Inspection·February 20, 2020

F 0550 continuity of staff. She stated the staff was competent, but they do not know the residents. Level of Harm - Minimal harm or potential for actual harm Resident #140 was admitted to the facility on [DATE] with diagnosis including Unspecified Dementia, Anxiety Disorder, Unspecified Mood Disorder. Resident #140's most recent MDS dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating cognition intact. Residents Affected - Some On 2/18/20 at 9:06 a.m., the surveyor observed Staff C, License Practical Nurse (LPN), at the nurse's cart and the call light to one of the rooms turned on. Staff C abruptly entered the room and asked the Resident #140 in a curt manner what he wanted. Resident #140 responded, the surveyor was unable hear what the resident said, but heard staff member C tell the resident in a curt manner that he had already received his medication. Resident #140 made another statement, the surveyor was unable to hear what the resident said, and Staff C responded, That's not me, that's this afternoon, and left the room. 3. Resident #407 was admitted on [DATE] with diagnosis including unspecified systolic heart failure, dyspnea, and Type 1 diabetes mellitus without complications. Resident #407's most recent MDS, dated [DATE], documented a BIMS score of 12 of 15 indicating intact cognition. Upon initial interview on 2/17/20 at 9:18 a.m., Resident #407 stated that the nurses were not as nice as they were downstairs. Resident #407 stated the nurse comes into the room rudely saying Get up and walk. Get up and walk. She then held up her arm and stated I am a fall risk while pointing to a yellow fall risk wrist band on her wrist. She stated she had been at the facility for two months, and the only thing she needed to do before going to an ALF was to get her ankle looked at because it was not healing well, and she needed to be able to walk. The surveyor asked Resident #407 if she knew who the nurse was, and she stated I am not sure what her name is, but she has glasses on, and her hair is pulled back today. She gave me my medications today six at a time. She did not have enough patience to take them one at a time, and I have a hard time taking pills. On 2/18/20 at 10:26 a.m., an interview was conducted the Administrator related to the observations and concerns expressed by Residents #140 and #407. The surveyor spoke with Administrator at 2:23 p.m. to follow up with the information reported earlier. The Administrator stated she and the Assistant Director of Nursing (ADON) performed a teachable moment with Staff C. She informed Staff C of the reported concerns and educated Staff C explaining that the residents have the right to take medications as they would like to. 4. Resident #406 was admitted [DATE]. The Face Sheet included diagnoses not limited to unspecified pain, aphasia following cerebral infarction, and apraxia. The quarterly Minimum Data Set, dated [DATE], revealed a Brief Interview of Mental Status score of 2, indicative of severe cognitive impairment. Staff Member C, Licensed Practical Nurse (LPN) was observed, on 2/18/20 at 9:34 a.m. enter Resident #406's room to obtain a blood pressure reading. The staff member placed a blood pressure cuff over the resident's sweatshirt on the left arm. After receiving one blood pressure reading, Staff Member C administered medications to the resident. Staff Member C removed the blood pressure cuff and attempted to remove Resident #406's right arm from the sweatshirt. As Staff Member C held the resident's arm above the residents' head, the resident was exclaiming [NAME], ah ah. The staff member sharply instructed the resident to Flex your arm and pulled the resident's arm from the sleeve as the resident continued to exclaim [NAME], ah ah. The staff member was able to remove Resident #406's arm from the sweatshirt and obtain a blood pressure, then placed the resident's arm back into the sweatshirt. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 2 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Nursing Home Administrator was informed, on 2/18/20, of the interaction between Resident #406 and Staff Member C. At 2:23 p.m. on 2/18/20, the Administrator stated a Teachable moment was conducted with Staff Member C. She stated she had interviewed Resident #406, who was unaware of the interaction. The staff member was informed that the residents should not be rushed. On 2/19/20 at 10:27 a.m., Resident #406 was observed sitting in wheelchair in the second-floor hallway outside of room. The resident was not able to inform writer of how long she had resided in the facility. The resident stated no staff had hurt her. The Care Plan for Resident #406 recognized a problem that the resident was at risk for an alteration of communication. The interventions included to allow the resident adequate time to express self; complete word or sentence if the resident was unable to do so and to allow adequate time to express self. The care plan indicated Resident #406 was at risk for pain. The interventions indicated nursing staff would assess for signs or symptoms of pain; facial grimace, guarding, moaning, agitation, anxiety, tearfulness, and/or combativeness. A problem identified within Resident #406's care plan indicated adjustments and instructed all staff to provide a safe, non-threatening environment. 5. On 02/17/20 at 2:10 p.m., Staff C, Licensed Practical Nurse (LPN), was observed going into Resident #73's room. The surveyor was standing outside of the door and overheard Resident #73 state, You don't have to snatch it off like that. Resident #73 was self-administering a nebulizer treatment at that time. A record review of the Face Sheet for Resident #73 revealed that she was admitted into the facility on [DATE] with a diagnosis that included but was not limited to unspecified Dementia without behavioral disturbance. Section C of the Quarterly Minimum Data Set with an effective date of 10/01/19 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderately impaired. A Teachable Moment document dated 02/18/20 was provided by staff and dated 02/18/20 after the concern was brought to the Administrator's attention. The presenter was listed as the Assistant Director of Nursing (ADON) and the Administrator. The topic was kindness and dignity. The content revealed, Teaching regarding taking time with residents, speaking slowly and clearly, and slowing down procedures to match resident's needs. Treating residents with respect in all matters. Staff member apologized to the three residents involved. The form was signed and dated by Staff C. 6. An interview was conducted with Resident #208, on 2/17/20 at 3:01 p.m. He stated that he came to the facility with one pair of shorts and a T-shirt. He stated that someone at the facility gave him a pair of pants. He stated that his family had not brought his clothing in. He had nothing else to wear and needed some assistance. An interview was conducted with Staff H, the rehab social worker, on 2/17/20, regarding Resident #208's lack of clothing concern She stated that she was aware of his concern over clothing. He was alert and oriented and called his family for clothes. She stated there were transportation and time problems with the family getting to the facility with clothes. A subsequent interview was held with Staff H on 2/19/20 at 3: 00 p.m She stated that a nurse, over the weekend, went out and bought him new underwear because he didn't have any, Out of the goodness of her heart. She stated that Resident #208 asked how he was going to pay the nurse the $12 for the underwear and she, Staff H, told him it was a gift from the nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 3 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/19/20 at 4: 20 p.m., an interview was conducted with the Executive Director, Assistant Director of Nursing (ADON) and Director of Nursing (DON) The Executive Director stated that there is no policy for supplying clothing, but there is a process . She stated that if a resident comes in without clothing, staff go to the laundry and look for clothing that will fit. If the clothes do not fit, the facility will reach out to the family. If the family does not respond, the Activities Department will purchase clothes for the resident. The Executive Director, ADON, and DON were not aware that Resident #208 did not have sufficient clothing. The statements of Staff H were discussed and the Executive Director, ADON, and DON all stated that clothing should have been provided when facility staff were made aware On 2/19/20 at 2: 45 p.m., Resident #208 stated his family had brought clothing to him last night. He stated he is glad he has clean clothes to wear and felt more comfortable leaving his room. 7. During an observation with resident's roommate on 2/18/20 at 9: 45 am, Resident # 213 was observed in his room this morning, seated in a wheelchair in a facility gown. An unidentified CNA came in room and asked him if he wanted a shower. Resident # 213 stated he had no clothes. The CNA looked in his closet and came back and said, Well, you can just wear a clean gown. At 10: 25 am on 2/18/20, Resident #213 was observed in the therapy room on a recumbent bike, dressed in two gowns, one back, one front. His legs were bent while peddling, his gown was pulled up, and his incontinence brief was fully exposed to anyone in the room. 12 residents plus staff were in the room. Two therapy staff were observed going over to talk to him during the 10 minute observation and no one assisted him to cover himself. Review of the record for Resident #213 was admitted on [DATE] at 1:00 p.m. Diagnoses on the face sheet included Unspecified Dementia. Review of an admission Combined Review, dated 2/17/20, revealed that Resident # 213 had memory problems and was not capable of making decisions. An Interview was conducted with the Executive Director, ADON and DON at 4:20 p.m. on 2/19/20. The Surveyor described the scenario of Resident #213, and the Executive Director and ADON all stated that was not acceptable . An interview was conducted with Staff F, the day shift nurse assigned to Resident # 213, on 2/20/20 at 11: 30 a.m. She stated Resident #213 came in with one shirt, one pair of pants, and slippers. She reached out to his wife, but she was not able to bring clothes in. She stated his shirt and pants must have been in the laundry. She said she had obtained some clothing for him from therapy and from laundry and will check his closet again to see if they can get him more clothes. 8. An interview was conducted with Resident #211 on 2/17/20 at 3:25 p.m. She said last week she was given a pair of clean used non-skid socks to wear. She felt like there was something under the bottom of her foot, and she asked the nurse to look at it. The nurse told her that there was nothing under her foot, and it must be in her sock. The nurse helped her take her sock off and they found a man's large toenail in the sock. On 2/19/20 at 3: 00 p.m., a subsequent interview was held with Resident #211. She described the nurse who removed the toenail from the sock and threw it in the trash. The resident stated she was grossed out by it She stated the nurse just walked by. The surveyor found the nurse matching the description and the nurse confirmed she was the correct nurse. She was Staff A, MDS RN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 4 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An Interview with Staff A was conducted on 2/19/20 at 3:10 p.m. She confirmed she did work with Resident #211 on Saturday and that the resident complained about something under her foot. She pulled the resident's sock off and it was a hard dried substance that looked like a toenail. She stated they do get used socks from residents from the laundry. She stated, I imagine she was grossed out by it. She stated it was not the resident's toenail. She stated she offered the resident new socks, but the resident declined and put the socks back on. On 2/19/20 at 4:20 p.m., an interview was conducted with the Executive Director, ADON, and DON regarding the sock incident. The Executive Director stated that this was not acceptable and It's an easy fix, we will throw out the used socks and get all new ones. The DON stated that Staff A should never have let Resident #211 put the sock back on and she should have thrown the socks away. 9. On 02/18/20 at 9: 45 a.m., Resident #212 was observed lying in bed uncovered, with legs and underwear briefs visible from the open doorway. He also was observed wearing different color non-skid socks on his feet. Review of the record for Resident # 212 revealed that he was admitted to the facility on [DATE] with diagnoses which included Multiple fractures of Pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, Chronic Kidney Disease (CDK), Muscle weakness, Other abnormalities of gait, History of falling, Pain, fever, Unspecified atrial fibrillation, COPD. A Minimum Data Set (MDS, admission assessment, with an assessment reference date of 2/7/20) revealed that the resident required assistance from staff for dressing and bed mobility. An interview was conducted with a companion of Resident #212, on 2/19/20 at 2:30 p.m. She was observed placing non skid socks on his feet. She stated sometimes the non-skid socks look soiled, and she pulled open the drawer and said Look, most of them don't match, and they are just thrown in the drawer in a heap. An interview was conducted with the Executive Director, ADON, and DON regarding the socks on 2/19/20 at 4:20 p.m. ADON stated she just discovered the issue with the socks being heaped in the drawer and mismatched. The Executive Director stated all the socks will be thrown out and new socks will be provided to the residents. On 2/19/20, a confidential resident council meeting was conducted with nine residents. Four of the nine residents resided on the 2nd floor and stated that Certified Nursing Assistants (CNAs) on the 11:00 p.m. to 7:00 a.m. shift and the 3:00 p.m. to 11:00 p.m. shift talk about residents in the hallway loud enough so they can be overheard. Eight residents in the meeting stated CNAs speak in a foreign language to each other and on their cell phones in front of residents and while providing care to residents. One resident in the confidential meeting stated that a CNA was providing care for her when the CNA's cell phone rang. She stated the CNA removed the cell phone from her pocket, told the resident she would be right back, and left the room. Six of nine residents in the confidential resident meeting stated they have been given used, soiled or torn non-skid socks to wear. Several residents stated they have refused the socks. 