Inspection·April 15, 2021

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure two (Residents #6 and #28) of forty sampled residents received the necessary services to provide grooming and personal hygiene related to showers, nail care, and shaves. Residents Affected - Few Findings included: 1. An observation and interview was conducted on Monday, 4/12/21 at 11:53 a.m., with Resident #6. The resident appeared to have a scruffy appearance and was unshaven. When asked if he choose to be unshaven, he stated he needed to be shaved. The resident stated he would allow staff to shave him if they asked. On Tuesday, 4/13/21 at 8:50 a.m., Resident #6 was observed lying in bed, his facial hair appeared to be unshaven and unclean. On 4/14/21 at 8:47 a.m., Resident #6 was asked if he had the amount of showers he wanted, he stated, I need to have more. Resident #6 stated staff help when they were able and when asked if he wanted to be shaved, the resident nodded head and chuckled. The admission Record for Resident #6 indicated that the resident had an admission date of 9/29/20 following an initial admission date of 6/28/19. The record included diagnoses not limited to unspecified Alzheimer's Disease, bipolar-type schizoaffective disorder, and acquired absence of right and left leg above the knee. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #6's Brief Interview of Mental Status (BIMS) score as 13 out of 15, indicative of an intact cognition. On 2:45 p.m. on 4/13/21, the facility's shower schedule was obtained from the Nursing Home Administrator (NHA). The NHA confirmed that the residents who resided in the A-bed (door) of even numbered rooms received showers on Monday, Wednesday, and Friday during the 7:00 a.m. - 3:00 p.m. shift, B-bed (window) residents in even numbered rooms received showers during the 3:00 p.m. - 11:00 p.m. shift on the same days, residents residing in odd numbered rooms received showers on Tuesday, Thursday, and Saturday following the same schedule for the A and B beds, and per resident preference. The review of the shower schedule indicated that Resident #6 was to obtain a shower three times a week on Monday, Wednesday, and Friday during the 7:00 a.m. - 3:00 p.m. shift. A review of bathing task documentation for the period from 3/15/21 to 4/13/21 indicated that out of the thirteen (13) bathing opportunities, the resident had received a bed bath on 3/15/21 and 4/7/21, refused bathing on 4/5/21 and 4/9/21, was unavailable on 4/2/21, and the task was not applicable on Friday 3/26/21 at 11:33 a.m., Wednesday 3/31/21 at 1:09 p.m., and at 2:49 p.m. on Monday 4/12/21. The Certified Nursing Assistant (CNA) task documentation did not specify an area in which staff would document shaving the residents. Review of Resident #6's progress note did not indicate the nurse had documented that the resident refused any bathing or assistance to be shaved. The Care Plan for Resident #6 identified that the resident had a deficit in Activities of Daily Living (ADL) and required assistance due to (d/t) recent hospitalization, impaired mobility, decreased strength, and endurance. The goal indicated that the resident would complete and/or maintain self-care tasks with assistance through next review and a corresponding intervention was to ensure Resident #6 had a clean neat appearance daily. The Functional Status of Resident #6's MDS indicated that during the assessment's 7-day period, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activity of bathing did not occur, the resident required extensive assist from 2 persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. The annual MDS, dated [DATE], indicated that per the resident it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The CNA [NAME] instructed staff was to notify physician and activated medical decision maker if non-compliant with preventative care/treatment and did not include that staff were to shave the Resident #6. At 9:38 a.m. on 4/14/21, Staff F, Unit Manager reported that aides (CNAs), nurses, and podiatry clip fingernails. She stated, mostly responsibility of aides and that the aides were to shave residents if they (residents) did not refuse. Staff F confirmed residents were to receive a shower three times a week and if a resident refused, the aides were to chart the refusal then let the nurse know of the refusal. She stated, If it's not charted it was not done. Staff F reviewed Resident #6's bathing task and confirmed that the resident did not get bathed as scheduled and that even if the resident was care planned for refusals it should be documented. Staff F stated that she had seen Resident #6 today and the resident had asked her for a razor. 