheimer's Dementia, Seizure disorder, Anxiety Disorder, Depression other than Bipolar. A review of the Psychiatric note dated 6/16/23 indicated the reason for the visit was to address Major depressive disorder, anxiety disorder, pseudobulbar affect, Vascular dementia. An interview on 08/24/23 at 2:00 p.m. with Staff Q revealed she, along with the social worker, reviewed the PASRR when the resident was admitted and if there were errors, the PASARR would be re-done and if a level II was needed all required documents would be sent for the review. 5. A review of the admission Record for Resident #110 showed he was admitted on [DATE], with diagnoses included but not limited to Schizophrenia, Unspecified, Psychotic Disorder with Delusions Due to known Physiological Condition, Major Depressive Disorder, Recurrent, Unspecified, Generalized Anxiety Disorder, Post - Traumatic Stress Disorder, Chronic, Abuse of Other Non- Psychoactive Substance. A review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status, (BIMS) score of 02, which indicated severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 5 of 21 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 08/24/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Preadmission Screening and Resident Review (PASRR), Level I Screen, showed Section 1, PASRR Screen Decision Making, not completed. During an interview on 8/24/2023 at 3:00 p.m., Staff Q stated she was responsible for ensuring Level II PASRR's were obtained for residents at the facility who were eligible for a Level II. Staff Q, ADON, confirmed she did not follow up to obtain a Level II PASRR for Resident # 110. 6. On 08/21/23 at 10:00 a.m., Resident #28 was observed in bed repeatedly hitting her head with her fist. The admission Record for Resident #28 showed she was initially admitted on [DATE] with diagnoses of major depressive disorder and generalized anxiety disorder. The admission Record revealed new diagnoses of vascular dementia, unspecified severity, with other behavioral disturbance documented on 10/01/22, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance documented on 10/01/22, schizophrenia documented on 05/18/22, anxiety disorder documented on 04/15/21, and unspecified psychosis not due to a substance or known physiological condition documented on 04/03/20 and the resident was not assessed for PASRR Level II. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #28 had a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Section I Active Diagnoses showed diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia and the resident was not assessed for PASSAR Level II. A review of Resident #28's PASRR Level I Assessment, dated 08/27/19 showed diagnoses of anxiety disorder and depressive disorder and no PASRR Level II was required. Review of the medical record showed the resident was not assessed for PASRR Level II. 7. The admission Record for Resident #130 showed he was initially admitted on [DATE] with a diagnosis of schizophrenia. The admission Record revealed new diagnoses of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance documented on 10/01/22, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety documented on 04/04/22, depression documented on 04/04/22, and the resident was not assessed for PASRR Level II. Section C Cognitive Patterns of the MDS dated [DATE] showed Resident #130 had a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Section I Active Diagnoses showed diagnoses of anxiety disorder and depression and the resident was not assessed for PASRR Level II. Review of Resident #130's PASRR Level I Assessment, dated 02/01/21 revealed no qualifying mental health diagnosis and that no PASRR Level II was required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 6 of 21 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 08/24/2023 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 0644 Review of the medical record revealed the resident was not assessed for PASRR Level II. Level of Harm - Minimal harm or potential for actual harm On 08/24/23 at 1:50 p.m., Staff Q said she completed and submitted the PASRRs. The Social Services Director and Administrator reviewed the PASRRs for accuracy. She looked at medications and diagnoses to determine what should be checked on the PASRR. Staff Q confirmed diagnoses were not indicated on the Level I PASARR for Resident #28 and #130. She stated the forms should have been corrected and resubmitted to Kepro for a Level II PASRR. Residents Affected - Few Review of the facility's policy titled PASRR Requirements Level I and Level II- Florida effective February 2021 revealed A resident review must be completed when there has been a significant change in a resident mental or physical condition resident review is also required if a resident is transferred to a hospital for care and the stay last longer than 90 consecutive days prior to readmission. 