10. Resident #148 was admitted on [DATE], and re-admitted on [DATE] and 6/28/19. The Face Sheet listed diagnoses including but not limited to senile degeneration of brain and dementia without behavioral disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 5 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/17/20 at 1:05 p.m., Resident #148 was observed wearing a white plastic bracelet and a yellow Fall Risk bracelet on the right wrist. The white bracelet appeared to be old and dirty-looking. The white bracelet had computer-generated scan dots, the name of the resident, and the Medical Records Number (MRN) printed on it. At 2:25 p.m. on 2/19/20, the resident was observed wearing a yellow plastic bracelet with Fall Risk printed on it and the above-mentioned white plastic bracelet. On 2/20/20 at 9:41 a.m., Resident #148 was observed wearing both the plastic white patient identifier bracelet and the yellow Fall Risk bracelets on the right wrist. On 2/19/20 at 2:26 p.m., Staff Member Q, Certified Nursing Assistant (CNA), was asked what the bracelets worn by Resident #148 were. She stated everyone on her assignment had fall risk bands, and the white bracelet was a hospital band and the resident had been wearing it since she started facility employment in November 2019. On 2/19/20 at 2:29 p.m., Staff Member P, Licensed Practical Nurse (LPN), confirmed the MRN 392657 was printed on the white bracelet. The LPN stated some residents have the bracelets on their wheelchairs because they (the residents) are able to remove them; otherwise the residents wear resident identifier bracelets. A review of the Resident #148's medical record, located on the unit, with Staff Member P revealed an acute facilities History and Physical report, dated 10/12/19. The Medical Record Number 392657 was printed in the upper right hand corner of the report. The staff member confirmed the MRN number printed on the report was the same number printed on Resident #148's white bracelet. On 2/20/20 at 2:56 p.m., the Director of Nursing (DON) stated the facility does not use hospital identifier or yellow Fall Risk bracelets. The facility used tubular plastic resident identifier bracelets. The Resident Rights handbook indicated that residents' rights are protected and promoted in the provision of care. The handbook revealed information related to the needs was documented in the residents' medical record for staff review and training on resident rights, confidentiality and abuse are available for all staff. 11. On 02/17/20 at 1:41 p.m., Resident #56 was observed in the bed in his room. The resident was observed to have a yellow wrist band on his left wrist with the words fall risk in big black letters. Resident #56 stated that he had the band on his wrist because he was a fall risk. On 02/19/20 at 12:50 p.m., Resident #56 was observed in bed from the outside of his room door. The yellow fall risk band was visible from the doorway. On 02/19/20 at 12:54 p.m., Staff L, Licensed Practical Nurse (LPN), verified the band on Resident #56. Staff L stated that the band looked like it came from the hospital. On 02/19/20 at 1:46 p.m., the Director of Nursing (DON) reported that the yellow fall risk band came from the hospital and should have been removed. A review of the Face Sheet for Resident #56 revealed that the resident was initially admitted into the facility on [DATE] with a diagnosis that included, but was not limited to, history of falling. A record review revealed that the resident's last discharge was to the hospital on [DATE]. 12. On 02/17/20 at 11:45 a.m., observations were made in the main dining room on the second floor during lunch. Resident #104 was seated at a table with three other residents. Resident #104 was in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 6 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some geri-chair and the chair was reclined at that time. The three residents were drinking and eating lunch, but Resident #104 did not have a lunch tray at that time. At 11:47 a.m., a staff member took him out of the dining room. When asked why she was removing him from the dining room, she stated because his dentures were coming out. The staff member brought the resident back into the dining room at 11:51 a.m. Resident #104's tray came out at 11:56 a.m. Staff L started assisting the resident with his meal at 12:00 p.m. On 02/18/20 at 11:14 a.m., observations were made in the main dining room on the second floor during lunch. Resident #104, Resident #127, and Resident #406 were seated at the same table. Staff U, Registered Nurse (RN), was distributing drinks in the dining room. Staff U opened a small can drink for Resident #127 and gave him a straw. Staff U opened a small can drink for Resident #406 and gave her a straw. Staff U gave Resident #104 a small can drink, but did not open it. At 11:20 a.m., Staff U pulled up a chair and sat at the table with the residents. Staff U asked Resident #127 if he wanted a drink and assisted him with the drink. Staff U did not open Resident #104's drink, and did not offer him a drink. At 11:35 a.m., staff started passing soup (chicken and rice) and asking residents if they wanted soup. At 11:38 a.m., Staff U gave Resident #127 and Resident #406 soup. At this time, 24 minutes later, Resident #104 had not been offered a drink or soup. Resident #104 was seated at the table in a reclined geri-chair, and was seated where he could see other residents drinking beverages and eating soup. Resident #104 received his lunch tray at 11:46 a.m. At 11:48 a.m., Staff T, LPN, went over to the table and asked him if he was ready to eat. Resident #104 was not offered a drink or meal until 34 minutes after Resident #127 and Resident #406, who were seated at the table with him eating and drinking. On 2/20/2020 at 9:59 a.m., in an interview with the Administrator, she stated that she was shocked that Resident #104 was in the dining room for lunch because he needs more assistance with his meals. The Administrator stated that he needs more assistance with his tray, and his tray was not on the cart because he was usually not in the main dining room for lunch. The Administrator stated, His food comes delayed because he needs more assistance. The Administrator repeatedly stated that she was shocked Resident #104 was in the dining room, because he was normally not in there. The Administrator reported that the delay in Resident #104 receiving his tray was probably due to his tray being on the cart with the trays that were sent to the halls. The Administrator reported that Resident #104 was not supposed to be in the dining room for lunch, due to him needing more assistance. The Administrator reported that the kitchen had to have at least a 24-hour notice if residents want to change from eating in their rooms to the main dining room. A policy was requested from staff related to dignity during dining and was not provided. A record review of the Face Sheet for Resident #104 revealed that he was admitted into the facility on [DATE] with diagnoses that included, but were not limited to, need for cognitive communication deficit, dysphagia, Dementia, and mild cognitive impairment. Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #104 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 7 of 46 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 105351 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 assess two residents (Resident #34 and #73) out of the sampled 58 residents for the self-administration of medications. Residents Affected - Few Findings included: On 02/17/20 at 2:05 p.m., Resident #34 was observed in her room administering her breathing treatment with a nebulizer machine without nurse assistance. On 02/17/20 at 2:08 p.m., Resident #73 was observed in her room administering her breathing treatment with a nebulizer machine without nurse assistance. On 02/17/20 at 2:09 p.m., the Staff C, Licensed Practical Nurse (LPN), confirmed that she was the nurse for both residents. Staff C was down the hall from the residents' room near the nurses' station on the medication cart. Staff C was asked if the residents could self-administer their own medications, and she stated that they were not self-administering their own medication. She stated that she gave them the treatment, and after 10 minutes she goes back to the room to check on them. A record review of the Face Sheet for Resident #34 revealed that she was admitted into the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, asthma, and shortness of breath. A review of the February 2020 Physician Order Sheet revealed the following: Ventolin HFA 90 mcg/actuation aerosol inhaler (2 puffs)- Every four hours as needed for COPD Ipratropium albuterol 0.5 mg-3mg (2.5 mg base)/3 ml nebulization soln (3 ml)- Every 6 hours as needed for shortness of breath Stiolto Respimat 2.5 mcg-2.5 mcg/actuation solution for inhalation (2 puffs)- Every 24 hours for COPD Bupropion HCL XL 150mg 24 hour tablet, extended release (150mg) for COPD Symbicort 160 mcg- 4.5 mcg/actuation HFA aerosol inhaler (1 puff)- two times daily for COPD There was no order for self-administration of medication and no assessment for self-administration of medication. A record review of the Face Sheet for Resident #73 revealed that she was admitted into the facility on [DATE] with a diagnosis that included, but was not limited to, Dementia. A review of the February 2020 Physician Order Sheet revealed the following: Ipratropium albuterol 0.5 mg-3 mg (2.5 mg base)/3 ml nebulization solution (1 vial)-every 6 hours for cough. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 8 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0554 Level of Harm - Minimal harm or potential for actual harm There was no order for self-administration of medication and no assessment for self-administration of medication. On 02/19/20 at 12:55 p.m., Staff L, Licensed Practical Nurse (LPN), reported that the nurse should stay with residents when giving breathing treatments. Residents Affected - Few On 02/19/20 at 1:42 p.m., the Director of Nursing (DON) reported that the nurse should be in sight when giving nebulizer treatments. The DON confirmed that Resident #34 and Resident #73 did not have an order to self-administer medications. The policy and procedure provided by the facility Self-Administration By Resident, dated 11/17, revealed the following: Policy Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Procedures 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of skill assessment conducted as part of the care plan process. 3. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 9 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the accuracy of the code status for one resident (Resident #26) out of the sampled 58 residents. Findings included: The Face Sheet revealed that Resident #26 was admitted into the facility on [DATE] with diagnoses that included but were not limited to Dementia and altered mental status. Section C of the Quarterly Minimum Data Set (MDS) with an effective date of 10/01/19 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A record review of the Face Sheet for Resident #26 under the Advance Directives section revealed that the resident's code status was listed as Full Code and Do Not Resuscitate (DNR). The banner at the top of the resident's electronic medical record indicated that she had a code status of DNR (photographic evidence obtained). The Face Sheet revealed that Resident #26 had a family member listed as the Power of Attorney (POA). A review of the February 2020 Physician Order Sheet revealed the following order: Full Code. The Care Plan had the resident's code status as Full Code under the Advance Directives section. There was a document in Resident #26's medical record that was signed by the POA on 05/10/29 that revealed that she did not want a DNR order. An interview on 02/20/20 at 1:27 p.m. with the POA revealed that she did not want Resident #26 to have a code status of DNR. The POA stated that Resident #26 was too young and in good health to have a code status of DNR. On 02/20/20 at 12:30 p.m., Staff L, Licensed Practical Nurse (LPN), reported that if a resident was coding, she would first look at the physician's orders to determine the resident's code status. She then stated that she would look in the hard chart if the information was conflicting. She stated she would call the doctor to check the resident's code status if the information in the hard chart was conflicting. On 02/20/20 at 2:38 p.m., an interview with the Director of Nursing (DON) revealed that if a resident was coding, she would expect staff to call the code, nurses would respond, and a nurse would bring the crash cart. She stated depending on the code status, they would proceed. The DON stated that she would expect staff to look in the hard chart for the code status first, because it was easily accessible. The surveyor asked the DON to observe Resident #26's electronic record and asked what the resident's code status was. The DON reported that she would think she was DNR by looking at the electronic record. The DON stated that she was not sure what the resident's code status was and that she would have to look in the hard chart. The DON agreed that there was confusion with Resident #26's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 10 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0578 code status. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 11 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform an Comprehensive Resident Centered Care Plans including a baseline care plan on admission for one of 58 sampled residents (#256). Findings included: 1. Observation on 02/17/20 at 1:10 p.m. Resident #256 was sitting at the dining room table having only eaten a few bites of his lunch. He stated he had eaten a big breakfast and was not very hungry. The resident had multiple discolored areas on both hands and arms. Observation on 02/19/20 at 3:45 p.m. the resident was in the dining room in a wheelchair. He was dressed and groomed for the day in shorts. He was noted to have discolored areas on both hands and arms as well as both knees. Resident #256 was admitted on [DATE]. Record showed diagnoses included but not limited to Cerebral Vascular Accident (CVA) and unsteady gait. A record review showed the chart lacked an admission assessment nor baseline care plan for the 02/15/20 admission. During an interview on 02/19/20 at 9:00 a.m. the Director of Nursing (DON) and the Corporate Director Case Manager reviewed the clinical record and were unable to locate the admission assessment nor the baseline care plan. Record review of the Care Plan Report showed it was performed on 02/19/20, 4 days after the admission. 2 Record review of the facility's policy, Care Plan Summary, revised 11/2017 showed this facility will provide the resident and / or their representative with a written summary of the baseline care plan that includes: the resident's initial goals, a summary of the resident's medications and dietary restrictions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, any updated information based on the details of the comprehensive care plan, as necessary. The care plan summary will be completed within 48 hours after the resident has been admitted to the facility. The care plan summary will be updated with changes to the care plan and provided to the resident and / or their representative per their desired means of communication. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 12 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interview, it was determined the facility did not ensure that a care plan was developed related to communication for 1 of 58 residents reviewed (#139). Findings Included: Review of the record for Resident #139 revealed that she was admitted to the facility on [DATE] from the hospital. Diagnoses on the face sheet revealed Displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, History of falling, Other specialized disorders of muscle, Other abnormalities of gait and mobility, Muscle wasting and atrophy, Dysphasia following cerebral infarction, pain, Hyperlipidemia, Anxiety disorder, Age related osteoporosis, Hypertension, Embolism and thrombosis of unspecified artery, Unspecified dementia without behavioral disturbance, Major depressive disorder. Review of the hospital record from the discharge on [DATE] revealed diagnoses which included Expressive Aphasia and Dysarthria secondary to old stroke. Review of the admission nursing assessment (2/19/2020) revealed Speech - yes. Writing messages to express or clarify daily needs - N/A, Signs/ gestures/ sounds - NA. Review of nursing daily skilled progress notes revealed : 1/23/20 Resident is alert when verbally prompted, she is able to communicate her needs although Aphasic. 1/27/20 Alert and communicates in low voice but mostly scribes words on paper. 1/29/20 Alert and oriented. Able to make needs known, patient uses dry erase board for communication. Hard to understand speech. An interview was attempted with Resident #139 on 2/18/20 at 12: 33 p.m. The resident mouthed words, but without sound, and used gestures to indicate that she was not happy with her lunch meal and, when asked if she wanted something else, she nodded. A communication board was observed on the bedside table, under a pile of paper and out of reach of the resident. Resident #139 gestured for the board to be handed to her. Staff D, Unit Manager, came into the room and Resident #139 wrote the words with a marker on the communication board three times before the nurse was able to understand that she wanted frosted flakes and toast with peanut butter instead. The resident appeared frustrated with trying to communicate her needs. Staff D indicated she would tell the CNA and left the room. Resident #139 gestured to the surveyor to place the communication board next to her on the bed, within her reach., Review of a speech therapy note, dated 2/11/20, revealed Moderated to severe Aphasia and Dysarthria noted at current level at this time. Prior living environment: Patient uses verbal expression/letter board to assist with communication due to poor legibility when writing to communicate. An interview was conducted with the day shift nurse, Staff E, who provides care for Resident # 139, on 2/20/20 at 11: 00 a.m. She stated that the resident can only say one syllable words - yes, no, pain. She communicates with her paper and pencil, communication board and a paper she has with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 13 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few letters on it. She stated the resident got frustrated with the communication board so she got her a legal pad and pen and she uses that. She stated If we can't make it out, she uses the letter paper to point to the letters. She stated Resident #139 is very alert and can communicate what she needs one way or another. An interview was conducted with Staff G, the day shift CNA, on 2/20/20 at 11: 00 a.m. She stated she can answer questions with a yes or no and if she says no, she asks her to write it on the communication board or paper. Review of an admission MDS, with assessment reference date of 1/29/20 found the resident had unclear speech, sometimes understood and her ability to express ideas and wants is sometimes understood. Her score on the Brief Interview for Mental Status (BIMS) was 13, which indicated cognitively intact. Under the section for Active Diagnoses, Aphasia was not checked and no additional diagnoses were added. Review of care plans for Resident #139 revealed no care plan related to communication. None of the care plans for Resident #139 indicated the use of a communication board, gestures, pen and paper or letter board for communication. An interview with the DON was conducted on 2/20/20 at 12: 00 p.m. She reviewed the care plans & stated there was no care plan related to communication needs. She reviewed the MDS and stated it did not list the diagnosis of Aphasia. An interview was conducted with two MDS LPNs, Staff A and Staff B, on 2/20/20 at 12:15 p.m. She reviewed the CAA and stated it was triggered for communication but no care plan was developed. On 2/20 at 1: 11 pm, Staff A, MDS nurse, provided a care plan decision note that stated to proceed to the care plan for communication. She stated she did not know why there was no care plan for communication. On 2/20/20 at 1: 30 pm, Staff D Unit Manager, who attends the interdisciplinary care plan meetings for her residents, stated that the lack of a communication care plan was an oversight. She stated that Resident #139 has been here multiple times and that staff know her and how she communicates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 14 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 observations, record review, and interviews, the facility failed to ensure that one resident (Resident #26) out of the sampled 58 residents who was identified as a risk for elopement was assessed appropriately. Findings included: On 02/17/20 at 1:58 p.m., a wanderguard was observed on Resident #26's right wrist. On 02/18/20 at 10:05 a.m., the resident was observed sitting in the hallway near the nurses' station. The wanderguard was observed on Resident #26's right wrist. On 02/20/20 at 1:48 p.m., Staff V, Certified Nursing Assistant (CNA), reported that Resident #26 had had the wanderguard for a while. When asked had Resident #26 ever tried to elope, Staff V stated that she had found Resident #26 downstairs on the first floor a few times and she had to bring her back up to the second floor. On 02/20/20 at 12:30 p.m., Staff L, Licensed Practical Nurse (LPN), reported that she did not see an order for the wanderguard. Staff L was asked where was the elopement book and she stated that she would have to look for it. At 12:35 p.m., Staff L reported that she could not find the book and that she would ask her manager. At 12:39 p.m. Staff L stated that Resident #26 was definitely at risk for elopement. On 02/20/20 at 1:58 p.m., Staff L, LPN, reported that the elopement book was kept downstairs at the reception desk and that they did not keep the book on the units. On 02/20/20 at 2:00 p.m. Staff T, confirmed that Resident #26 was at risk for elopement. Staff T stated that Resident #26 tries to get out of the building and would say that she was looking for her keys and her car. Staff T stated that the wanderguard prevented her from leaving the unit. On 02/20/20 at 2:04 p.m., Staff T was asked if she could find the order or an assessment for the wanderguard. Staff T proceeded to look for the documentation and confirmed that there was not an order for the wanderguard and no assessment. She stated the order was put on hold when the resident went out to the hospital a few months ago and the order was not reactivated. The resident had gone out to the hospital in September reported Staff T. Staff T stated that she was going to get the order now. A record review of the Face Sheet for Resident #26 revealed that she was admitted into the facility on [DATE] with diagnoses that included but were not limited to altered mental status and Dementia. A review of the February 2020 Physician Order Sheet revealed that the resident did not have an order in place for a wanderguard. A review of Section C of the Quarterly Minimum Data Set (MDS) revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of Section P of the MDS revealed that the resident did not have a wanderguard. A review of the Care Plan revealed that there was not a care plan in place for a wanderguard or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 15 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 elopement. Level of Harm - Minimal harm or potential for actual harm An elopement assessment was not found in the medical record. Residents Affected - Few The elopement books were only located at the receptionist desk and not on the units. A review of the elopement book revealed a photo of Resident #26 on an Elopement Risk form. The form indicated that Resident #26 had a wanderguard on her right ankle, an expiration date of 07/2019 for the wanderguard, and her room location as 220B. All of this information was inaccurate. On 02/20/20 at 2:43 p.m., the Director of Nursing (DON) reported that the order for the wanderguard had not been reactivated and she had just found this out. The DON stated that she was told by the unit manager that the order was put on hold and was not reactivated upon return from the hospital. The DON stated that she did not see an assessment for elopement. I don't know why it was not there prior to today, stated the DON. The DON stated that the elopement books should be kept on both units. A review of the policy provided by the facility, Elopement, Risk for or Wandering Resident revealed the following: Policy To provide for the safety of residents who are at risk for elopement or wandering. 1. Assess residents for elopement or wandering risk prior to admission and after any new onset of wandering. 4. When any resident's behavior is witnessed such as attempting to exit the building, trying to exit secured doors, attempting to enter an elevator or continued verbalization of wanting to leave the facility, this behavior must be documented and reported to RN supervisor and passed along and the resident immediately put at risk for elopement. Any resident observed to be aimlessly wandering by staff are also to notify the nurse. If any of these behaviors occur and have not been previously documented or care planned, all interventions used to keep the resident safe must be documented in the nurse's notes and added to the resident's plan of care. The nurse will complete the Elopement Risk Assessment and place resident on Wanderguard Precautions, if applicable. 5. The nurse and care planning team will identify if the resident is at risk for elopement or if the resident is demonstrating aimless or pointless wandering and develop individualized care plans to ensure the resident's safety. 7. When a resident is identified at risk for elopement the Activities Department will be notified to take a photo of the resident which will then be placed at the front desk, nursing and personal care units where only staff is able to view them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 16 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on resident interview, staff interview, resident record review and review of policy and procedure, it was determined that the facility did not ensure that a resident who was admitted as continent of bladder and bowel received services and assistance to maintain continence for one (#210) of 58 residents reviewed. Findings included: Review of the record for Resident # 210 revealed that she was admitted from the hospital on 1/30/20. Review of the admission nursing clinical note, dated 1/31/20 revealed that the resident was continent of bowel and bladder. Review of the the nursing admission evaluation, completed on 1/3/120 revealed that the resident was continent of bladder. Bowel continence status was not documented. A Minimum Data Set ( MDS) admission assessment, with a lock date of 2/12/20, indicated a score of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated cognitively intact. The MDS assessment indicated the resident needed the extensive assist of two persons for bed mobility, transfer, dressing and toilet use. Urinary incontinence and bowel incontinence were marked as frequently incontinent. The MDS question for Has a trial of a toileting program been attempted on admission/ entry or reentry or since urinary incontinence was noted in the facility was marked as No. Care plans effective 1/31/20 indicated: Risk of urinary incontinence Goal : will remain continent of urine during daylight hours Interventions: will be cued for increased po fluid intake as tolerated/ within dietary guidelines, will have call light in reach, will have physician follow up prn, Staff will assess for s/s of Uti, dysuria, hematuria, frequency, urgency, concentrated urine, malodorous urine, fever, back pain. Staff will cue to call for assist with toileting as needed to call for assist with toileting as needed, staff will positively reinforce l efforts to participate in interventions to maintain continence. Staff will take to bathroom upon arising, before and after meals, at bedtime, and offer toilet/ bed pan with rounds on 11:00 p.m.-7:00 a.m. shift and as needed, staff will transfer with assist for toileting. Review of CNA task for February 2020 for continence revealed that the resident was coded as frequently incontinent of bladder and bowel. An Occupational Therapy evaluation, dated 2/6/20, revealed that patient will safely perform toileting tasks using standard commode and grab bars with moderate assistance for correct hand foot placement, for safety awareness and for use of compensatory strategies while maintaining good balance. An interview was conducted with Resident #210, on 02/17/20 at 2:32 p.m. Resident #210 stated she was continent but had to use a brief as it took a lot to transfer her and staff were busy during meal times. She stated last week a CNA insisted on helping her transfer to the toilet. She told the CNA she couldn't do it herself but the CNA insisted. During the transfer, the resident said she went crashing down on the toilet She couldn't get up off the toilet and did not want the one aide to help. She told the CNA to get someone to help her. She stated a male therapist came in and told the CNA she should never have done that. He told the CNA that she did not know her patient. She stated he told her that she needed a 3 in 1 commode and would look high and low to get her one. She stated she had not received one and has to use the brief. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 17 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0690 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff D, Unit Manager, on 2/20/20 at 11:15 a.m. She stated she would have to have the resident evaluated for a 3 in 1 commode. An interview was conducted with Staff G, CNA, on 2/20/20 at 11: 20 a.m. She stated that when Resident #210 was out of bed, she toilets her, but when she was in bed, the resident does not initiate toileting. Residents Affected - Few An interview was conducted with the Director of Nursing, on 2/20/20 at 3: 25 p.m. She stated we do a bowel and bladder protocol in the care plan but she was not sure how it was worded. She stated she would get a copy of the protocol. Review of a policy, provided by the DON, undated and entitled Bowel and Bladder Function Assessment revealed: Policy A nurse will initate the assessment using the Bowel and Bladder Function Assessment Tool on admission, quarterly and when there is a significant change in status. Procedure : 1. Each assessment shall include: Assessment of bowel and bladder function Any past Urology Consults Review of medications Bowel and Bladder diary for three days after admission, Examination by attending physician Observation of toileting behavior Evaluation of responsiveness to promts to voud. 3. The resident, resident representative, interdisciplinary staff, along with the physician will develop and individualized preventative or active treatment plan. 4. The nurse will evaluate the plan periodically for the effectiveness of the plan 5. Complete assessments are kept in the medical record Review of the record for Resident #210 revealed no assessment other than the initial nursing admission assessment and no bowel and bladder diary for three days after admission. The resident was documented as continent on admission. An interview was conducted with Resident # 210 on 2/20/20 at 4: 17 p.m. She stated she now had a 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 18 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in 1 commode as of today and it would be easier for her to be continent. She stated she was continent at home because her bed at home went up and down and she was closer to the bathroom and she had the full use of her right arm. She stated since her gastric bypass, she doesn't get much notice that she has to use the bathroom. She stated by the time the staff answer the call light, transfer her to the bed pan or to the bathroom, she could become incontinent. She stated she feels she will be able to use bathroom better now that toilet seat is not too low. The Resident stated, I only use briefs at night. Event ID: Facility ID: 105351 If continuation sheet Page 19 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A confidential resident council meeting was held on 2/19/20 at 1: 00 p.m. 02/19/20 1:22 PM Residents Affected - Some Resident Council Meeting 1:00 p.m. on 2/19/20. Nine of nine residents in the meeting expressed issues with sufficient staffing, especially on the 3:00 p.m. to 11:00 p.m. shift. These residents stated call lights are not answered timely when they are short staffed with times for response, ranging from 30 minutes to an hour on this shift. One resident stated I feel left behind when they don't answer my call light. Another resident stated she has had to wait to be assisted to the bathroom when the call light is not answered sometimes over 30 minutes. All nine residents in the confidential meeting stated there are a lot of agency staff, they don't recognize the staff and the agency staff don't know how to take care of them, the residents have to tell them. They stated the agency staff don't know the residents and the residents don't know their names. Based on observations, record reviews, and interviews, the facility failed to ensure sufficient staffing was maintained to provide necessary care and services to the residents. Findings included: 1. On 2/18/20 at 9:01 a.m., Resident #315 reported insufficient number of staff at night, during mealtimes, and between shifts. The resident identified the need to be assisted to ambulate to the restroom, and sometimes the need to use the restroom was urgent with a capital U. Resident #315 described staff ignoring the call light or stick head in and being informed of having to wait due to staff being busy, I'm busy. On 2/19/20 at 6:46 a.m., Staff Member X, Certified Nursing Assistant (CNA), stated the facility generally replaces staff call-offs, short-staffing happens, and the facility have implemented more agency staff. Staff Member X reported feeling rushed and not being able to get the work done when staffing was short. At 7:05 a.m. on 2/19/20, Staff Member Y, Licensed Practical Nurse, stated the facility was not short on nurses but usually aides on the weekends due to multiple call-offs. On 2/18/20 at 6:29 a.m., the Director of Nursing (DON) stated the facility utilized both agency CNA's and nurses daily. She reported the facility has had staffing overturns and are trying to build back up. The DON stated once the new system (electronic record) came in, and again when she started in October, the facility lost staff, both nurses and aides. The DON said depending on the day, the facility usually did not have more than two agency staff during the day. She said the facility did not usually have agency staff during the weekend, as the regular staff were willing to pick up shifts. She stated agency nurses do not receive a formal orientation, but the offgoing nurse was supposed to acquaint them with the residents and the supervisors are to do a mini-orientation. The DON confirmed there was no competency checkoff list for agency staff. She reported that CNA preceptors acclimate agency aides. On 2/20/20 at 4:08 p.m., the Social Worker/Grievance Coordinator reviewed grievances, listed under (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 20 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0725 Staffing. Level of Harm - Minimal harm or potential for actual harm - 1/8/20: nursing concerns, oral care, nursing not assisting the resident as recommended by the Speech Language Pathologist, and the resident not being cleaned of urine. The issues were addressed with the staff and educated. Residents Affected - Some - 1/8/20: complaint regarding staff. Stated they were rude and not slow enough for her. The aide was removed from the assignment and educated on customer care and allowing for more time. - 1/21/20: a resident stated staff member was rude and not attentive. The nurse removed the staff member (assumed it was an aide) and was educated on customer service. - 1/27/20: grievance included an aide was rude, did not want to help just stood and watched, and was rough. Another aide was rude. Presses call light and staff do not respond. Staff was re-educated on customer service. A review of the 2-week staffing calculations indicated the facility did not meet the state minimal requirements for Certified Nursing Assistants on Sunday 12/1/19, Saturday 12/14 and 12/21/19, Wednesday 12/25/19, Tuesday 12/31/19, and Sunday 1/5, 1/12, 1/26, 2/2, and 2/9/20. On 2/20/20 at 3:30 p.m., the Staffing Coordinator confirmed having an issue with staffing on weekends. She stated when short, the facility tries to ask people (staff) to come in and pickup or to come in early, most of the time staff will only work 4 extra hours, or a 12-hour shift. The Nursing Home Administrator, present during the interview, stated the facility does try to get staff to stay or come in early even it is just for an hour. At 11:10 a.m. on 2/20/20, the Executive Director stated the facility does not have a policy for staffing, but provided the staffing portion of the facility matrix. The facility matrix indicated the facility staffs above state minimum requirements with a specific focus on adequate CNA staffing to accommodate the greater need for additional assistance with Activities of Daily Livings (daily care, bed mobility, transfer, walk-in room, toilet use, and eating). The population of the facility and the staffing levels provided are deemed sufficient based on: resident satisfaction, Quality Assurance/Compliance committee data, resident council feedback, resident interviews and observations, clinical outcomes, and functional improvements. 2. On 02/17/20 at 1:41 p.m., an interview with Resident #56 revealed that during breakfast and lunch they are short staffed. He stated that if you press the light during these mealtimes, you would not get assistance because all staff was in the dining room. Resident #56 reported that if you have a bowel movement, then you would have to wait until they are done in the dining room. A record review of the Face Sheet for Resident #56 revealed that he was admitted into the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS) with effective date of 10/01/18 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. On 02/18/20 at 12:14 p.m., Staff W, Certified Nursing Assistant (CNA), reported that they do not have enough staff. She stated that they are short sometimes. Staff W stated that she had to assist two people in the dining room because they do not have enough staff to assist with meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 21 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the pharmacy recommendations were acted upon for three of six sampled residents (#36, #50 and #118). Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). Record review of the physician orders and Medication Administration Record (MAR) for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day started 08/13/19 and discontinued on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day started 01/24/20 for major depression, an order date of 01/23/20. A physician order dated 01/23/20 showed increase Zoloft (Sertraline) to 150 mg in the a.m. A physician order dated 02/12/20 showed change Sertraline (Zoloft) to 50 mg daily. A review of the Pharmacy Review dated 01/15/20 showed The resident is currently receiving Sertraline 100 mg / day. Sometimes, the decision about whether to continue a medication is clear; for example, someone with a history of multiple, episodes of depression or recurrent seizures may need an antidepressant or anticonvulsant medication indefinitely. Often, however, the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline. Consider Sertraline (Zoloft) 50 mg daily. The physician agreed on 02/12/2020. The medication card showed Sertraline (Zoloft) HCL 100 mg tablet, give one tablet by mouth once a day for depression. There were 15 pills in the medication card. During an interview on 02/20/20 at 11:05 a.m. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) reviewed the February 2020 Physician Order Sheet as well as the pharmacy recommendation regarding Resident #36's Sertraline (Zoloft). They verified that the physician orders showed Sertraline HCL (Zoloft) 50 mg (150 mg) every day as of 01/23/20. The DON stated that the order was not clear. She called the floor and asked the Unit Manager to bring down the resident's actual medication card. Staff T, Registered Nurse (RN) Unit Manager (UM) brought the medication card to the administration office and it showed Sertraline HCL 100 mg, one a day for depression. There were 15 pills left in the medication card. Staff T, RN, UM also brought a physician order dated 02/12/20 that showed change Sertraline to 50 mg daily. Staff T and the surveyor went to the nurses' station. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 22 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R, LPN was the nurse administering the resident her medications for the day. Staff R, LPN reviewed the order on the electronic MAR and verified it showed Sertraline 50 mg (150 mg) give one tablet. She verified that the medication card showed Sertraline 100 mg daily. She stated that she had been administering one tablet or 100 mg to the resident. When asked if she was following the physician's order, she said, No. Staff T, RN, UM also presented a physician order dated 01/23/20 that showed to increase Zoloft to 150 mg every a.m. The pharmacy recommendation showed the resident was on 100 mg and to decrease by 1/2 and give 50 mg with a physician signature on 2/12/20 was reviewed by the DON, ADON and UM. The DON, ADON and UM reviewed all the orders and signed pharmacy review and agreed there was a medication error and they would call the physician. Review of the Investigation of Possible Medication Error dated 02/20/20 showed the original order was for Zoloft 100 mg daily. On 01/23/20 the physician increased the Zoloft to 150 mg daily. The nurse transcribed the order onto the MAR as follows: Zoloft 50 mg tablet (150 mg) take one tablet by mouth daily at 9 a.m. On 02/12/20 the physician, following the recommendation by the pharmacy, wrote an order to decrease the Zoloft to 50 mg tablet, give 1 tablet daily. The nurse signed the order noting it but failed to put the order in the computer. In addition, neither the order on 01/23/20 or 02/12/20 were faxed to pharmacy. The original dose pack of 100 mg tablets was found in the cart and confirmed by the nurse to be the medication that was being administered. The investigation showed multiple errors made by multiple nurses resulting in the incorrect dosage of a medication being administered for 28 consecutive days. The UM called the prescribing physician to clarify the order for Zoloft. The physician confirmed the order for Zoloft 50 mg daily. The resident was assessed by the attending physician on 02/20/20. 2. Observation on 02/17/20 at 1:06 p.m. Resident #50 was sitting at a dining table. She was trying to stand, and the staff was reminding her to stay seated. She was sitting in a high back chair and was chatting. She was able to feed herself and ate all of her lunch. On 02/18 at 8:50 a.m. she was sleeping in her bed. A fall mat was present beside the bed. At 9:30 a.m. she was noted to be in the dining room drinking juice. Resident #50 was admitted on [DATE]. Record showed diagnoses included but not limited to vascular dementia, altered mental status, psychosis, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 (severe impairment). She required extensive assistance for bed mobility, transfers and toileting. Her medications included an antipsychotic and an antianxiety. Review of physician orders and Medication Administrative Record (MAR) for February 2020 showed the resident was on Ativan 0.5 mg every 6 hours as needed for anxiety since 01/20/20 Review of the Medication Regimen Review (MRR) for 12/01/19 to 12/23/19 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR report that showed Physician chart on rationale, review at psych meeting. Review of the Medication Regimen Review (MRR) for 01/01/2020 to 01/17/20 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR that showed see physician note for rationale. Review of the psychoactive drug and behavior management committee minutes for Resident #50 showed she was reviewed on 12/19/19 no changes, will review next month. on 01/16/20, no changes, will review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 23 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0756 next month. Level of Harm - Minimal harm or potential for actual harm Record review of the physician's progress note dated 12/05/19 showed Resident #50 had done better in general with less agitation and aggressive behaviors. The plan included to change Risperdal to 1 mg at bedtime and 0.5 mg at 2 p.m. and to continue the Depakote. The note dated 12/19/19 showed the resident continued to exhibit episodes of agitation and irritability. She yelled out for no apparent reason. She had a bad day yesterday. The plan was to increase the Ativan to routine and increase the Risperdal. The note dated 01/09/20 showed the resident had been better in the past month with aid. The staff reported the resident does not do well with the 2 p.m. Risperdal. The plan was to attempt to decrease the Risperdal to find a minimum effective dose. Residents Affected - Few During an interview on 02/19/20 at 3:15 p.m. the Director of Nursing (DON) verified that the physician progress notes did not address or give a rationale as to why Resident #50 needed to continue on Ativan as needed. She stated that the note stated they increased the Ativan in an attempt to decrease the Risperdal. The physician increased the Ativan to include a continuous p.m. dose, it did not address the as needed dose. During an interview on 02/20/20 at 8:50 a.m. Staff S, Licensed Practical Nurse (LPN) stated Resident #50 had behaviors at times. She stated at present there were no pharmacy recommendations. During an interview on 02/20/20 at 2:52 p.m. the DON stated that the pharmacy did not send a pharmacy recommendation for the physician unless it is directly about a medication. If the recommendation was regarding a lab test only, they send multiple residents on the same recommendation. The facility nurses address these types of recommendations with the physician individually. She stated that if the recommendation was not acted on in a month then the recommendation will be addressed again the next month. During an interview on 02/20/20 at 5:48 p.m. the consultant pharmacist stated that the pharmacy recommendations should be acted on within 30 days and if they have not been acted on it should be followed-up on within 30 days. Record review of the facility's policy, Medication Regimen Review and Reporting, dated 09/18 showed Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative. The nursing care center assures that the consultant pharmacist has access to residents and the residents' medical records. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care. Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and / or physician. A record of the consultant pharmacist's observations and recommendations is made available in a easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 24 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completion. The nursing care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record. If there is potential for serious harm and the attending physician does not concur, or refuses to document an explanation, the director of nursing and the consultant pharmacist contact the medical director. If the attending physician is also the medical director, a meeting shall be arranged to discuss issues and come to an agreement in order to ensure that no actual harm occurs. Per review of the Consultant Pharmacist Medication Regimen Review for Resident #118 on 12/1/2019-12/23/2019, the Pharmacist wrote, Remeron is recommended to be administered in the evening due to sedation. Consider discontinuing AM dose. The Corporate Director stated on 2/20/2020 at 10:38 a.m., We do not have pharmacy recommendations for November and December for Resident # 118. The Note to Attending Physician Prescriber dated 1/14/2020 revealed: Current Orders: Remeron 7.5mg daily, Sertraline 50mg daily, Trazodone 100mg at bedtime. Pharmacist recommendations These antidepressants may not be necessary and periodic dose reduction are recommended. Consider. D/C Remeron as it is recommended at bedtime (currently 9am). Other. Continue current therapy as benefit outweigh risk of current medication orders. The Physician responded D/C trazodone. Signed and dated 2/12/2020 Review of Electronic Medication Administration Records (eMAR) for December: Resident # 118 received 9:00 a.m. and 9:00 p.m. Remeron 7.5mg tablets 13 out of 13 days. Then continued to receive Remeron 7.5mg tablets at 9:00 a.m. and Remeron 15mg tablets for 8/8 days. Review of January MAR revealed Resident # 118 continued to receive 9:00 a.m. Remeron 7.5mg tablets 24 out of 24 days and 9:00 p.m. Remeron 15mg tablets 2 out of 24 days. Additionally, the eMAR for February 2020 revealed that Resident #118 continued to receive Remeron 7.5mg tablets at 9:00 a.m. 20 out of 20 days, with order date 1/30/2020. The Pharmacist stated during an interview on 02/20/20 at 05:58 p.m. that she Will sometimes make a recommendation and if it is not completed, she will rerecommend if she feels it is something the physician should look at. It is expected that a recommendation should be responded to and followed within 30 days. If the physician decides not to follow the recommendations, there needs to be a written rationale that is signed and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 25 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview and record review, the facility failed to ensure the medication regimen was free from unnecessary psychotropic medications for five of six sampled residents. Three residents (#118, #130 and #36) lacked behavior monitoring and two residents (#104 and #50) lacked the rationale for the use of as needed psychotropic medications for over 14 days. Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). The physician orders and Medication Administration Record (MAR) for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day starting 08/13/19 and discontinue on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day starting 01/24/20 for major depression, an order date of 01/23/20. No behavior monitoring was evident in the MAR for January or February 2020. A physician order dated 01/23/20 showed increase Zoloft (Sertraline) to 150 mg in the a.m. A physician order dated 02/12/20 showed change Sertraline (Zoloft) to 50 mg daily. The medication card showed Sertraline (Zoloft) HCL 100 mg tablet, give one tablet by mouth once a day for depression. There were 15 pills in the medication card. Record review of the care plans showed the resident had a behavioral symptom care plan which showed she refused treatment at times. Interventions included but were not limited to monitor behavior episodes and attempt to determine underlying cause. Intervene as needed for safety. Review of the care plan related to anti-depression showed interventions included but not limited to assess and record effectiveness, monitor for sedation and anticholinergic and extrapyramidal symptoms, attempt Gradual Dose Reduction, monitor behaviors and response to medications. The behavior care plan showed interventions included to monitor for effectiveness and side effects of medications, monitor for behavior episodes and determine the underlying cause. During an interview on 02/19/20 at 3:10 p.m. the Director of Nursing (DON) verified that Resident #36 did not have behavior monitoring documented related to receiving an antidepressant. She stated that they do not monitor residents on antidepressant. During an interview on 02/20/20 at 8:56 a.m. Staff R, Licensed Practical Nurse (LPN) stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 26 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #36 was weepy sometimes. She stated that they do not perform behavior monitoring for her. She stated that if they did do behavior monitoring it would be in the blue book and the computer chart. 2. Observation on 02/17/20 at 1:06 p.m. Resident #50 was sitting at a dining table. She was trying to stand, and the staff was reminding her to stay seated. She was sitting in a high back chair and was chatting. She was able to feed herself and ate all of her lunch. On 02/18 at 8:50 a.m. she was sleeping in her bed. A fall mat was present beside the bed. At 9:30 a.m. she was noted to be in the dining room drinking juice. Resident #50 was admitted on [DATE]. Record showed diagnoses included but not limited to vascular dementia, altered mental status, psychosis, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 (severe impairment). She required extensive assistance for bed mobility, transfers and toileting. Her medications included an antipsychotic and an antianxiety. The February 2020 behavior monitoring showed she was anxious on February 2, 6, 13, 16, and 17. Review of physician orders and Medication Administrative Record (MAR) for February 2020 showed the resident was on Ativan 0.5 mg every 6 hours as needed for anxiety since 01/20/20; physical monitors: behaviors, non-drug behavioral intervention, number of incidents and side effects. Review of the Medication Regimen Review (MRR) for 12/01/19 to 12/23/19 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR report that showed Physician chart on rationale, review at psych meeting. Review of the Medication Regimen Review (MRR) for 01/01/2020 to 01/17/20 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR that showed See physician note for rationale. Review of the psychoactive drug and behavior management committee minutes for Resident #50 showed she was reviewed on 12/19/19 No changes, will review next month. On 01/16/20, No changes, will review next month. Record review of the physician's progress note dated 12/05/19 showed the resident had done better in general with less agitation and aggressive behaviors. The plan included to change Risperdal to 1 mg at bedtime and 0.5 mg at 2 p.m. and to continue the Depakote. The note dated 12/19/19 showed the resident continued to exhibit episodes of agitation and irritability. She yelled out for no apparent reason. She had a bad day yesterday. The plan was to increase the Ativan to routine and increase the Risperdal. The note dated 01/09/20 showed the resident had been better in the past month with aid. The staff reported the resident does not do well with the 2 p.m. Risperdal. The plan was to attempt to decrease the Risperdal to find a minimum effective dose. During an interview on 02/19/20 at 3:15 p.m. the Director of Nursing (DON) verified that the physician progress notes did not address or give a rationale as to why Resident #36 needed to continue on Ativan as needed. She stated that the note stated they increased the Ativan in an attempt to decrease the Risperdal. The physician increased the Ativan to include a continuous p.m. dose, it did not address the as needed dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 27 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/20/20 at 8:50 a.m. Staff S, Licensed Practical Nurse (LPN), stated the resident had behaviors at times. She stated at present there were no pharmacy recommendations. She stated that the behavior monitoring was in blue book and was also in the computer. She stated that they were still using both. During an interview on 02/20/20 at 5:48 p.m. the consultant pharmacist stated that she was not sure if the facility was monitoring behaviors for residents on anti-depressants or not. She was not sure of the facility's policy regarding monitoring behaviors. She stated that we used to not monitor for these types of behaviors, but most facilities are doing behavior monitoring for antidepressants now. The facility has gone to a computer system and was doing some behavior monitoring on both paper and in the computer. She stated that they should be doing a paper or computer monitoring. She stated that she hoped they would get it in one spot. She stated that she would check on the monitoring the next time she was at the facility. She stated that she has spoken with the psych physician, the physicians, the DON, and nurses about the prn psychotropic medications and got, the yeses and have not seen any changes. The physician needs to document the rationale for the need for the prn psychotropic, if they are going to continue the medication. Record review of the facility's policy, Stop Orders for Acute Conditions, dated 11/17 showed new medication orders for acute conditions are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. the following classes of medications will not be automatically refilled after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given or in cases where the automatic discontinuation of a medication may lead to an adverse outcome. PRN psychotropic medications (14 day). NOTE: PRN antipsychotic medications may only be renewed pursuant to the provider's direct re-evaluation of the resident. Prescribers are notified prior to actual discontinuation in situations where termination/ discontinuation may result in treatment failure, clinical deterioration, or other adverse outcomes. When the prescriber gives the order for a medication covered by a stop order policy, the nurse requests a specific duration of therapy for that order. This then overrides the automatic stop order policy with the exception of PRN antipsychotic medications. Record review of the facility's policy, Medication Administration, dated 09/19 showed when prn medications are administered, the following documentation is provided: date and time of administration, dose, route of administration; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time results were noted. 4. A record review of the Face Sheet for Resident #104 revealed that he was admitted into the facility on [DATE] with diagnoses that included but were not limited to Dementia and anxiety disorder. Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #104 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of the February 2020 Physician Order Sheet revealed the following order: Ativan 0.5 MG Tablet (1 tablet)- Give one table by mouth as needed every 6 hours for anxiety starting on 01/20/20 A review of the February 2020 Medication revealed that Ativan was administered on 02/05/20 for continuous yelling/screaming. A review of the Consultant Pharmacist's Medication Regimen Review created between 11/01/19 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 28 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0758 11/25/19 revealed the following: Level of Harm - Minimal harm or potential for actual harm Both PRN (as needed) orders need rationale and duration of therapy. Residents Affected - Some A review of the Consultant Pharmacist's Medication Regimen Review created between 12/01/19 to 12/23/19 revealed the following: For therapy greater than 14 days, Ativan PRN needs a rationale and duration for continued therapy. The follow through note indicated physician to chart and monitor through psychotropic meeting. A review of the Consultant Pharmacist's Medication Regimen Review created between 01/01/20 to 01/17/20 revealed the following: Clarify Ativan PRN order. This order needs a duration of therapy with physician documented rationale. For therapy greater than 14 days, Ativan PRN needs a rationale and duration for continued therapy. The follow through note indicated. Order updated 01/20/20. There was no documentation that indicated that the physician had reviewed the recommendations. On 02/19/20 at 1:48 p.m., the Director of Nursing (DON) reported that PRN psychotropic meds should have a stop date. On 02/19/20 at 2:11 p.m., the DON stated that Resident #104 was on a PRN Ativan because he was on hospice. She stated I would have to contact the hospice nurse to see why he had been on the Ativan longer than 14 days. On 02/20/20 at 6:02 p.m., a phone interview with the Consultant Pharmacist revealed that she had an issue with residents being on PRN psychotropic meds for longer than 14 days. She stated that she had talked to the psychiatrist, DON, the physician, and everyone that she needed to. They just have not done it, stated the Consultant Pharmacist. The policy provided by the facility Behavior Management Plans and Suggestions revised on 11/2016 revealed the following: Procedure 2. Behaviors must be quantitatively and objectively documented, persistent, not caused by preventable reasons and are causing the resident to present danger to himself/herself or others or continuously screams, yells or paces which causes impairment in functional capacity. The policy provided by the facility Stop Orders for Acute Conditions revealed the following: Procedures f. PRN psychotropic medications (14 days). Note: PRN antipsychotic medications may only be renewed pursuant to the provider's direct re-evaluation of the resident. 