2. An observation and interview was conducted on 4/12/21 at 9:50 a.m. with Resident #28. The observation revealed that his fingernails on both hands were long, extending approximately 1/4 inch above the tip of the finger, with orange-brown residual under the nails. The resident's hair was long and disheveled, his beard was scruffy with white particles in it, and not combed. As the resident was non-verbal, he was able to answer questions with nodding/shaking head and facial expressions. He indicated that he did not want the beard shaved but when asked if he wanted his fingernails clipped, he looked at them and nodded his head yes. On 4/13/21 at 8:55 a.m., Resident #28 was observed with his hair uncombed and his beard unkempt. At 8:51 a.m. on 4/14/21, Resident #28 was observed with the same long fingernails with orange-brown residual underneath. At 3:02 p.m. on 4/14/21, Resident #28 was asked if he wished he had received more showers, he nodded his head yes. Resident #28 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified cerebral infarction, aphasia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. The review of the facility showering schedule indicated that Resident #28 was to receive a shower/bath on Monday, Wednesday, and Friday during the 7:00 a.m. to 3:00 p.m. shift. A review of the Certified Nursing Assistant (CNA) documentation of the resident's bathing task for the 30 days prior to 4/14/21 indicated that the resident received a bed bath on Wednesday 3/31/21 and Wednesday 4/7/21, refused on 4/9/21, was not available on 4/2/21, and on Wednesday 3/24/21 at 2:59 p.m., Friday 3/26/21 at 2:16 p.m., and Monday 4/5/21 at 2:58 p.m. the task was not applicable. The facility had provided bathing twice and the resident had refused one time in the thirteen opportunities from 3/15/21 to 4/14/21. The CNA care [NAME] indicated the task of bathing and bathing as necessary without describing specifics and indicated that care was to be used when shaving or cutting nails. The Quarterly MDS identified that the resident required extensive assist from one person for bed mobility, dressing, toilet use, and personal hygiene and was totally dependent upon one person for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bathing. The Annual MDS, dated [DATE], identified that Resident #28 felt that chooses between a tub bath, shower, bed bath, or sponge bath was somewhat important. The Care Plan for Resident #28 included the following focuses and interventions: - Had self-care performance deficit related bathing/showering/dressing/hygiene/toileting related to (r/t) impaired mobility, impaired strength to right arm (contracture), initiated 4/30/19 and revised 4/9/21. The goals for the resident were last revised on 4/30/19 and did not include a target date that the goal should be achieved. The interventions for Resident #28 instructed staff to assist customer getting in and out of bed, assist with lower body dressing, assist with meal set up, keep oral mucous moist, and to provide oral/hygiene mouth care. The interventions did not include care instructions regarding the assistance that the resident required for bathing/showering. - Had behavioral tendencies r/t refusal of care. Frequently refuses baths. The focus was initiated and revised on 4/9/21. The interventions instructed that staff were to discuss implication of non-compliance with therapeutic regime and to explain risk versus (vs) benefit. The progress notes from 3/13-4/14/21 for Resident #28 indicated that the resident was alert and oriented to place, time, situation and able to make needs known. The progress notes did not include documentation that the resident refused showering/bathing. An agency CNA, Staff E stated, on 4/14/21 at 8:57 a.m., that bathing was documented in the computer as she pointed to the computer monitor on the wall. She stated staff documented the type of bathing done (shower or bed bath) and if the resident was assisted with 1 or 2 people. She stated if a resident refused to bathe, staff document it on the computer and have to tell the nurse. On 4/14/21 at 9:07 a.m., Staff C said during showers, staff did shave the residents and if the residents refused bathing, she would re-offer twice then after the third refusal she would let the nurse and Unit Manager know. On 9:36 a.m. on 4/14/21, Staff G, Registered Nurse (RN), reported that the CNAs did let her know if residents refuse showering/bathing and that they did not have a paper form to fill out for showers, they chart on the kiosks. At 9:52 a.m. on 4/14/21, Staff F, Unit Manager stated that Resident #28 did refuse to be showered and/or shaved. She reviewed the bathing task of Resident #28 and confirmed that the resident had not received bathing as scheduled. When asked if she had seen his fingernails, she stated no and when asked how often staff assisted the resident with hand washing, she stated his hands were washed often as the resident used his hands to eat his pureed diet and refused to allow staff to assist him. This writer and the Unit Manager visited the resident immediately following the interview and the resident confirmed he wanted his fingernails clipped and then showed Staff F his nails on both hands. On 4/14/21 at 11:45 a.m., when asked if CNAs informed him when a resident refused to be showered or bathed Staff I, Licensed Practical Nurse (LPN), stated, Honestly they don't tell me if a resident refuses, mostly agency staff. At 10:38 a.m. on 4/14/21, the Director of Nursing reviewed Resident #28's bathing task and said that the resident often refused. She stated staff were using the not