Health inspection·May 18, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm stated personal belongings were held for 24 hours in the resident's room. After 24 hours, the certified nursing assistants (CNAs) would package these belongings, label, and place them in the day room. Staff N stated the Inventory Sheet should be in the resident's chart. A record review of Resident #109's medical record revealed no inventory sheet was present. Residents Affected - Few On 05/16/2023 at 3:39 p.m., Staff L, LPN/UM stated the inventory sheet may be in Resident #109's former chart and to ask the Nursing Home Administrator (NHA) to locate the inventory sheet from previous admissions. On 5/16/2023 a review of the physician orders for Resident #109 revealed no current medical or therapy orders for specialty shoes. A review of the Grievance Logs from May 2022 to May 2023 revealed no grievances filed on behalf of Resident #109 related to his missing specialty shoes. On 05/16/2023 at 3:50 p.m., Staff N stated she called the [spouse] and confirmed Resident #109 had specialty shoes and they should be in his room. Staff N confirmed she found one shoe present in his room during investigation but was not aware of another missing specialty shoe. Staff N would confirm with physical therapy to see if the shoe was present in therapy room. Staff N confirmed a grievance was not filed for Resident #109. Staff N stated, This is the first time I have heard of missing specialty shoes for [Resident #109]. On 05/17/2023 at 10:50 a.m., Staff N arrived with Resident #109's two shoes, claiming they were found in Staff L's LPN/UM office, labeled with Resident #109's name and room number. Staff N stated she talked to the Rehab Director this morning and stated, Today was the first day that the Director found out [Resident #109] was missing his specialty shoes. On 05/17/2023 at 1:58 p.m., an interview was conducted with both Staff G, Director of Rehabilitation and Staff K, PT. Staff G stated Resident #109 had a past medical history of bilateral transmetatarsal (toe/partial foot) amputations. Staff K, PT stated upon Resident #109's admission, he could not recall specialty shoes for the resident. The Rehab Director stated there were no orders for the placement of specialty shoes for Resident #109. Both Staff G and Staff K confirmed a grievance should have been made on behalf of Resident #109 related to his missing specialty shoes. Review of Resident #109's admission Record showed and original admission date of 3/23/2023 and diagnoses to include acquired absence of other right toe(s) and acquired absence of other left toe(s). A record review of Resident #109's Minimum Data Set (MDS), dated [DATE], revealed in Section C Cognitive Patterns a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. Section G - Functional Status showed the resident as a one person assist for bed mobility, and two persons assist from bed to wheelchair and standing position. Review of Resident #109's admission inventory sheet, dated 3/23/2023, had shoes checked off for initial admission. In addition, a review of inventory sheet for Resident #109 readmitted on [DATE] after a short stay in an acute hospital setting showed NO belongings. (Photographic Evidence Obtained) A review of the facility's policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, showed in #5 item c: Policy Statement: All grievances and complaints filed with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 2 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0585 facility will be investigated and corrective actions will be taken to resolve the grievance(s). 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: 105426 If continuation sheet Page 3 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure Preadmission Screening and Resident Review(s) (PASRR) were completed accurately and updated as needed for three (Residents #48, #473, and #77) out of 28 initially sampled residents. Findings included: 1. The admission Record for Resident #48 indicated the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to disorganized schizophrenia, moderate recurrent major depressive disorder, and unspecified anxiety disorder. The psychiatry note, dated 4/27/23, indicated the primary psychiatric diagnosis of disorganized schizophrenia with secondary diagnosis of moderate recurrent major depressive disorder and tertiary diagnosis of other specified anxiety disorders. The note revealed the resident was currently stable on dosing with labile situationally related fluctuations in level of anxiety and depression that are deemed tolerable at this time. A PASRR, dated 8/11/22, that was completed by Staff Member H, Minimum Data Set (MDS) Coordinator, at the facility, indicated Resident #48 had a Mental Illness diagnoses of Anxiety disorder, Depressive disorder, and Schizophrenia. A PASRR, dated on 2/14/23, that was completed at an acute care facility, identified Resident #48 had no Mental Illness diagnoses and that the finding was based on documented history, medications, and behavioral observations. The PASRR indicated that a Level II evaluation was not required. On 5/17/23 at 1:08 p.m., Staff H reviewed Resident #48's PASRR dated 2/14/23 and confirmed that it should have been redone. The staff member reported being new at this, was still learning, and confirmed that the staff member and the Social Service Director were new. 2. On 5/15/23 at 