2. Written notification requirement for Level II referral: upon completion of the Level I PASRR screen, if the resident has a diagnosis of or suspicion of having a Serious Mental Illness (SMI), Intellectual Disability (ID) or both the screener must send the resident or legal representative written notice stating the individual has a diagnosis of, or is suspected of having an SMI, ID, or both and is being referred for a Level II evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 7 of 21 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 08/24/2023 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 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** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent further decrease in range of motion for one (Resident #3) of three sampled residents. Findings included: On 8/21/2023 at 10:12 a.m., 11:45 a.m., 12:50 p.m., and 1:55 p.m., Resident #3 was observed in her room, lying flat in bed and with her head on a pillow. One quarter bed rails on both sides of the bed were up. Resident #3 had eyes closed and with the bed linen over her and covering the lower part of her body. She was not presenting with any behaviors, pain or discomfort during all observed times. Further observations revealed both of her upper extremities (hands) were contracted. Her hands were positioned and leaning on bed rails in a manner that appeared uncomfortable. Resident #3 was not interviewable. The resident was observed not wearing any splints or braces on either of her hands. On 8/22/2023 at 7:06 a.m. and 8:20 a.m., the resident was observed in bed in a flat position with both bed rails up. Both of her hands were positioned and leaning on the metal bars of the bed rails and appeared to look uncomfortable. She was not observed wearing any splints or braces on either of her hands during all observed times. On 8/22/2023 at 12:15 p.m., the Resident #3 was observed out of bed and in a reclining chair, positioned next to her bed. She had covers and a blanket over her with her eyes closed and resting comfortably. She was not observed presenting with any behaviors, pain or discomfort. Resident #3's hands could not be observed as they were placed beneath the blanket/linen. The side of the blanket/linen was lifted slightly to observe her hands. Both hands were observed without any splints or hand devices. On 8/23/2023 at 7:10 a.m., Resident #3 was noted in bed, lying flat and under the covers. Both bed rails were up. Both of the resident's arms and hands were out from the bed linen/covers and positioned on her sides. Both of the resident's hands were noted without any splints or braces on. She was also observed at 8:01 a.m., 8:30, and 9:45 a.m. lying in bed with no splints or braces on either of her hands. On 8/23/2023 at 10:10 a.m. an interview with Staff F, Certified Nursing Assistant (CNA) was conducted. She said she had the resident on her normal working assignment and had her on a regular basis. Staff F said she was knowledgeable of the resident and her care. Staff F revealed the resident had been at the facility for a very long time and she needed total care with all of her Activities of Daily Living (ADL). Staff F confirmed Resident #3 had contractures on both of her hands. Staff F was asked if the resident utilized splints or guards. Staff F said the resident did but she had not placed them on her yet. She was asked if there were special tasks regarding palm guard/splints and she confirmed there was and it was noted in the CNA [NAME] [daily task plan]. She confirmed the palm guard/splints were to be positioned and placed during the day at the start of the 7:00 a.m.-3:00 p.m. shift. Staff F confirmed she had not gotten to it yet and was going to place them on the resident shortly. She confirmed the resident did not refuse to wear the palm guards/splints. When asked how Staff F documented the palm guards/splints were placed on each day, she revealed there was no check list for that but if there were any problems with the palm guards/splints and if the resident were to refuse, she would tell either the unit nurse or the unit manager. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 8 of 21 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 08/24/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Staff F confirmed she worked on 8/22/2023 as well and believed she put the palm guard/splints on but was not sure. She had no documentation to support the palm guard/splints were on that day. A review of the medical record showed Resident #3 was admitted to the facility on [DATE], and was readmitted on [DATE]. Residents Affected - Few Review of the diagnosis sheet revealed diagnosis sheet revealed current diagnoses to include but not limited to: Dysphagia, Contracture, unspecified joint, Contracture, unspecified hand, Epilepsy, and Intellectual Disability. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed: (Cognition/Brief Interview Mental Score or BIMS score - Not score, but indicated resident had short term/long term memory problem and with severely impaired decision making skills); (ADL - BED MOBILITY = Total Dependence, TRANSFER = Total Dependence, DRESSING = Total Dependence, TOILET USE = Total Dependence, PERSONAL HYGIENE = Total Dependence); (Upper Extremity - Impairment both sides, Lower extremity Impairment on both sides, Mobility device - None). A review of the current Physician's Order Sheet (POS) dated for the month of 8/2023 showed: - Monitor pain every shift and record pain number on a 0-10 scale x shift. - Resident to wear bilateral palm guards on in a.m. , and off in p.m., as tolerated. May remove for care and inspection of skin integrity x day shift (order date 4/6/2023). A review of the Care Plan Interdisciplinary Team (IDT) note dated 5/30/2023 showed - Care plan meeting held today with resident/[family