3. Review of Resident #118's Care Plan dated 5/21/19, Problem: Resident # 118 will not have adverse effects related to the use of Psychoactive Medications through next review. Interventions: (include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 29 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0758 Level of Harm - Minimal harm or potential for actual harm but are not limited to) Staff will monitor behavior tracking Record. Observer Resident # 118 for change in mood/behavior (sleep pattern, fatigue, appetite, ability to concentrate, participation in activities and crying). Interview with corporate director on 2/20/2020 at 10:38 a.m. We do not have pharmacy recommendations for November and December for Resident #118. Residents Affected - Some The Pharmacist stated during an interview on 02/20/20 at 5:58 pm that all residents on psychotropic medications should be monitored for behaviors. Review of Resident #130's Care Plan dated 6/11/19, revealed Problem: Psychoactive Medication, risk of adverse effects antianxiety and anti-psychotropic. Intervention: (includes but is not limited to) Staff will record behavior on Behavior Tracking Record. Observe Resident # 130 for changes in mood/behavior (sleep pattern, fatigue, appetite, ability to concentrate, participation in activities, crying.) Review of February 2020 Non-PRN Treatment notes for Resident #130 revealed that Resident #130's behavior is to be monitored during medication pass three times per shift. 14 out of 19 days No Behavior was entered. Per review of the resident's progress notes and medical record, there was no documentation of the resident exhibiting any behaviors. Additionally, on the Non-PRN Treatment notes behavior monitoring, there was no corresponding coding for outcomes of the intervention[s] attempted to reduce the behavior[s], the outcome of the intervention[s] used, and any side effects if a medication was used. Resident # 130 had no order for daily behavior monitoring three times daily. The medication and behavior to be monitored was not mentioned. On 2/20/20 at 2:47 p.m. the surveyor asked if she was able to identify the behaviors being monitored or the medication being monitored for side effects on the Non-PRN Treatment notes. The DON stated behavior monitoring in the February Non-PRN Treatment notes was following behavior as stated in care plan. The surveyor asked if there should be separate monitoring logs for anti-anxiety medications and anti-depressant medications. The DON stated, Yes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 30 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three (#155, #103, and #130) of seven residents observed. These errors constituted a 14.29% medication error rate. Residents Affected - Few Findings included: On 2/18/20 at 4:20 p.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #155. Staff Member I was observed administering the following medications: - Active Protein 30 milliliters (mL) orally - Novolog 100 unit/mL Flexpen, 10 units subcutaneously Prior to the administration, Staff Member I obtained a blood glucose level, using an Evercare G3 glucometer, of HI. The staff member informed the resident the doctor would need to be notified. A review of Resident #155's February Medication Administration Record (MAR) revealed a sliding scale of units to be administered dependent on the blood glucose level of the resident. The sliding scale identified 10 units of Novolog insulin was to be administered and the physician was to be called. The staff member gathered the Novolog Flexpen from the medication cart and returned to the resident. Staff Member I cleaned the right upper abdominal quadrant of Resident #155 with alcohol, placed a needle on the Flexpen, dialed it to 10 units, and injected the insulin quickly in the abdomen. The staff member did not prime the Flexpen prior to the administration. When asked why she had not primed the pen, the staff member asked, Am I supposed to? Haven't ever heard of priming the pens. The staff member documented a blood glucose level of 401 in Resident #155's medical record and called the physician. On 2/18/20 at 5:16 p.m., an observation of medication administration with Staff Member J, Registered Nurse (RN), was conducted with Resident #103. Staff Member J obtained a blood glucose level of 360 from the resident utilizing a glucometer. Staff Member J was observed administering the following medications: - Novolog Flexpen 100 u/mL - 12 units subcutaneously - Docusate Sodium 100 milligram (mg) softgel orally - Gabapentin 100 mg capsule orally - Lisinopril 40 mg tablet orally - Lorazepam 0.5 mg tablet orally - Memantine 10 mg tablet orally - Xarelto 20 mg tablet orally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 31 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The staff member was observed removing the Novolog Flexpen from the medication cart and dialed it to 12 units. Staff Member J returned to the resident, raised Resident #103's right arm sleeve, cleaned the area above the elbow with alcohol, applied a needle to the Flexpen, and injected the insulin. Staff Member J did not prime the Flexpen prior to dialing it to 12 units and administering the Novolog. The February Physician Order summary for Resident #103 identified the resident was to be administered 12 units of Novolog via a Flexpen for a blood glucose level of 360. On 2/19/20 at 10:48 a.m., an observation of medication administration with Staff Member K, RN was conducted with Resident #130. Staff Member K was observed administering the following medications: - Risperidone 0.25 mg tablet orally - Multiple Vitamin with mineral tablet orally - Lorazepam 0.5 mg orally - Ensure Plus orally A review of the Medication Administration Record (MAR) for Resident #103 revealed the above medications were scheduled to be administered at 9:00 a.m. The physician orders for Resident #130 identified the medication Risperidone was to administered three times daily at 9:00 a.m., 1:00 p.m., and 5:00 p.m. and Lorazepam was to be administered at 9:00 a.m. and 5:00 p.m. The progress notes did not indicate the physician and/or family was notified of the late administration of the above medications. The electronic medication profile for Resident #103 indicated the medications were 55 minutes overdue. Staff Member K confirmed the medications were late due to some residents were taken to a religious activity without notifying the nurse that did not normally work the shift, and some residents take a little more patience. On 2/18/20 at 6:12 p.m., the Director of Nursing (DON) stated the procedure for insulin administration via a Flexpen was to uncap the pen, clean the tip with alcohol, apply a needle, prime it with two units of insulin, then dial to the correct dosage. She identified staff do receive competency training with insulin pen and syringe training as part of new hire orientation and during the facility's annual competency fair. A review of the observation of the insulin administration for Resident #155 and #103 was discussed with the DON. She confirmed the residents did not receive the correct dosage of insulin due to the nurses not priming the Flexpen prior to the dialing the dosage. According to https://www.novo-pi.com/novolog.pdf, an airshot should occur when using an insulin pen before each injection to avoid injecting air and to ensure the proper dosage. The Novolog instructions indicated users should apply a needle to the pen, turn the dose selector to 2 units and while holding the pen with the needle pointing upwards tap the cartridge to allow air bubbles to collect at the top, and press the buttom all the way until the selector returns to 0 (zero). The policy titled, Medication Administration - Subcutaneous Insulin, dated 5/16, indicated the following instructions for the use of an insulin pen: - apply needle to cartridge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 32 of 46 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 105351 B. Wing (X3) DATE SURVEY COMPLETED A. Building 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0759 - Always perform the safety test before each dose. Performing the safety test ensures you get an accurate dose by ensuring that the pen and needle work properly and to remove air bubbles. Level of Harm - Minimal harm or potential for actual harm - The illustration indicated the safety test was to select 2 units. Residents Affected - Few - Hold the pen with the needle pointing upwards. - Tap the insulin reservoir so that any air bubbles rise up towards the needle. - Press the injection button all the way in. Check if insulin comes out the needle tip. The policy titled, Medication Administration - General Guidelines, dated 9/18, indicated medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. On 02/20/20 at 3:16 p.m., the DON stated one hour before and after the scheduled time and procedure is to call physician prior to the administration of meds. On 2/20/20 at 5:48 p.m., the Consultant Pharmacist stated most Flexpens need to be primed prior to the administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 33 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0760 Ensure that residents are free from significant medication errors. 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 two of 58 sampled residents was free from a significant medication error related to one resident receiving an incorrect dosage of Zoloft (#36) and one resident not receiving all their medications on dialysis days (#151). Residents Affected - Few Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). The physician orders and Medication Administration Record for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day starting 08/13/19 and discontinue on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day starting 01/24/20 for major depression, an order date of 01/23/20. No behavior monitoring was evident in the MAR for January or February 2020. A physician order dated 01/23/20 showed increase Zoloft (Sertraline) to 150 mg in the a.m. A physician order dated 02/12/20 showed change Sertraline (Zoloft) to 50 mg daily. A review of the Pharmacy Review dated 01/15/20 showed the resident is currently receiving Sertraline 100 mg / day. Sometimes, the decision about whether to continue a medication is clear; for example, someone with a history of multiple, episodes of depression or recurrent seizures may need an antidepressant or anticonvulsant medication indefinitely. Often, however, the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline. Consider Sertraline (Zoloft) 50 mg daily. The physician agreed on 02/12/2020. The medication card showed Sertraline (Zoloft) HCL 100 mg tablet, give one tablet by mouth once a day for depression. There were 15 pills in the medication card. During an interview on 02/20/20 at 11:05 a.m. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) reviewed the February 2020 Physician Order Sheet as well as the pharmacy recommendation regarding Resident #36's Sertraline (Zoloft). They verified that the physician orders showed Sertraline HCL (Zoloft) 50 mg (150 mg) every day as of 01/23/20. The DON stated that the order was not clear. She called the floor and asked the Unit Manager to bring down the resident's actual medication card. Staff T, Registered Nurse (RN) Unit Manager (UM) brought the medication card to the administration office and it showed Sertraline HCL 100 mg, one a day for depression. There were 15 pills left in the medication card. Staff T, RN, UM also brought a physician add order dated 02/12/20 that showed change Sertraline to 50 mg daily. Staff T and the surveyor went to the nurses' station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 34 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff R, LPN was the nurse administering the resident her medications for the day. Staff R, LPN reviewed the order on the electronic MAR and verified it showed Sertraline 50 mg (150 mg) give one tablet. She verified that the medication card showed Sertraline 100 mg daily. She stated that she had been administering one tablet or 100 mg to the resident. When asked if she was following the physician's order, she said, No. Staff T, RN, UM also presented a physician order dated 01/23/20 that showed to increase Zoloft to 150 mg every a.m. The pharmacy recommendation showed the resident was on 100 mg and to decrease by 1/2 and give 50 mg with a physician signature on 2/12/20 was also reviewed by the DON, ADON and UM. The DON, ADON and UM reviewed all the orders and signed pharmacy review and agreed there was a medication error and they would call the physician. Review of the Investigation of Possible Medication Error dated 02/20/20 showed the original order was for Zoloft 100 mg daily. On 01/23/20 the physician increased the Zoloft to 150 mg daily. The nurse transcribed the order onto the MAR as follows: Zoloft 50 mg tablet (150 mg) take one tablet by mouth daily at 9 a.m. On 02/12/20 the physician, following the recommendation by the pharmacy, wrote an order to decrease the Zoloft to 50 mg tablet, give 1 tablet daily. The nurse signed the order noting it but failed to put the order in the computer. In addition, neither the order on 01/23/20 or 02/12/20 were faxed to pharmacy, and the original dose pack of 100 mg tablets was found in the cart and confirmed by the nurse to be the medication that was being administered. The investigation showed multiple errors made by multiple nurses resulting in the incorrect dosage of a medication being administered for 28 consecutive days. The UM called the prescribing physician to clarify the order for Zoloft. The physician confirmed the order for Zoloft 50 mg daily. The resident was assessed by the attending physician on 02/20/20. 