11:15 a.m. Resident #473 was heard yelling got to [expletive], where's my shoes, and needing to have lunch with friend. The residents' roommate reported not being able to sleep due to the resident yelling all night. The electronic record indicated medical diagnoses of Resident #473 that included unspecified dementia. The Nursing Home Administrator stated, on 5/17/23 at 9:00 a.m., the facility was going to have psych come in and see the resident. The resident could be heard, from the nursing station, screaming help me, they took my shoes. The resident was overheard informing an unknown person that it was the only way of getting any attention. Resident #473 was recently readmitted from an acute care facility. Section III of the residents' PASRR, dated 5/9/23 that was completed at the acute facility, showed the resident was being admitted under a Hospital Discharge Exemption. The section showed,An attending physician's signature is required for those individuals admitted under a 30-day hospital discharge exemption if the full screening was completed by someone other than a physician licensed in the state of Florida. Section IV of the PASRR identified that the resident was able to be admitted to the Nursing Facility as No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, the available selection of Hospital Discharge Exemption was not checked in section IV. The PASRR was completed by a Registered Nurse at the acute facility on 5/9/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 4 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/17/23 12:21 p.m., the Social Service Director (SSD) reported that the Admissions department should be reviewing them before the residents were admitted . The SSD stated she did not do the PASRR but gave to the MDS) staff (to do). The SSD reported she reviewed the PASRR for accuracy, filled one out and passed it to MDS because they had access to KEPRO, and MDS was responsible for redoing it (PASRR). The Social Service Director (SSD) reviewed, on 5/17/23 at 12:37 p.m., Resident #473's PASRR and stated, this one had been redone, after returning to the interview a few minutes later, the SSD stated that it had been missed. The SSD confirmed the PASRR should have been signed by the attending physician. 3. A review of Resident #77's electronic medical record revealed that the resident was admitted to the facility on [DATE] and diagnoses that included Major Depressive Disorder, Generalized Anxiety, Vascular Dementia Unspecified Severity, with Other Behavioral Disturbances. A review of the Preadmission Screening and Resident Review (PASRR) revealed this document was completed by hospital personnel on 3/13/23. Continued review of the PASRR revealed Section I-A indicated the resident had MI (mental illness) or suspected MI that was identified as Anxiety Disorder and Depressive Disorder. Section II-6 of the PASRR indicated resident did not have a secondary diagnosis of dementia, related to neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an Serious Mental Illness or Intellectual Disability Review of the resident's diagnosis list indicated the resident had diagnoses that included Generalized Anxiety Disorder, Vascular Dementia, Unspecified severity, with other behavioral Disturbance and Major Depressive Disorder, Recurrent, Moderate. Review of the residents hospital records prior to admission from 3/1/23 to 3/3/23 revealed that on page 2, 8, 21, 27, 31, 32, and 36 all reflect a diagnosis of Dementia. An interview on 05/17/23 at 12:45 p.m. with the Social Service Director revealed that she did not do the PASRR's, that she gave the PASRR's to the Minimum Data Set (MDS) Coordinators. The Social Service Director reported she just made sure the PASRR was present at the time of admission and verified the PASRR was accurate. She reported that she did not know if things changed with the resident and if so the MDS Coordinator would be responsible for initiating a Level II PASRR. The Social Service Director reviewed the resident's PASRR and confirmed the resident Absolutely requires a level II evaluation. An interview on 05/17/23 at 12:55 p.m. with Staff H, MDS Coordinator, Registered Nurse (RN) she revealed reviewed the PASRRs after social services reviewed them. She reported she was new to PASRRs, so may not be sure about how it works. Resident #77's record was reviewed with Staff H to include the PASRR level I, hospital records prior to admission to the facility and the facility diagnosis list. Staff H reported based on the documentation, a level II PASRR should have been requested for the resident Review of the facility policy titled Comprehensive Assessments with a revised date of March 2022 revealed that Comprehensive assessments are conducted to assist in developing person-centered care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 5 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure nutritional assessments were completed for two (Residents #29, and #61) of three residents sampled for nutrition. Residents Affected - Few Findings included 1. Review of Resident #29's electronic medical records revealed this resident was admitted to the facility on [DATE] and readmitted on [DATE], had a Brief Interview for Mental Status score of 7 (Severe Cognitive Impairment). Observations of Resident #29 on 05/15/23 at 9:11 a.m., revealed him sitting up in bed with his morning meal tray still in front of him. The