applicable column as refusals and she wanted to get rid of that column. When she reviewed Resident #6's bathing task she stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Sometimes staff do not chart if the resident refused so they could reapproach the resident and inform the nurse of the refusal. The Nursing Home Administrator (NHA) stated, on 4/14/21 at 12:03 p.m., the facility did not have a policy for Activities of Daily Living or a procedure for showering/bathing. The findings of Resident #6 and #28 was discussed with her and she stated refusals should be documented and that the issue regarding residents not receiving showers/baths as scheduled sounds like a management problem. A Customer Council Summary, dated 1/28/2021, indicated that five (5) customers attended the meeting and that the concern of Shower days was voiced. The Department Response Form indicated that Customers feel shower days not consistent and sometimes missed. The form did not include a response to this concern. A review of a Team Member/ Nursing/ Inservice Education, dated February 2, 2021, provided by the Director of Nursing indicated that CNAs were to ensure you are checking your shower schedule at beginning of shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure an accident free environment for one (Resident #56) of three residents sampled for accidents. Findings included: On 4/12/21 at 12:16 p.m., Resident #56's oxygen tubing was observed on the floor and under the resident's bed. A review of the Resident #56's face sheet revealed that the resident was admitted on [DATE], readmitted on [DATE], and was his own responsible party. A review of Section E (Mood and Behaviors) of Resident #56's Minimum Data Set (MDS) completed on 3/10/21 revealed that the resident had no identified areas of concern for behaviors. Section O (Special Treatments) revealed that the resident received oxygen therapy. A review of Resident #56's event history for the last 120 days revealed an event on 2/8/21 at 3:30 p.m. that stated, [Resident #56] observed lying on the floor in his room [Resident #56] stated 'I trip [sic] on the oxygen cord and fell, I'm ok just get me up.' A review of Resident #56's care plan completed on 3/17/21 revealed a focus area for oxygen dependence that included interventions of monitor changes in vital signs, oxygen at 2 liters per minute (LPM), and promote increased rest periods. A second focus area identified Resident #56 as a fall risk. Interventions included ensure the call bell is always in reach when resident is in room, and when [Resident #56] is in bed to place all necessary items within reach. A review of Resident #56's progress notes revealed a post event follow up note on 2/11/21 at 2:51 p.m. that read as follows, IDT (Interdisciplinary Team) met r/t (related to ) post fall. Intervention in place and effective at this time. [Resident #56] has no complaint of pain/discomfort at this time. This progress note was entered by the Director of Nurses (DON). On 4/13/21 at 8:19 a.m., Resident #56 was observed in a wheelchair at his bedside. The oxygen tubing was on the floor wrapped in a pile under the bed near the wheelchair's wheels. On 4/13/21 at 1:51 p.m., Resident #56 stated that he kicks the tube under the bed, so he doesn't trip on it. On 4/14/21 at 9:07 a.m., an observation revealed that Resident #56's oxygen tube remained on the floor. Photographic evidence obtained. On 4/14/21 at 1:33 p.m., Staff A, Certified Nursing Aide (CNA), stated in regards to residents receiving oxygen therapy, CNAs were responsible to ensure the oxygen was on and flow rate was according to physician's orders, ensure the tubing is not on the floor, and if the tubing is on the floor to notify the nurse to replace it. On 4/14/21 at 2:05 p.m., Staff B, Registered Nurse (RN), stated regarding Resident #56, Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few educates [Resident #56] on oxygen treatment safety, ensure [Resident #56]'s room is free of clutter. If [Resident #56]'s oxygen tubing is found on the floor, then a nurse will replace it. When asked about the sanitation of the oxygen tube being on the floor, Staff B stated, That is definitely a concern. On 4/15/21 at 8:24 a.m., Staff A was observed walking by Resident #56's room and looking in the area of the resident's oxygen tube that was on the floor. Staff A did not stop to assist. On 4/15/21 at 8:50 a.m., the DON stated that after the Resident #56 fell due to the oxygen tubing, therapy evaluated the resident and provided education about the safety of keeping it off the floor. When asked about the intervention that was added to the care plan, the DON stated, That is something that would be in the therapy notes. When asked what her expectation would be for oxygen tubing, she stated her expectation may be different than the policy and that she would provide the policy. Therapy documentation and policies were requested. When showed the progress note about interventions being put in place post event, the DON could not recall what specific intervention was implemented regarding the oxygen tubing. A review of the Occupational Therapy notes for Resident #56 revealed a note that stated Max [verbal cue] needed for safety with [oxygen] hose. Treatment was noted as completed in resident's room with no adverse effect noted. A review of the facility's policies Nasal Cannula and High Pressure Oxygen Cylinders revealed no procedure regarding the maintenance of oxygen tubing being on the floor. A policy regarding the oxygen tubing was requested from the Administrator and DON but was not provided. On 4/15/21 at 10:19 a.m., the DON confirmed that the only intervention included in Resident #56's care plan related to the fall event due to the oxygen tube was Maintain a clutter free environment in customer's room. On 4/15/21 at 10:31 a.m., the DON returned with an updated care plan intervention within the Resident #56's care plan which stated, Ensure oxygen tubing is neatly secured off floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations the facility failed to assess eight (#6, #10, #11, #14, #18, #30, #45, and #73) out of forty sampled residents for the use of bed/side rails prior to their use, to obtain consent for their use from the resident or/and representative prior to their use, failed to obtain a physician order for their use, and to include the use of side rails in the resident's care plan. Findings included: The policy number ROP-44 was obtained from the Director of Nursing (DON), titled: Proper Use of Side Rails, and created 11/17, indicated the facility prohibits the use of side rails as a restraint. The Explanation and Compliance Guidelines of the policy included the following: - 2. An assessment of the resident's symptoms and the reason for using side rails will be conducted prior to use, including their mental status and reason for use of the side rail, and will be documented in the residents record. - 3. The physician will also review and order side rails usage as he deems necessary. - 4. Side rails may only be used in order to assist in mobility and transfer of residents. - 6. The use of side rails as an assistive device will be addressed in the residents' care plan. An interview was conducted, on 4/14/21 at 4:51 p.m., with the Director of Nursing (DON). She stated that she had been working on getting rid of the side rails. The DON stated that therapy screened the residents for the use of rails/enablers and therapy used the rails to assist the resident with positioning and enabling. She reported that the rails/enablers were assessed quarterly, should be care planned and had contacted families regarding the use but did not have signed consents for their use. The DON stated she knows that she had written notes regarding contacting the family. The DON asked to speak with the Minimum Data Set (MDS) Coordinator because she works with it. The DON left the interview and returned with the MDS Coordinator at 4:59 p.m. who stated they considered the rails as facilitators and residents would have a physician order, an assessment, and the siderails/enablers would be care planned. When a discussion regarding observations made of the use of side rails, the DON stated she did assessments of persons needing them when she first arrived at the facility in 2019. 1. Resident #6 was observed on 4/14/21 at 3:01 p.m. lying in bed with bilateral quarter side rails raised. On 4/15/21 at 2:22 p.m., the resident was observed lying in bed with bilateral side rails raised while his eyes were closed. The resident was admitted on [DATE] and 9/29/20. The admission Record included diagnoses not limited to Acquired absence of Right and Left leg above knee, unspecified Alzheimer's Disease, and unspecified Cerebral Infarction. The Quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicative of an intact cognition. A review of the clinical record, as of 4/15/21, did not include a physician order for bilateral side rails. A review of Resident #6's current care plan did not include the resident's use of side/bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0700 rails or enablers despite identifying that he had a deficit in his Activities of Daily Living. Level of Harm - Minimal harm or potential for actual harm On 4/15/21 at 2:19 p.m., the DON provided a Bed Rail Evaluation, effective 4/15/21 at 1:27 p.m., for Resident #6. The evaluation indicated appropriate alternatives were attempted which included placing the call bell within reach with reminders to use, and the bed in low position. The evaluation indicated these alternatives were effective and the use of perimeter reminders such as body pillow/cushions or mattress with raised edge were not effective. The evaluation indicated no other alternative was attempted. The bed rail was considered for mobility/transferring assistance and to assist during care. The evaluation questioned can the customer ambulate without assistance to and from the bathroom and can the customer safely exit or enter the bed in which the DON had answered both not applicable. The Interdisciplinary Team Recommendations indicated that Bed Rails were recommended at this time because other and instructed if chosen other to list which the team had documented see below. Section H3 of the evaluation indicated that bed rails were not recommended at this time due to Customer is immobile and makes no attempt to exit or shift in bed. The recommended frequency of use was during care as enabler and the use was discussed with the customer. Residents Affected - Few The care plan initiated 6/29/19 and revised on 10/13/20, for Resident #6 identified that the resident had a deficit in Activities of Daily Living(s) (ADL) and required assistance due to (d/t) recent hospitalization, impaired mobility, decreased strength, and endurance and was at risk for falls related to (r/t) history of (h/o) fall with fracture, impaired mobility and cognitive impairment. The interventions related to these deficits did not include the use of side/bed rails and/or enablers to assist with care. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 13, indicative of an intact cognition. The care plan indicated that the resident had established advanced directives which included a statement of incapacity with a decision maker. The admission Record identified a family member as the resident representative for decision making. 2. On 4/12/21 at 10:01 a.m., Resident #10 was observed lying in bed with eyes closed. The observation identified that the bed in which the resident was lying had bilateral quarter side rails raised and a trapeze hanging above her head. At 3:04 p.m. on 4/14/21, the resident was observed in bed with the side rails in the raised position. On 4/15/21 at 2:25 p.m., an observation was conducted of Resident #10. The resident was lying in bed with bilateral raised side rails and a visitor sitting beside the bed. Resident #10 was admitted on [DATE] and 9/3/20. The admission Record included diagnoses not limited to fusion of spine at lumbar region, unspecified Chronic Obstructive Pulmonary Disease, and unspecified dementia without behavioral disturbance. A review of the quarterly MDS, dated [DATE], identified Resident #10's BIMS score of 15, cognitive intact. The Functional Status portion of the MDS indicated that the resident required extensive assistance by 2 persons for bed mobility. A review of the clinical record for Resident #10, active as of 4/15/21, did not include a physician order for bilateral side rails and/or enablers. The care plan for the resident did indicate that the resident had a deficit in ADL(s) and required assistance d/t recent hospitalization, impaired mobility, decreased strength, and endurance, initiated 8/23/20 and revised 9/15/20. The interventions included the use of 1/2 side rails to assist with turning and repositioning, initiated 1/17/20 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0700 revised 9/3/20. Level of Harm - Minimal harm or potential for actual harm A request was made to the MDS Coordinator for Resident #10's Bed Rail Evaluation. The evaluation was not provided. Residents Affected - Few 3. An observation was conducted on 4/12/21 at 10:03 a.m. of Resident #11 lying in bed with bilateral quarter side rails in the raised position and bed was at thigh-high level. The resident was holding the right side rail and no staff were observed in the room. At 11:43 a.m. the bilateral side rails continued to be in the raised position with no staff in the room. On 4/14/21 at 3:05 p.m., Resident #11 was observed lying in bed with the bilateral side rails in the raised position. At 2:26 p.m. on 4/15/21, the resident was observed lying in bed with the side rails in raised position with no staff in the room. Resident #11 was admitted on [DATE] and 10/2/20. The admission Record included diagnoses not limited to other seizures, myasthenia gravis without (acute) exacerbation, and unspecified Type 2 Diabetes Mellitus without complications. A review of the clinical record for Resident #11, active as of 4/15/21, did not include a physician order for the use of side rails or enablers. The Quarterly MDS, dated [DATE], indicated a BIMS score of Resident #11 of 10, indicating moderate cognitive impairment. The Functional Status assessment of the resident indicated that she required extensive assist by one-person for bed mobility and transferring only occurred once or twice during the assessment period with one-person assist. The care plan included a focus that identified the resident was at risk for falls secondary to impaired mobility with limitations of her extremities, use of hypnotic medication, a diagnosis of seizure disorder, and declined use of padded side rails, initiated on 7/9/15 and revised on 12/15/17. The goal for this focus was to implement appropriate interventions to minimize the risk of falls through next review, revised on 6/11/18. The interventions related to the resident's risk for falls did not include the use of side rails. The care plan indicated Resident #11 had established advanced directives including a Determination of Incapacity, initiated on 7/9/15 and revised on 3/14/17. The care plan identified that the resident was totally incontinent of bowel and bladder, required total assist with toileting needs, had the potential for constipation related to impaired mobility and the use of multiple pain medications. The intervention, initiated 4/14/21, indicated the resident