2. Resident #151 was admitted on [DATE]. Record showed diagnoses included but not limited to End Stage Renal Disease, renal dialysis, Alzheimer's dementia, hypertension, Glaucoma and diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 06 (severe impairment). The resident required extensive to dependence assistance for bed mobility, transfers and toileting. Review of physician orders and Medication Administration Review for January and February of 2020 showed Muro 128 2% eye drops (1 drop) left eye every 6 hours starting 08/13/19 for Glaucoma. The medication was scheduled for 6 a.m. 12 noon, 6 p.m. and midnight. He did not receive the noon dose on Tuesday, Thursday and Saturday due to Resident on LOA or resident not available; he was at dialysis. He had an order for Calcium Acetate 667 mg (2001 mg), give 3 capsules with meals and at bedtime, four times a day starting 08/15/19 for end stage renal disease. His 1:00 p.m. dose was not given on Tuesday, Thursday, or Saturday due to Resident on LOA or resident not available; he was at dialysis. Record review of the dialysis care plan showed the interventions included but not limited to staff will follow instructions provided by dialysis clinic Tuesday, Thursday, and Saturday. Observation on 02/17/20 at 2:52 p.m. Resident #151 was lying in bed watching TV. He stated that he went to dialysis on Tuesday, Thursday and Saturday. He left at 10:00 a.m. and took his lunch and a notebook with him. The facility arranged his transportation. During an interview on 02/19/20 at 11:04 a.m. the Corporate Director of Case Management reviewed Resident #151's physician orders and Medication Administration Record for January and February 2020. She verified there was not an order to hold his medications on his dialysis days nor was there documentation in the progress notes showing the physician was notified of the missed eye drops and Calcium Alginate on Tuesday, Thursday, and Saturdays. She stated that she would expect to see an order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 35 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0760 regarding what to do with the missed medications on dialysis days. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/19/20 at 1:46 p.m. Corporate Director of Case Management stated that she reviewed the documentation and did not find an order from the physician regarding not taking his medications on dialysis days. She stated that the Unit Manager called the physician regarding the missed medications. Residents Affected - Few During an interview on 02/20/20 at 8:56 a.m. Staff R, Licensed Practical Nurse (LPN) stated that the resident does miss some of his medications when he goes to dialysis. He misses his calcium. She stated that she had not informed the physician he was missing it because it was ordered by the dialysis center and they know he was not getting it because he was at dialysis. She stated that normally she would call the physician and family if a resident was not taking their medications. 3. During an interview on 02/20/20 at 5:48 p.m. the consultant pharmacist stated that a medication error such as giving the wrong dosage or a dialysis resident not receiving the medications on dialysis days should be reported to the physician. For the dialysis resident the physician may want to change the time the medication was scheduled or give an order to skip the medications that day. But the facility should speak with the physician. 4. Record review of the facility's policy, Non-Controlled Medication Orders, dated 12/12 showed medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe. Medication orders include the following specifics: date, name of medication, strength of medication, dose and dosage form, time or frequency of administration. Any dose or order that appears inappropriate, considering the resident's age, condition, allergies or diagnosis, is verified by nursing with the prescriber. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the Physician Order Sheet (POS) / Telephone Order Sheet (TO) if it is a verbal order, and on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). New Orders: the order is transcribed onto the Physician's Order Sheet or Telephone Order Sheet; order is noted by the nurse receiving the order; order is recorded on the MAR or TAR; send the appropriate copy of the telephone order form to the prescriber for signing in a timely manner; transmit the appropriate copy of the order to the pharmacy for dispensing; place the signed copy of the order on the designated page in the resident's medical record. Record review of the facility's policy, Medication Administration, dated 09/18 showed medications are administered as prescribed in accordance with manufacturers' 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. Medication Preparation: Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label. Medication Administration: Medication are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 36 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the nursing notes and elsewhere in the medical record as appropriate. Verify medication is correct three (3) times before administering the medication. When pulling medication package from the med cart; when dose is prepared; before dose is administered. Documentation: If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Record review of the facility's policy, Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 09/10 showed the facility utilizes a system to assure that medication usage is evaluated on an ongoing basis. Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and / or prescribers, the pharmacy if needed. Medication Error / Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling dispensing, distributing, administration, education, monitoring and use. Medication errors and adverse drug reactions are considered significant if they: require discontinuing a medication or modifying the dose. Procedure: the interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. When a resident receives a new medication, the medication order is evaluated for the following: dose. In the event of a significant medication error immediate action is taken, as necessary, to protect the resident's safety and welfare. the prescriber is notified promptly of any significant error. Any new prescriber's orders are implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 37 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 and interviews, the facility failed to ensure medications were stored in an orderly manner in one medication cart (2nd floor #1), and medications with a shortened open life were dated as opened in two medication carts (West 2 and [NAME] 3) out of three medication carts reviewed, and two of two refrigerated narcotic storage boxes were permanently affixed to the refrigerator. Findings included: An observation was conducted, on 2/18/20 at 11:06 a.m., with Staff Member L, Licensed Practical Nurse (LPN) of the 2nd Floor #1 medication cart. The blister packaged medications was divided in the drawers by separators labeled with room numbers and bed letters. In the area designated as 213A were blister packages containing medications prescribed to two different residents, both residing in room [ROOM NUMBER]. The staff member confirmed the area for 213A contained medications for two different residents. On 2/19/20 at 7:20 a.m., an observation of the [NAME] #3 medication cart was conducted with Staff Member M, LPN. The observation identified three opened vials of Lantus 100units/milliliter (u/mL), one opened vial of Humalog 100 u/mL, one opened Lantus insulin pen, and two opened Novolog Flexpens. The insulin vials and pens were undated with an open date. All of the insulin containers were labeled with a yellow sticker with areas to label with the date opened and the date of expiration. The yellow stickers instructed staff to discard after 28 days. The observation indicated an opened foil package of Ipratropium-Albuterol vials. Two vials were observed outside of the foil packaging. According to medline.gov/druginfo for Albuterol and Ipratropium oral inhalations, users were to keep unused vials of nebulizer solution in the foil pouch until ready to use them. An opened bottle of Dorzolamide and Timolol Ophthalmic drops was undated. A green sticker on the bottle of the Ophthalmic drops indicated it should be discarded after 60 days. Photographic evidence was obtained. Staff Member M confirmed the observation findings of the medication cart, [NAME] #3. On 2/19/20 at 7:40 a.m., Staff Member N, Registered Nurse (RN) was observed dating a Lantus insulin pen, 2/19/20. When asked if he had opened the pen, he stated no. Another insulin pen, Humalog, was observed dated 2/19/20, the staff member also confirmed he had dated the pen and had not opened it. Staff Member N confirmed both pens had been already opened and had dated them for today. A review of the [NAME] #2 medication cart with Staff Member N revealed an opened bottle of Latanoprost Ophthalmic solution. The bottle was undated as to when opened or an expiration date. A sticker on the Latanoprost bottle indicated the medication should be discarded after 42 days. An opened bottle of Active Liquid Protein was undated with an open date. The Active Liquid label revealed a 3 month shelf life from date opened. A clear bag contained several foil pouches of Ipratropium/Albuterol inhalation solution. Each of the foil pouches instructed the user not to remove from foil pouch. The clear bag contained 2 vials of the inhalation solution outside of the foil pouches. The bottom drawer of the medication cart contained injectable medication, topical patches, and oral medications stored within the same separated area. On 2/20/20 at 10:23 a.m., a review was conducted of the second floor medication room with Staff Member L, LPN. An observation of the medication refrigerator inside of the room indicated a metal box, unlocked, sitting on a grate-style shelf. The box was attached to the shelf, however the shelf had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 38 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the ability to be removed from the refrigerator. Staff Member L confirmed the box and shelf could be removed from the refrigerator. The box contained two vials of Lorazepam prescribed to a resident and an emergency kit with four vials of Lorazepam. On 2/20/20 at 10:44 a.m., an observation of the [NAME] medication room was conducted with Staff Member D, LPN/Unit Manager. A plastic narcotic box was attached to a grate-like shelf inside of the refrigerator. The box contained three bottles of Lorazepam prescribed to a resident and a box of four vials of Lorazepam as an emergency drug kit. The Unit Manager confirmed the box and shelf could be removed from the refrigerator. On 2/20/20 at 3:12 p.m., the Director of Nursing (DON) stated the insulin Flex pens should be dated when opened, Anything with a shelf life should be dated. At 5:44 p.m. on 2/02/20, an observation was conducted with the DON of the [NAME] medication storage room. The DON stated the narcotic box should be permanently attached to the inside of the refrigerator. When the narcotic box was shown to be removable, she hung her head and shook it. At 5:48 p.m. on 2/20/20, the Consultant Pharmacist was interviewed via the telephone. The Consultant stated a nurse comes to the facility but was unsure if the medication carts were reviewed during those times. The consultant said the pharmacist does monthly reviews, but does not review all of them. The Consultant stated medications with a short-shelf life should be dated to ensure when the meds should be discarded and the narcotic boxes in the refrigerator should be permanently attached to the inside of the refrigerator. She confirmed two residents' medications should not be stored intermixed together. A policy titled, Medication Storage, dated 09/18, indicated medications were stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The procedure portion of the policy internally administered medications are stored separately from medications used externally and insulin products should be dated on the label when first used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 39 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record reviews, and interviews, the facility failed to store, prepare, and distribute, serve food in accordance with professional standards for food service safety and failed to maintain the kitchen in a sanitary condition. Findings included: On 02/17/2020 starting at 9:15 a.m., an initial tour of the kitchen was conducted with the Operations Manager and the Corporate Food Service Director. An excessive amount of dust was observed on the ceiling vent above the ice machine. Black buildup was observed on the ceiling vent in the area between the stove and walk in cooler. The ceiling tiles near the cooking and food prep area were observed to have an excessive amount of food splatter and dust (photographic evidence obtained). Water damage was observed on the ceiling tile right above the food serving area. The Operations Manager reported that the ceilings were cleaned every couple of months. There was a missing vent above the tilt skillet and the third vent was ajar (photographic evidence obtained). The Operations Manager that they had a work order in for the vents. The sanitizer in the three-compartment sink in the dish washing room was tested at 500 parts per million (ppm). The Operations Manager stated he would call state chemical now because the sanitizer should be at 200 ppm. Black buildup was observed near the corner of the three-compartment sink. The tile in the corner was also noted to be cracked, and there was food splattered on the wall (photographic evidence obtained). Paint was peeling on the wall next to the three-compartment sink. The Operations Manager reported that they had a work order in for the wall. Boxes of water were stored on the floor in the hurricane closet. The Corporate Food Service Director stated that the boxes should not be on the floor. A review of the policy provided by the facility Dry Storage Areas, undated, revealed the following: 1. All items must be stored at least 6 inches off the floor. On 02/17/19 at 10:37 a.m., the Corporate Food Service Director reported that they had started replacing ceiling tiles in the kitchen tiles. At 10:46 a.m., he reported that cleaning solutions had fixed the sanitizer in the three-compartment sink. A Work Order for the hood system was created on 12/11/19 and had not been repaired. A Work Order for painting the dish room wall was created on 12/23/19 and had not been repaired. On 02/19/19 at 10:42 a.m., the Operations Manager reported that some things are quicker than others to get fixed. The hood vents had to be customized, but the work order was submitted. On 02/20/20 at 10:00 a.m., the Executive Director reported that they did not have a policy in place for maintenance requests or maintenance of the facility. At 10:37 a.m., the Executive Director reported that all work orders were submitted electronically and that there was a 24 hour turnaround time. On 02/19/19 at 10:35 a.m., the surveyors entered the kitchen for a follow up observation. At 10:40 a.m., wet lids for the trays were observed stacked on top of one another (photographic evidence