resident had eaten his bowl of oatmeal and was still finishing his juice. The resident's plate contained sausage patty, toast, and scrambled eggs untouched. The resident reported that he did not want anymore and did not want anything different. The resident was noted to have tremors to his hands. The resident was noted to utilize a regular plate and regular eating utensils. Observations of Resident #29 on 05/16/23 at 12:22 PM revealed him eating his midday meal in the main dining room. The resident was noted to eat independently. He slowly used a regular plate, regular eating utensils and consumed 25% of his meal. The resident had tremors to his hands. An interview with Staff F, Certified Nursing Assistant (CNA) at this time, revealed the resident was encouraged to eat more, however, the resident refused. She reported the resident was offered other food, but declined. A review of the resident's weights revealed on 12/16/2022, he weighed 190.6 lbs. On 05/08/2023, the resident weighed 178.6 pounds which is a -6.30 % Loss. A review of the Quarterly Dietary Profile dated 5/11/23 reflected the following: -NAS diet, Regular texture, thin consistency -Snacks available prn -Meal portions regular -Eats in room -Regular utensils -Resident is currently on a NAS diet, Regular texture, Thin consistency. Per documentation, PO intake is good. Last weight of 178.6 lbs with no significant change. Malnutrition risk factors include depression. A review of the resident's current physician orders revealed the following: OT Clarification Order: Patient to have weighted utensils with all meals to increase independence with self feeding 4/24/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 6 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0692 Level of Harm - Minimal harm or potential for actual harm OT Clarification Order: Patient to have divided plate with all meals to increase independence with self feeding. A review of the resident's record revealed that there was no current Nutritional Assessment in the record. The last Nutritional Assessment noted in the record was from 2021. Residents Affected - Few In an interview on 05/17/23 at 9:41 a.m., Staff D, Registered Nurse (RN) revealed the resident was on a regular diet and received regular eating utensils and a regular plate for all meals. He reported he did not think the resident spilled any food. In an interview on 05/17/23 at 9:45 a.m.,Staff C, CNA revealed she worked with the resident often and was very familiar with him. She reported the resident utilized regular eating utensils and regular plates for all food with no spillage. During an interview on 05/17/23 at 9:52 a.m., Staff A, Registered Dietician (RD) and Staff B, Certified Dietary Manager (CDM) reported they both did not currently work for the facility but were covering the facility in the staffs' absence. They both reported the facility had an issue with a staff member not documenting weights appropriately and there was an issue with the scale in January/February. Staff B reported she completed a Dietary Profile in March to see the accuracy of interventions and root cause analysis and found that the resident forgets that he has food and forgets to eat. Continued interview at this with Staff A and Staff B, Staff A reported she was responsible for nutritional assessment and they were to be done at admission, re-admission, significant change and annual, but she was not sure why an assessment was not done. Both said Resident #29 did not utilize adaptive equipment. Staff A and Staff B reviewed the resident's current physician orders and both confirmed the resident had current orders to include weighted utensils and divided plate. A review of Resident #61's record revealed on 12/16/22, the resident weighed 194.2 lbs. On 05/08/2023, the resident weighed 139.3 pounds a 28.27 % Loss. 05/15/23 at 09:40 a.m., Resident #61 a dialysis patient, stated he did not like the food because it had no taste. He stated his roommate ordered out food and they often share. The resident stated he had lost weight, but he did not know how much. 05/16/23 at 12:53 p.m., Resident #61 was observed in his room during lunch. The resident did not eat his meal. He stated the fish did not have any taste. He stated he did not know what else they had to offer. The resident stated he was diabetic, and he never received snacks. The resident said, if you don't like the meal, it is too bad for you. A review of Resident #61's record revealed he was admitted to the facility on [DATE] with a primary diagnosis of unspecified local infection of the skin and subcutaneous tissue, end stage renal disease, specified diabetes mellitus, and severe sepsis. A quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #61 had a BIMS (brief interview for mental status) score of 15, which indicated intact cognition. Section G showed the resident required extensive assistance for Activities of Daily Living (ADL). A review of Resident #61's record revealed a nutritional assessment conducted on 08/31/22. The review confirmed Resident #61 was not assessed upon admission and/or with noted weight loss concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 7 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/17/23 at 9:22 a.m., an interview was conducted with the Registered Dietician (RD) and the Certified Dietary Manager (CDM). The RD stated Resident #61 was particular about his meals. She