member] in facility. IDT members information given [by] UM [unit manager], CNA, Activities Director and MDS. Discussed [NAME], medication and treatment. She uses Bilateral palm guards and is on pain meds. [Family member] says she is happy when everything is good. Plan of care will continue. A review of the all nursing notes dated from 11/25/2022 through to current 8/23/2023 did not show documentation to support Resident #3 had ever refused the use of the palm guards or hand splints. A review of the Certified Nursing Assistant (CNA) tasks/[NAME] document, showed a section for : Splint task splint type - Bilateral palm guard apply to: Splint bilateral palm guards on in am care (during day) off pm care (at night). May remove for skin sweep on 7-3, as tolerated. This task was noted assigned to CNA and RNA (Restorative Nursing Assistant). The task history for this device noted the same direction on 4/5/2021, 10/29/2021, and 1/16/2021. There were no device notes since 1/16/2023. A review of the care plans with next review date 11/15/2023, showed the following problem areas: a. Cognition - Has impaired cognitive function/dementia or impaired thought process r/t Severely impaired BIMS score of 0-7, Disease process, with interventions in place as reviewed and observed. b. Resident has a problem with communication: Rarely or never understood - unable to express ideas or want, Rarely/never understands, with interventions in place as reviewed and observed. c. Has an ADL Self Care Performance Deficit as evidence by: Cannot complete ADL tasks independently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 9 of 21 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 08/24/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm and requires individualized interventions to maintain because; Weakness, Impaired cognition, with interventions to include but not limited to: Range Of Motion - Limitations to Lower and Upper extremities encourage/provide passive/active with routine care and within physical capacity; Side Rails - Left and Right ¼ rails up as mobility aid and/or for safety during care provision and is medically appropriate for use because of weakness. Residents Affected - Few d. Range of Motion: Resident has a risk or actual limitations in Range of Motion as evidenced by: Impairment on both side hands bilateral palm guards, with interventions to include but not limited to: Splint task, Splint type: Bilateral palm guard apply to: blank no information; Splint to bilateral palm guards on in am care (during day) off pm care (at night). May remove for skin sweep on 7-3, as tolerated; Observe and Report decline in ROM. e. Skin Integrity risk - Resident has potential/actual impairment to skin integrity r/t keloids all over her back, with interventions to include but not limited to: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. On 8/24/2023 at 8:40 a.m., an interview with Staff A, Licensed Practical Nurse (LPN) showed during her shift she would make rounds and ensure her staff were implementing care plan interventions per the [NAME] and care plan problem areas. She confirmed Resident #3 had contractures on both of her hands and she was to wear splints/palm guard devices on both hands during the day to include all of the 7:00 a.m. - 3:00 p.m. shift. Staff A said the assigned aide for the day was responsible for applying the splint/palm guard daily but there was no documentation to support if the splints/palm guards were placed on or not. Staff A also said the aides did not put the splint/palm guards on, then she would do it. She confirmed as far as the donning and doffing of the splints/palm guard, the restorative staff were not responsible to do that. On 8/24/2023 at 12:30 p.m., an interview with the 100 Unit Manger Staff E confirmed the resident had a long standing of contractures on both her right and left hands. Staff E said Resident #3 had resided at the facility for many years and she required and used palm guards on both of her hands on a daily basis to reduce further contracture. Staff E was not aware Resident #3's palm guards were not applied on 8/21/2023, 8/22/2023, and the morning of 8/23/2023. She said all staff were aware to look at their [NAME] daily care plans and were to follow each intervention. She said the floor nurse as well as herself made rounds to ensure all interventions were in place, per each assignment. Staff E could not provide any documentation to support palm guards were placed and positioned each day, or if the palm guards were ever refused. Staff E said, to her knowledge, Resident #3 had never refused the use of the palm guards. During an interview on 8/24/2023 at 2:00 p.m. with the Nursing Home Administrator, she said the facility did not have a specific Contracture Management policy and procedure for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 10 of 21 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 08/24/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders related to side effect monitoring for psychotropic medications for one (Resident #161) out of five sampled residents. Findings included: The admission Record showed Resident #161 was initially admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, generalized anxiety disorder, and altered mental status. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed Resident #161 was rarely/never understood. Section N Medications indicated the resident took antianxiety and antidepressants for 7 days. The Order Summary Report with active orders as of 08/24/23 revealed the following orders: side effect monitoring; Ativan oral tablet 0.5 MG- Give 1 tablet by mouth (po) at bedtime for anxiety; buspirone HCL oral tablet 10 MG- Give 1 tablet po three times a day related to generalized anxiety disorder; divalproex sodium oral capsule delayed release sprinkle 125 MG- Give 2 capsule po three times a day for mood disorder; mirtazapine oral tablet 7.5 MG- Give 1 tablet po at bedtime for depression; and sertraline HCL oral tablet 25 MG- Give 1 tablet po at bedtime for depression. A review of the Medication Administration Record (MAR) and Treatment Medication Record (TAR) for June 2023, July 2023, and August 2023 revealed side effects were not monitored as ordered. The care plan initiated 04/17/23 showed a focus area of the use of psychotropic medications related to antidepressants to manage depression and anxiety. Interventions included antidepressant side effect monitoring and psychotropic side effect monitoring. On 08/24/23 at 1:20 p.m., the Director of Nursing (DON) stated she would have to check on the order related to side effect monitoring but did not follow up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 11 of 21 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 08/24/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and two errors were identified for two (#87 and #106) of six residents observed. These errors constituted a 8% medication error rate. Residents Affected - Few Findings included: 1. On 8/22/23 at 8:55 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #87. The staff member dispensed the following medications: - Acidophilus Probiotic 1 billion over-the-counter (OTC) capsule - Retrieved from medication refrigerator. - Amlodipine Besylate 2.5 milligram (mg) tablet - Baclofen 20 mg tablet - Vitamin D 25 microgram (mcg) - 2 tablets OTC - Loratadine 10 mg tablet OTC - Vitamin B-12 1000 mcg - 2 tablets OTC - Praxada 150 mg capsule - Potassium chloride Extended Release 20 milliequivalent (meq) - Furosemide 20 mg tablet - Gabapentin 100 mg - 2 capsules - Tamsulosin 0.4 mg capsule - Lubiprostone 24 mcg capsule - Metformin 500 mg tablet Review of Resident #87's Order Summary Report revealed an order for Acidophilus Oral Capsule (Lactobacillus) - Give 2 capsule by mouth two times a day for GI Probiotic. The review of Resident #87's August Medication Administration Record (MAR) showed Staff H had documented 2 capsules of Acidophilus had been administered. The observation of Staff H dispensing Resident #87's oral medications and the confirmation from Staff H that 16 tablets/capsules had been dispensed verified the resident did not receive 2 capsules of the probiotic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 12 of 21 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 08/24/2023 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 0759 2. On 8/22/23 at 9:19 a.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #106. Staff I dispensed the following medications: Level of Harm - Minimal harm or potential for actual harm - Docusate Sodium 100 milligram (mg) capsule over-the-counter (OTC) Residents Affected - Few - Folic acid 400 microgram (mcg) - 2 tablets OTC - Lactulose 10 gram/15 milliliter (mL) - 15 mL's - Tamsulosin 0.4 mg capsule - Vitamin D3 50 mcg (2000 international unit (iu)) OTC Staff I confirmed 5 tablets/capsules and one liquid medication had been dispensed. Staff I administered the medications to Resident #106. Review of Resident #106's August Medication Administration Record (MAR) showed the resident was scheduled at 9:00 a.m. to receive 17 grams of Polyethylene Glycol powder mixed with 8 ounces of water one time a day for constipation along with the above dispensed medications. The MAR showed Staff I had administered the Polyethylene Glycol. The observation did not show the resident had received Polyethylene Glycol. On 8/24/23 at 9:08 a.m., the Director of Nursing (DON) and Staff P, Regional Nurse Consultant (RNC) were notified of the medication errors observed. Review of Medication Administration, dated 09/18, revealed that Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The procedure instructed that Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 13 of 21 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 08/24/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure 1. one (secured 400-hall) out of five treatment carts were locked while unattended by authorized personnel on two separate occasions, 2. a tube of medicated topical ointment prescribed for a resident was not left on the dresser in a room that the resident did not reside, and 3. one (2-High) out of eight medication carts did not contain an unopened vial of Insulin Lispro. Findings included: 1. On 8/21/23 at 9:28 a.m., an observation was conducted on the secured behavioral 400-hall of a treatment cart parked behind the nursing desk next to a dining/common area. The area did not have a latched gate or door and was accessible to residents, unauthorized personnel, and visitors. The observation revealed the first drawer of the treatment cart held 2 bottles of Thick Hand Sanitizer, a box that indicated it contained a tube of Hydrocortisone cream, multiple packages