obtained). This was confirmed by the CDM (Certified Dietary Manager). At 10:44 a.m., the three-compartment sink in the dish room tested at 400 ppm. The Operations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 40 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Manager stated that they would drain and retest it. He stated that he would get the chemical company back out to fix it. The Operations Manager reported that staff knew that the sanitization was too high and did not report it. He was asked why they were recording 200 ppm on the log every day and he stated that he asked the same question. A dirty fan was observed blowing on clean dishes while staff were washing dishes. Staff reported that they had the fan to keep them cool. Stacks of trays were observed cracked and chipped. Sheet pans were observed very worn with black buildup. At 10:54 a.m., the CDM reported that the trays were just old. At 11:17 a.m., staff was getting ready to put meal trays on a sheet pan for serving. The surveyor observed old dried-up food stuck to the sheet pan. Surveyor asked the staff member what was on the pan and she peeled old food from the pan. Old food was observed on another sheet pan. CDM told staff not to use the sheet pans. The ice machine on the east and west units were observed to have white buildup and rust (photographic evidence obtained). At 11:26, on the care unit, the microwave was observed to have rust in the inside at the top. The CDM reported that it needed to be replaced. A review of the Main Kitchen Cleaning Deep Clean Schedule revealed that ice machine was cleaned by a contracted company and the vents and ceilings were cleaned quarterly. A review of the contact for cleaning the ice machine revealed that the ice machine was cleaned every 6 months. A review of the Dish Room Pot Sink Sanitizing Log revealed that the PPM (parts per million) was 200 everyday from 02/1 through 02/18. A review of the policy provided by the facility Cleaning Dishes Manual Dishwashing, undated, revealed the following: Policy Dishes and cookware will be washed after each meal to assure that all dishes are clean and sanitary. Procedure: Sink 3 Sanitize 1. Measure appropriate amount of sanitizing chemical into appropriate amount of water (following manufacturer's guidelines). 2. Test sanitizing solution in sink using manufacturer's suggested test strips to assure appropriate level. 3. Place dishes in the sanitizing sink. Allow to stand according to manufacturer's guidelines for sanitizer. 4. Allow dishes to air dry. Invert dishes in a single layer to air dry. Check all dishes to be sure they are clean and dry prior to storing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 41 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was accurate and complete for one (#138) of 58 sampled records related to falls. Findings included: Observation on 02/17/20 at 12:54 p.m. Resident #138 was out of bed sitting in a broda chair. She had enablers in an up position with a mat in place beside of her bed. The medical record showed she had fallen out of bed. She had an egg-shaped swollen area over her right eye. There was a purplish yellow discolored area from her eye down her right cheek. She was dressed and groomed for the day including her hair being combed. She was drinking a soda. On 02/19/20 at 3:50 p.m. it was noted that she had a discolored area on her right hand also. Record review of the facility's policy, Fall Prevention Program, not dated showed to assure proper follow-up is carried out to reduce the amount of resident falls through assessment and staff awareness and implementation of appropriate interventions. The members of the Interdisciplinary team (Director of Nursing (DON), Assistant Director of Nursing (ADON) Director of Therapy, Social Work, Nurse Manager, Dietary, MDS nurse) will review the Incident Report and causation of fall at (Interdisciplinary Team) IDT meeting and do a root cause analysis to determine cause of fall. Resident #138 was admitted on [DATE]. The record showed diagnoses included but were not limited to dementia without behavioral disturbance, insomnia, depression, altered mental status, history of falls, unsteady gait, weakness, syncope, and Alzheimer's psychosis. Record review of the significant change Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 07 (severe impairment). The resident required extensive assistance for bed mobility, transfers and toileting. The resident had 2 or more falls with no injury. Record review of the nursing progress notes showed inaccurate documentation related to falls. The progress notes dated 12/10/19, 12/27/19, and 02/01/20 showed a fall had occurred but the time of the fall was not documented. The progress note dated 01/10/20 showed the resident had fallen, the note lacked the actual fall date which was 01/09/20 and time. The nursing progress notes lacked documentation for the fall that occurred on 01/16/20. The progress notes reviewed from December 2019 through February 20, 2020 revealed no documentation related to IDT meetings related to the resident's falls. During an interview on 02/18/20 at 6:40 p.m. the Director of Nursing (DON) stated that the facility had morning meetings at which time they discussed each fall including new interventions. She stated that the nurse was to document the falls on a facility report including the details of the fall, possible reason for the fall and interventions. During an interview on 02/19/20 at 8:00 a.m. the Nursing Home Administrator (NHA) and the DON stated the surveyors were not able to look at the facility reports in the electronic record. They stated that the nurses were supposed to document in the nursing notes about the fall including date and time. When asked about the IDT meetings and subsequent documentation of the meetings, they stated that it was kept in a Fall Book. They verified that neither the facility report nor the IDT meeting information was part of the resident's chart. The NHA stated that she had never thought about it, but the documentation could be scanned into the chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 42 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0842 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/20/20 at 11:10 a.m. the NHA and the DON stated that Resident #138 had fallen on 01/16/20. She reviewed the medical record and was unable to locate any documentation related to the 01/16/20 fall in the progress notes. She also verified the discrepancy of the documentation regarding the 01/09/20 related to the fall being documented on the 01/10 instead of 01/09. She stated that the nursing notes should include both date and time as well as a description of each fall. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 43 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to use appropriate hand hygiene while assisting two residents (Resident #85 and #12) with their meals, left nebulizer tubing unbagged for one resident (Resident #2), a catheter bag was stored inappropriately for one resident (Resident #127), and failed to ensure two glucometers were cleaned and disinfected in between residents appropriately and according to manufacturer's recommendation. Residents Affected - Some Findings included: 1. On 02/18/20 at 11:41 a.m., observations were made in the main dining room on the second floor. Staff W, Certified Nursing Assistant (CNA), was observed sitting in the middle of Resident #85 and #12 at the table and assisting them with their meals. Continued observations revealed Staff W was assisting both residents with their meals by using her right hand only to assist both residents and was not noted to wash or sanitize her hands in between assisting the residents. Staff W was also observed giving the residents juice from a cup with the right hand only and was not noted to wash or sanitize her hands in between assisting the residents. At 11:45 a.m., Staff T, Licensed Practical Nurse (LPN), came to the table and gave Staff W a small bottle of sanitizer. On 02/18/20 Staff W stated that she did not know the procedure for assisting two residents at the same time. She stated that she had not had training on infection control. She confirmed that she assisted the residents with the same hand without sanitizing in between feedings. Staff W stated that the rules are changed every day. She stated, This person tells you one thing and the next person tells you something else. On 02/20/20 at 1:50 p.m., the Director of Nursing (DON) confirmed that you should be sanitizing in between feeding residents. A policy was requested related to infection control during dining and was not provided. On 02/17/20 at 11:51 a.m., Resident #127's catheter bag was observed on the floor in main dining room on the second floor. On 02/17/20 at 1:17 p.m., Resident #127 was observed sitting in the hallway near the nurses' station with the catheter bag on the floor. On 02/20/20 at 12:56 p.m., the resident was observed in his room and the catheter bag was on the floor. Staff K, Registered Nurse (RN), confirmed the bag on the floor. Staff L, Licensed Practical Nurse (LPN), stated that the bag was clipped on the bottom bar of the wheelchair and should have been on the top bar of the wheelchair. A review of the Care Plan Report revealed that the resident had a care plan in place for an indwelling urinary catheter with a goal date of 04/30/20. Interventions included but were not limited to staff would keep drainage bag off of floor and below bladder level. On 02/19/20 at 1:11 p.m., the Director of Nursing (DON) confirmed that catheter bags should not be on the floor. The policy provided by the facility Catheter Drainage Bag revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 44 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0880 g. Ensure bag is positioned below level of the bladder and does not touch the floor. Level of Harm - Minimal harm or potential for actual harm On 02/17/20 at 10:00 a.m., an observation of Resident #2 revealed a nebulizer mask and tubing were laying on the bed. The resident stated that they did not normally keep it in a bag. On 02/18/20 at 11:12 a.m., the nebulizer mask and tubing were observed on the floor in Resident #2's room. On 02/19/20 at 12:49 p.m., the nebulizer mask and tubing were observed on the bed in Resident #2's room. Staff L verified the nebulizer mask and tubing on the bed. Residents Affected - Some On 02/19/20 1:15 p.m., the DON stated that the mask should be put in the bag and stored up in the drawer or on the table. The policy provided by the facility Nebulizers, undated, revealed the following: At the end of treatment, make sure med container is empty, and place T-piece or mask in clean bag. 2. On 2/18/20 at 4:20 p.m., an observation was conducted with Staff Member I, Licensed Practical Nurse (LPN) during a medication administration. The staff member removed an Evencare G3 glucometer from the medication cart, removed a Clorox Healthcare Bleach wipe from a canister in the bottom drawer. Staff Member I wiped the glucometer front and back with the bleach wipe and then discarded the wipe. The glucometer was visibly wet. The staff member placed another bleach wipe into a plastic cup; another bleach wipe was used to clean a gray plastic tray. When asked how long the glucometer was to stay wet, Staff Member I voiced she did not know. The Clorox bleach wipe container was reviewed and the staff member confirmed the contact time for the wipe was 3 minutes. Staff Member I confirmed the bleach wipe was not in contact with the glucometer for 3 minutes and had not killed, if any, C-diff spores. A review of the Clorox Healthcare Bleach Germicidal Wipes container, indicated the wipes kills C. Difficile spores in 3 minutes in a yellow square on the front panel. The instructions indicated: - wipe surface to be disinfected. - Use enough wipes for treated surface to remain visibly wet for the contact time listed. - Let air dry. The container of Clorox wipes indicated the following contact times to kill pathogens: - Clostridium difficile - 3 minutes - Bacteria - 30 seconds - Viruses - 1 minute - Bloodborne pathogens - 1 minute - TB - 3 minutes - Parvoviruses - 3 minutes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 45 of 46 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 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave 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 0880 - Fungi - 3 minutes Level of Harm - Minimal harm or potential for actual harm On 2/18/20 at 5:16 p.m., Staff Member J, Registered Nurse (RN), was observed to obtain a blood glucose level and administer medications to a resident. When asked how the glucometer was cleaned, the staff member looked at a clipboard on the medication cart, flipped it over, removed a Medline MicroKill wipe from the bottom drawer, and wiped the glucometer. Residents Affected - Some The container of Medline Micro-Kill One Germicidal Alcohol Wipes listed pathogens that did not include Clostridium difficile. To kill pathogens with Micro-Kill One wipes, surfaces were to remain wet for one full minute. The Director of Nursing stated, on 2/18/20 at 6:12 p.m., her expectation for cleaning a glucometer was to clean it before and after each resident. She stated staff were to use the purple top wipe, Germicide (Micro-Kill One), contact time was one minute, and allow it to air dry. The DON stated the germicide kills everything and was the glucometer manufacturer recommendation. At 6:25 p.m. on 2/18/20, the DON provided a container of both a purple topped Micro-Kill One and Clorox Bleach wipes. She confirmed C-diff was not listed on the germicide and the glucometer, if disinfected with Clorox, should be wet for 3 minutes. When asked how the facility dealt with the disinfection of a glucometer used for a resident with C-diff, the DON stated incorrectly using Micro-Kill. The policy titled, Glucometer Disinfection, undated, indicated glucose monitors will be disinfected after each patient's use to prevent the spread of Bloodborne Pathogens per the manufacturer's recommendations. The policy identified the equipment needed was gloves and Medline Micro-Kill+. The procedure portion of the policy instructed staff to clean the meter surface with Medline Micro-Kill disinfecting wipes and allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions of use. The policy titled, Clostridium Difficile, revised 10/1/19, revealed alcohol rubs are not effective as C. difficile is a spore producing organism and bleach is the only effective environmental cleanser to date. According to https://www.medline.com/media/catalog/Docs/MKT/MAN_EvenCare%20G3%20Users%20Guide.pdf, the following products are approved for the cleaning and disinfection of the Evencare G3 glucometers: - Dispatch Hospital Cleaner Disinfectant Towels with Bleach - Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol - Clorox Healthcare Bleach Germicidal and Disinfectant Wipes - Medline Micro-Kill Bleach Germicidal Bleach Wipes FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 46 of 46