reviewed the record and confirmed Resident #61 should have had a nutritional evaluation done on admission, to reassess his nutritional needs and meal preferences. The RD stated they conduct nutritional evaluations and assessments upon admission, annually, and when there was a significant change. She confirmed Resident #61's last evaluation was completed on 08/31/22. She said, an evaluation should have been done. The resident was originally admitted on [DATE] and readmitted to the facility on [DATE]. A review of a facility policy titled, Nutritional Assessment revised October 2017, showed as part of the comprehensive assessment, a nutritional assessment including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment time frames) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic multidisciplinary process that includes gathering and interpreting data and using the data to help define meaningful interventions for the resident at risk or with impaired nutrition. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risk for nutritional complications. Such interventions will be developed within the context of the residents prognosis and personal preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 8 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure Oxygen orders were in place for one (Resident #323) of four residents and did not ensure respiratory equipment was stored appropriately for four (Residents #323, #53, #113 and #26) of four residents sampled for respiratory care in one (hall 100 upper) of four halls. Residents Affected - Few Findings included: 1. During a facility tour on 05/15/23 at 11:03 a.m., Resident #323 was observed in her room. Her Oxygen tubing and nasal cannula were noted on the floor. In an immediate interview, the resident stated she had been using her oxygen as needed. The resident confirmed she used her oxygen at night. A review of Resident #323 physician's orders on 05/15/23 revealed the resident did not have active orders for oxygen use. Subsequent facility tours on 05/16/23 at 12:27 p.m. and 05/17/23 at 12:20 p.m. revealed Resident #323's oxygen tubing and cannula exposed to the elements. A review of Resident #323's admission record revealed she was admitted to the facility on [DATE] with diagnosis to include other asthma. A care plan for Resident #323 dated 05/12/23, showed a focus indicating Resident #323 had potential for complications of respiratory distress related to diagnoses of asthma and CHF (congestive heart failure). Interventions included to obtain oxygen saturations as ordered, to administer oxygen as ordered, perform lung sounds/respiratory assessment as needed, observe for signs and symptoms of respiratory infection update physician if noted, observe for signs and symptoms of respiratory distress and update physician if noted. A review of Resident #323's MAR (Medication Administration Record) showed no documentation of the oxygen use. A Review of Resident #323's physician orders revealed on 05/17/23 at 2:45 p.m., an order was initiated a follows; Oxygen at 2 liters /minute via nasal cannula as needed for SOB saturation below 92% Record review showed Resident #323 was admitted on [DATE]. The review of record showed no evidence of Oxygen orders from 5/11/23 - 5/17/23. 2. On 05/15/23 11:26 a.m., 05/16/23 at 12:04 p.m., and 05/17/23 09:14 a.m., Resident #53's CPAP (Continuous Positive Airway Pressure) was observed at his bedside table, exposed to the elements. The tubing and cannula were not bagged. A review of Resident #53's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure with hypoxia, sleep apnea, obstructive sleep apnea (adult), pulmonary hypertensive, presence of cardiac pacemaker and dependence on supplemental oxygen. A care plan for Resident #53 initiated on 04/21/23 showed the resident has a potential for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 9 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complications of respiratory distress related to diagnoses of chronic respiratory failure, obstructive sleep apnea, and requires CPAP. Interventions included CPAP/BiPAP treatment as ordered, oxygen saturations as ordered and administer oxygen as ordered. Review of physician orders for Resident #53 showed to apply CPAP auto 4-20 CM H20 (water) for sleep Apnea. encourage resident to wear CPAP when sleeping, order dated 5/17/23. 3. On 05/16/23 at 12:31 p.m., Resident #113's oxygen tubing and cannula were noted hanging behind her wheelchair. Not appropriately stored. The cannula and tubing were exposed to the elements. Review of Resident #113's admission record revealed the resident was admitted to the facility on 04/11/ 23 with diagnosis to include acute respiratory failure with hypoxia. A review of the physician orders for Resident #113 showed orders to administer oxygen at 2 liters/minute via nasal cannula PRN (as needed) for SOB (shortness of breath) saturation below 92%. A care plan for Resident #113 initiated 04/12/23 showed the resident has a potential for complications of respiratory distress related to diagnoses of CHF, has shortness of breath when lying flat. Interventions included to administer oxygen as ordered. 