of denture cleanser, and a bottle of a reddish-brown liquid. The second drawer held multiple tubes of prescribed medicated ointments, the third drawer held sterile packages of wound care supplies, a spray bottle of a liquid, and a bottle of body cleanser, the fourth drawer contained sterile packages and two bottles that contained unknown substances, and the bottom drawer contained multiple items including unpackaged cigarettes and a bottle of hair cleanser. (Photographic evidence obtained) An interview was conducted on 8/21/23 at 9:32 a.m., with Staff L, Licensed Practical Nurse (LPN). Staff L arrived to the nursing desk area from assisting with the passing of breakfast trays to residents in their rooms and confirmed the treatment cart was unlocked. Staff L stated the residents of the secured behavioral unit couldn't go through the cart then stated residents shouldn't (go through the cart). 2. On 8/22/23 at 11:12 a.m., an observation was conducted with Staff K, LPN, of a tube of medicated ointment on a dresser of a 4-bed room (room [ROOM NUMBER]) that was currently under Enhanced Barrier Precautions and where 4 residents did reside. The staff member confirmed the observation and said the medication was prescribed to a resident that did not reside in the room and stated she must have grabbed the wrong tube. Staff K confirmed the medicated topical ointment should not have been left in the room. (Photographic evidence was obtained) 3. On 8/24/23 at 10:54 a.m., a review of the 2-High medication cart was conducted with Staff M, Registered Nurse (RN)/Unit Manager (UM). The observation identified an unopened vial of Humalog (Insulin Lispro). The pharmacy label instructed Refrigerate until opened then store at room temperature. Staff M confirmed the resident had an opened vial of the same insulin that was almost full and that the unopened vial should be refrigerated. Review of the policy - Medication Storage, dated 09/18, revealed that Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. In order to limit access to prescription medications, only licensed nurses, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 14 of 21 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 08/24/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm pharmacy staff, and those lawfully authorized to administer medication (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. The procedure revealed that Insulin products should be stored in the refrigerator until opened. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 15 of 21 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 08/24/2023 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 ensure that one (Resident #37) of one resident reviewed for dental services was provided with dental follow-up for missing dentures. Residents Affected - Few Findings included: An interview with Resident #37 on 08/21/23 at 10:17 a.m. revealed he had broken upper and lower teeth. The resident said he had dentures and lost them. He said he thought someone was working on getting new ones, but he was not sure who was working on it. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated the following: -No broken or loose fitting dentures -No cavity or broken natural teeth Review of the Nutrition Evaluation dated 6/28/23 indicated the following: -chewing problems -dysphagia A review of Resident #37's care plan showed has potential oral/dental problem dated 9/26/18. The care plan, including the interventions, had no mention of the use of dentures. A review of the dental vendor Patient Progress report dated 4/19/23 showed that Patient presents for evaluation. Top denture and lower partial fit ok. No follow up needed Observations of Resident #37 on 08/24/23 at 8:44 a.m. revealed the resident lying in bed and noted to have no missing upper teeth. During an interview with the resident at this time, he reported that he had his top dentures but his bottom dentures were lost. The resident showed his mouth which reflected his upper dentures present and his lower dentures not present. During an interview on 08/24/23 at 8:46 a.m. with Staff S, Certified Nursing Assistant (CNA), she located the resident's denture cup from his nightstand which was empty and voiced his upper dentures was present at the end of her shift last evening. The resident took his upper denture from his mouth and then placed it in the cup, Staff S reported the resident was transferred from another unit with only the top dentures which he used daily. She said she was not aware of the resident having bottom dentures while on this unit. An interview on 08/24/23 at 8:52 a.m. with Staff I, Licensed Practical Nurse (LPN), revealed the resident transferred from the 300 unit and only had upper dentures since being on the 400 unit. She said Social Services was responsible for dental follow-up. An interview on 08/24/23 at 8:55 a.m. with Staff T, Social Service Director, revealed she was not aware of the resident having missing dentures. She said nursing would usually tell Social Services if there was a dental problem, and would then schedule an appointment for the resident to be seen by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 16 of 21 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 08/24/2023 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 the dental vendor. She said she was not sure when then resident was last seen by the dental vendor. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Dental Services Policy indicated the following: Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 17 of 21 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 08/24/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and record review, the facility failed to ensure 1. One of one walk in freezer unit was maintained in a manner to prevent frosting and heavy ice build up on shelving and packaged food items and 2. Failed to ensure one of one dish washing machine was operating within wash and rinse water temperature specification requirements. Findings included: 1. On 8/21/2023 at 9:15 a.m., an interview was conducted with Staff B, Dietary Manager and Staff C, Registered Dietician. Staff B said he had only been working at the facility for a couple of weeks. Staff C said she too was new to the facility and was only a Traveling Dietician. Staff B and Staff C confirmed there was a full time Dietician for the facility that was currently in the hiring process. An initial kitchen tour was conducted with Staff B and Staff C. During the tour, they said the dish machine did not normally operate until 10:00 a.m. as the facility is very large and each meal service took some time to complete. On 8/21/2023 at 10:18 a.m., a second kitchen tour was conducted with Staff B. Staff R, Dietary Aide was operating the dish washing machine. Staff B and Staff R both said the dish washing machine was a Low Temperature machine and that it had been operating properly with no issues. Both said the Wash and Rinse temperatures had been optimal and reached the machine specifications requirement. Staff B and Staff R pointed out on the machine a specifications plate that showed the machine's requirements, and showed the machine operated at low temperature with a chemical sanitizer. Staff R revealed the Wash cycle temperatures should reach about 120 degrees F (Fahrenheit) and the Rinse cycle should reach at least 130 - 135 degrees F. Staff B. confirmed this as well. A review of the specifications plate on the machine showed Wash cycle should reach at least 120 degrees F. and the Rinse cycle should reach at least 120 degrees F. Staff R and Staff B were asked what the chemical sanitizer range should reach and how they identified that. Staff B said he utilized the litmus paper test strips to test the sanitizer during each meal service, and on a daily basis to test the sanitizer output. He was then asked what the Parts Per Million (PPM) range should read. He said the range should be 150 - 400 PPM. A review of the machine specifications plate with Staff R and Staff B revealed the PPM should be in range between 50 and 100 PPM. There was signage hanging on the wall that indicated PPM range between 50 and 150 PPM. Staff B confirmed the machine should be operating with PPM between 50 and 150 PPM. Staff R was not sure what the PPM range should be with the sanitizer component of the machine. Prior to demonstrating the machine use and temperature requirements, both Staff B and Staff R said there had not been any concerns with the machine and the maintenance company had been out to check the machine and provided routine maintenance on it with no concerns. Staff B provided the Dish Machine Log for months 8/2023, 7/2023, and 6/2023 for review. It was determined through review of all three months logs, and for each day and each meal service, that the Wash temperatures were documented at 125 degrees F and above, the Rinse temperatures were documented at 125 degrees F. and above, and the PPM sanitizer was documented at 100 PPM. At 10:22 a.m. Staff R along with Staff B, demonstrated the use of the dish washing machine. The first demonstration of the machine at 10:22 a.m. revealed; The Wash gauge reached around 100 - 105 degrees F. The Rinse gauge when the rinse cycle started and finished, only reached 105 degrees F. The gauge face was observed fogged up and almost unreadable. However, after using a bright light, the gauge could then be read more clearly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 18 of 21 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 08/24/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some At 10:24 a.m. a second crate of dishes was run through and again the Wash temperature reached 100 105 degrees F. and the Rinse temperatures reached 108 degrees F. Both the Wash and Rinse cycle were confirmed by Staff B, Staff C and the Dietician. At 10:30 a.m. Staff B said the dish washing machine was working appropriately when first started this morning and had been working fine prior to that. He confirmed the temperature gauge was very hard to read and he would need to call the maintenance department and ask how the water heater boosters were and if they needed to be adjusted. Staff B revealed he would call the dish machine maintenance company to have them come out and look at the machine and see about getting a new temperature gauge. He said would use paper and plastic until the machine was fixed. On 8/23/2023 12:00 p.m., during an interview with the Dietary Manager and the Maintenance Director, both had indicated the facility's water heater booster had to be adjusted to a higher temperature, so the required heating temperatures reached the dish machine. It was confirmed that the kitchen and laundry room shared the same water heater booster. The Nursing Home Administrator also provided the Dish Machine Temperature Log policy and procedure with an effective date of 1/2021 for review. The Policy revealed; To monitor dish machine temperatures and chemical saturation (parts per million PPM), for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes. The Procedure section revealed; #1 Record month and year at the top of the form #2 Send an empty dish rack through the dish machine prior to recording temperature. a. This allows the water to reach appropriate temperatures. b. May take 3-4 times. 