used a bedside enabler during care. This intervention was initiated two (2) days after the initial observation of Resident #11's raised side rails and the observations did not include staff caring for the resident. The Bed Rail Evaluation, completed by the DON and effective 4/14/21 at 5:34 p.m., indicated that appropriate alternatives were and were not attempted to considering bed rail and the following alternatives were effective: - Call bell easily within reach with visual and verbal reminders to use call bell. - Bed placed in low position. (Multiple observations during the survey period revealed the resident bed in a knee-high or higher level.) The use of perimeter reminders such as body pillow/cushions or mattress with raised edge was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few effective. The evaluation indicated that the reason the Bed Rail was being considered was due to mobility/transferring assistance during care. The Mobility and Transfer Evaluation portion of the Bed Rail Evaluation asked if the customer could ambulate without assistance to and from the bathroom and can the customer safely exit or enter the bed, which the DON answered, not applicable. The Interdisciplinary Team Recommendations indicated that Bed Rails were recommended other: see below and that Bed Rails were not recommended at this time due to the customer being immobile and made no attempt to exit or shift in bed. The recommended frequency of use was during care as enabler and use of the bed rail was discussed with the customer. The evaluation did not indicate an informed consent, or a physician order was obtained. 4. Resident #14 was observed 4/14/21 at 3:00 p.m. lying in a low-positioned bed with bilateral raised side rails. The observation did not include staff providing care to the resident. Resident #14 was admitted on [DATE] and 10/8/20. The admission Record included diagnoses of unspecified dementia without behavioral disturbance and unspecified dementia with behavioral disturbance. The Quarterly MDS, dated [DATE], identified the residents' BIMS score of 3 out of 15, indicative of severe cognitive impairment. The Functional Status of the MDS indicated the resident required extensive one-person assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of the clinical record for Resident #14, active as of 4/15/21, did not include a physician order for the use of side rails. The care plan for the resident identified that he had a deficit in ADL(s) and required assistance d/t recent hospitalization, impaired mobility, decreased strength, and endurance, initiated and revised on 3/20/21. The interventions related to the ADL deficit did not include the use of side rails. The facility did not provide the Bed Rail Evaluation for Resident #14 as requested on 4/15/21. 5. An observation was conducted on 4/12/21 at 10:14 a.m. of Resident #18. The resident was lying in a low-positioned bed with one side rail raised. The observation did not identify staff were assisting the resident with care. On 4/14/21 at 3:04 p.m., an observation of Resident #18 revealed the resident was lying in bed and bilateral quarter side rails were in the raised position. The observation did not indicate staff were assisting the resident. On 4/15/21 at 2:25 p.m., an observation identified that Resident #18 was lying in bed with raised bilateral side rails and no staff were in the resident's room. Resident #18 was admitted on [DATE] and 9/1/20. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance and unspecified lack of coordination. The Quarterly MDS, dated [DATE], did not include a BIMS score for the resident as she was rarely/never understood. The Functional Status of the MDS indicated that Resident #18 required extensive one-person assist with bed mobility, transfers, and dressing and was total dependent for one-person for eating, toilet use, personal hygiene, and bathing. A review of the clinical record for Resident #18, active as of 4/15/21, did not include a physician order for the use of side rails. Resident #18's Quarterly Therapy Screen, effective 1/28/21, indicated the following areas were impaired-no change: cognitive status, communication, self-feeding, swallowing with the comment of peg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tube, Upper Extremity (UE) self-care, Lower Extremity (LE) self-care, bed mobility, transfer, gait, and safety awareness. The screen identified that no skilled therapy was indicated and that the resident utilized side rails. The care plan for Resident #18 indicated she had a deficit in ADL(s) and required assistance d/t impaired mobility, decreased strength, and endurance, initiated 12/30/18 and revised on 9/15/20. The care plan indicated the intervention for side bed enablers during care was initiated on 4/14/21. The care plan identified that the resident had established advanced directives which included an Incapacity statement and a Healthcare Proxy. A Bed Rail Evaluation, effective 4/14/21 at 6:06 p.m. and completed by the Director of Nursing (DON), indicated that appropriate alternatives were and were not attempted to considering bed rail. The effective