2. During the initial kitchen tour on 8/21/2023 at 9:15 a.m., both the walk in refrigerator and walk in freezer were observed. Upon walking in the refrigerator, there was a door in the back of the unit that lead to the inside of the walk in freezer. The analog thermometer in the walk in refrigerator that was hanging on one of the shelves in the unit read 40 degrees F. Staff B said they had just had the door open while bringing in packages of food items. After the temperature for the walk in refrigerator was read, the door to the walk in freezer unit was observed closed, but the above the door hinge and arm was not clicked in to indicate the door was completely shut. The door pulled open easily. Upon walking into the freezer unit, the back wall appeared with a double fan motor unit and with a shelving system below the motor unit. The back wall of the unit had a three tiered shelving unit with the top shelf approximately one foot below the motor unit housing. Further observations revealed packages of food items to include packaged spinach x 3 with heavy built up ice. There were clumps of ice built up on these packs of food items measuring from five inches across and six to eight inches high. The packaged food items were positioned on the top shelf, and directly below the motor unit housing. There was also very heavy ice built up on the top shelf measuring approximately six to ten inches across to five to eight inches high. There was was heavy ice built up on the floor of the unit, behind the bottom shelf. Staff B confirmed the observations. He was not sure why so much heavy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 19 of 21 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 08/24/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ice was built up but confirmed that none of the packaged food items should have ice build up. Photographic evidence was obtained On 8/24/2023 the Nursing Home Administrator confirmed they did not have a specific Dish Machine operations policy and procedure. She provided the Safety Policy and Procedure, with and effective date of 1/2021, for review. The Policy revealed; The facility promotes an optimal safe work environment in daily work routines and equipment operations. The procedure section revealed; #2 Follow manufacturer directions for each piece of equipment for property safety procedures. #4 Maintain equipment in proper working order. Report malfunctions immediately to the Maintenance Department. The Nursing Home Administrator revealed that the above policy and procedure is an interpretation of the facility's Dish Washing Machine and it's use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 20 of 21 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 08/24/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure all residents/representatives was appropriately informed and provided consent for Pneumococcal and influenza vaccinations for four (Resident #59, #81, #82, #141) of five residents reviewed for immunizations. Residents Affected - Few Findings included: 1. Review of Resident #59's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident requested the Pneumococcal vaccination and the annual influenza. Further review of the form indicated the form was signed by a facility representative on 10/14/22. There was no signature present from the resident or responsible party. 2. Review of Resident #81's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident declined the Pneumococcal vaccination and the annual influenza. Further review of the form showed the form was signed by a facility representative on 6/19/23. There was no signature present from the resident or responsible party. 3. Review Resident #82's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident declined the Pneumococcal vaccination and the annual influenza. Further review of the form showed the form was signed by a facility representative on 4/27/23. There was no signature present from the resident or responsible party. 4. Review Resident #141's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form indicated the resident declined the Pneumococcal vaccination and the annual influenza. Further review of the form indicated the form was signed by a facility representative on 8/3/23. There was no signature present from the resident or responsible party. An interview on 08/24/23 at 2:22 p.m., with the Director Of Nursing (DON) revealed she did not know why consents were not signed by the resident/representative, she indicated the consents might have been by phone but confirmed that should have been reflected on the form. A request was made of the facility for a policy on immunization consents, but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105299 If continuation sheet Page 21 of 21