alternatives attempted included call bell use with visual and verbal reminders and the bed in low position. The evaluation indicated that the reason for the bed rail to be considered was for mobility/transferring assistance during care. The Mobility and Transfer portion of the Bed Rail Evaluation indicated that the questions Can the customer ambulate without assistance to and from the bathroom and Can the customer safely exit or enter the bed were not applicable. The Interdisciplinary Team (IDT) Recommendations identified that bed rails were not recommended at this time due to customer was immobile and makes no attempt to exit or shift in bed. The IDT also identified that bed rails were recommended because other and if chose other, please list: see below. The recommended frequency of use of bed rails was during care and that the bed rail use had been discussed with the customer and that the plan of care had been updated. 6. An observation on 4/12/21 at 10:01 a.m., indicated Resident #30 was lying in bed with bilateral raised side rails. The resident was holding onto the right side rail and staff were not providing care. On 4/14/21 at 3:04 p.m., the resident was observed lying in bed with bilateral raised side rails. Resident #30 was admitted on [DATE] and 12/26/17. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance, and history of falling. The Quarterly MDS, dated [DATE], identified Resident #30's BIMS score of 8, indicative of moderate cognitive impairment. The Functional Status of the MDS identified that the resident required extensive one-person assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS revealed that the activity of moving from seated to standing position, walking, and turning around did not occur and that the resident was only able to stabilize self with staff assistance for moving on and off toilet and with surface-to-surface transfer. A request was made on 4/15/21 for Resident #30's Bed Rail Evaluation. The evaluation was not provided. A review of the clinical record for Resident #30, active as of 4/15/21, identified that there was no physician order for the use of bilateral side rails. The care plan for Resident #30 did not identify that the resident utilized bilateral side rails. 7. On 4/12/21 at 10:03 a.m., an observation was made of Resident #45 lying in bed with bilateral raised side rails. At 3:05 p.m. on 4/14/21, the resident was lying in bed with bilateral side rails in the raised position. An observation was conducted at 2:26 p.m. on 4/15/21, of the resident lying in bed with eyes closed and raised bilateral side rails. Resident #45 was admitted on [DATE] and 9/22/20. The admission Record included diagnoses not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0700 Level of Harm - Minimal harm or potential for actual harm limited to unspecified dementia without behavioral disturbance and unspecified sequelae of cerebral infarction. The Annual MDS, dated [DATE], identified a BIMS score of 0, indicative of severe cognitive impairment. The Functional Status of the MDS indicated that the resident required extensive one-person assist for bed mobility, dressing, and eating, was totally dependent upon one-person for transfers, toilet use, and personal hygiene. Residents Affected - Few A review of Resident #45's clinical record, active as of 4/15/21, did not include a physician order for the use of side rails. Review of the resident's care plan did not include use of side rails. The facility did not provide Resident #45's Bed Rail Evaluation as requested. 8. An observation on 4/14/21 at 3:03 p.m., indicated Resident #73 in bed with bilateral side rails in the raised position. On 4/15/21 at 2:24 p.m., Resident #73 was observed lying with eyes closed in bed with bilateral raised side rails. The observations did not indicate staff was providing care to the resident. Resident #73 was admitted on [DATE] and 12/25/19. The admission Record included diagnoses not limited to unspecified chronic obstructive pulmonary disease and unspecified single episode major depressive disorder. The Annual MDS, dated [DATE], indicated a BIMS score of 15, indicative of an intact cognition. The Functional Status of the MDS indicated that Resident #73 required extensive assistance from one-person for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of the clinical record for Resident #73, active as of 4/15/21, did not include a physician order for the use of side rails. The care plan for Resident #73 indicated that the resident had an alteration in memory/decision making r/t Cerebrovascular Accident, alert with confusion noted, unclear speech, staff continued to redirect/orient as needed (prn) and BIMS 3 (severe cognition impairment). The care plan did not include the utilization of side rails. The facility did not provide a Bed Rail Evaluation for Resident #73 as requested. An interview was conducted on 4/15/21 at 2:18 p.m. with Staff Member C, Certified Nursing Assistant (CNA). The staff member stated when residents were out of bed, the side rails were down and she only pulls the side rails up if the residents were fall risks when they were in bed, so they won't fall. On 4/15/21 at 2:19 p.m. the DON stated she had some assessments (Bed Rail Evaluations) that the facility did but they did not include any of the residents that this writer had spoken to her about on 4/14/21. She stated that the side rails were not restraints. The DON provided three Bed Rail Evaluations for residents that were not sampled and one Bed Rail Evaluation for a resident sampled but not for bed rail concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to implement an effective Antibiotic Stewardship program related to the monitoring of antibiotic use of one (Resident #27) of one resident sampled for Transmission-based precautions. Residents Affected - Few Findings included: The Facility Matrix indicated that Resident #27 was on Transmission-based precautions. An observation on 4/13/21 at 4:03 p.m. of the area outside of Resident #27's room, did not indicate that any Personal Protective Equipment was available for staff or any signs were posted with the type of precautions to be observed while caring for the resident. On 4/13/21 at 4:04 p.m., Staff J, Registered Nurse Supervisor, stated there was not anyone on Transmission-based Precautions. When asked about Resident #27, she stated she had spoken to the physician and that the precautions were discontinued as the resident had been on an antibiotic for eight days. A review of the April Medication Administration Record (MAR) for Resident #27 indicated the resident received Linezolid 600 milligrams (mg) by mouth every 12 hours for Vancomycin Resistant Enterococci (VRE) in urine on 4/1 to 4/14/21. The Infection Onset Report for Resident #27, dated 4/1/21, indicated that symptoms of the Urinary Tract [Infection] were observed on 3/28/21. The Criteria indicated that, If the Customer has not had an indwelling catheter in the past 48 hours: at least one response from #1, #2 and #3 must be present. The responses indicated that the resident exhibited symptoms in #2: supra-pubic pain and #3: at least a 100,000 colony count of any organisms in a urine specimen. The criteria did not indicate that the resident exhibited symptoms listed in group #1. During an interview on 4/15/21 at 8:51 a.m., the Infection Control Preventionist (ICP) stated that she looked at all the orders and had only identified the antibiotic ordered for Resident #27 on 3/5 to 3/12/21. She stated the line listing for April was current as of 4/12/21. A review of the April Line Listing did not include Resident #27's antibiotic use. The ICP reviewed the April MAR for Resident #27 and confirmed that the resident had received an antibiotic (Linezolid) from 4/1 to yesterday. When asked why the resident was not included on the line listing, she stated she did not know. She reviewed the line listing for March and it indicated that the resident had been added then crossed off. She stated she thought maybe she started to put it on the list but when the Cipro (order prior to sensitivity) was discontinued and the Linezolid was ordered on 3/31/21, but not started until April, It got missed. The ICP added Resident #27 to end of the April Antibiotic Line Listing. The ICP reviewed the Infection Onset record for Resident #27 and indicated that the infection did not meet McGreer criteria. She stated that the floor nurses filled out the criteria and when an antibiotic was ordered, she would confirm that an Infection Onset report was completed. She would review progress notes to see if the resident had the third criteria, if necessary, and if it did not meet criteria, she would call the Unit Manager and ask that the provider be called to discontinue the antibiotic. She stated that the resident should have been on Transmission-based precautions for the entire course of antibiotics and could not definitely identify if Resident #27 was on isolation at all since the order was missed. The ICP reported that physician orders were not reviewed during the morning meetings and that she was not included in the Change In Condition meetings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 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 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 4/15/21 at 10:31 a.m., the Director of Nursing (DON) stated that the ICP should be notified prior to the discontinuation of precautions but was unsure if the Unit Manager had informed the ICP. At 10:42 a.m., the DON stated the Unit Managers are telling the ICP that precautions are discontinued, the ICP does not tell Unit Manager. On 4/15/21 at 11:27 a.m., the ICP said that the facility did not have a policy regarding Antibiotic Stewardship but provided a Monthly Infection Control Report, revised on 8/29/2017. The report described the Antibiotic Days of Therapy, Adverse Drug events related to (r/t) Antibiotics, Rate of Antibiotic, Prophylactic Antibiotic Therapy, and a short description of the Constitutional Criteria. The ICP provided education regarding the Core Elements for Antibiotic Stewardship in Nursing Homes from the Centers for Disease Control and Prevention, and a power point education titled, Antibiotic Stewardship. Event ID: Facility ID: 105305 If continuation sheet Page 15 of 15