4. On 05/17/23 12:46 p.m. an observation was made of Resident #26's Oxygen tubing and cannula on the floor by her bedside. On 05/17/23 at 12:53 p.m., an interview was conducted with Staff I, Registered Nurse( RN). Staff I did not state what the expectation was related to equipment storage. Staff I, RN visited Resident #26's room and observed her Oxygen cannula on the floor and tubing tangled under the bed. Staff I, RN did not identify any concern with the oxygen storage. The DON entered the room and observed the nasal cannula and tubing on the floor. She stated she would provide in-services for the nurses. She said, They should know to keep the equipment sanitary. On 05/17/23 at 12:30 p.m., an interview was conducted with Staff L, Licensed Practical Nurse (LPN), Unit Manager. She stated respiratory equipment should be put in a bag with the resident's name and should be dated. She stated if the tubing and cannula were found on the floor, they would throw them away and give the resident new supplies. On 05/17/23 at 12:42 p.m., an interview was conducted with Staff N, RN. During the interview, the nurse could not explain what the process of storing respiratory equipment was. Staff N did not state the expectation for cleaning, maintaining, or storing the equipment. On 05/17/23 at 12:48 p.m., a follow-up interview was conducted with Staff N, RN, and the Director of Nursing (DON). During the interview, they both observed Resident #323' s oxygen tubing and cannula tied on top of the concentrator, exposed to the elements. The DON said to the nurse, You know the tubing and nasal cannula should be stored in the bag? The DON stated to the nurse, You need a bag. An interview was conducted with the DON on 05/18/23 at 09:36 a.m. She said, related to resident's oxygen orders initiated on 5/17/23, I did not know the resident was using the oxygen. Therapy thought the resident was needing oxygen and that was why the concentrator and tubing was brought to the room. She stated she did not believe the oxygen was administered without orders. She stated she would see if there was a progress report. 05/18/23 at 11:56 a.m. the DON stated she initiated education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 10 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete She stated she went over respiratory equipment expectation, related to orders, cleaning and storage. She stated one of the nurses felt bad that he had not noticed the equipment was not properly stored himself. The DON said, I did not understand what happened to the other nurse. They normally communicate well with me. I have not had a problem communicating with them or them understanding me. Review of a facility policy titled, Departmental (respiratory Therapy)- Prevention of Infection, revised in November 2011, showed the purpose of the procedure it's to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps and procedures revealed an expectation to keep the oxygen cannula and tubing used PRN (as needed ) in a plastic bag when not in use and to store the circuit in a plastic bag, marked with date and resident's name, between uses. Event ID: Facility ID: 105426 If continuation sheet Page 11 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 record review and interview the facility failed to ensure that their Consultant Pharmacist made recommendations regarding irregularities in the residents drug regime for one (Resident #77) of five residents reviewed for unnecessary medications. Findings included: Review of Resident #77's electronic medical record revealed that the resident was admitted to the facility on [DATE] and had diagnoses that included Essential Hypertension, Major Depressive Disorder, Generalized Anxiety, Vascular Dementia Unspecified Severity, with Other Behavioral Disturbances. A review of the March 2023 and April 2023 pharmacy review revealed the resident was reviewed during both months and there were no recommendations for Resident #77 by the Consultant Pharmacist. A review of the resident's physician orders revealed a current order dated 3/29/23 for Midodrine HCI Oral Tablet give 5 mg every 8 hours as needed for hypotension. the residents orders revealed there was no order in place for parameters to guide staff in administering the Midodrine HCI. An interview on 05/17/23 at 11:08 a.m. with the Director of Nursing (DON), Registered Nurse (RN), revealed there should have been parameters in place if it was an as needed medication. She reported the nurses would need to have orders for the parameters in order to give this medication. A phone interview on 05/18/23 at 3:13 p.m. with the Consultant Pharmacist revealed there should have been parameters in place to hold medication if it dropped below a certain number. He reported he would typically review for this and make recommendations for parameters. He reported he might have missed this. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 12 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to arrange for dental services for one (Resident #12) of three residents sampled for coordination of care services. Residents Affected - Few Findings include During an interview with Resident #12 on 05/15/23 09:28 a.m., she was observed to have many missing and broken bottom teeth and two visible top teeth visible that were black at the bases. Resident #12 said she had broken her teeth years ago and was supposed to have them fixed. She said her teeth hurt when she ate and she wanted to see a dentist. A review of Resident #12's Minimum Data Set (MDS) dated [DATE], showed in Section C, the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Section L was marked to indicate, No mouth or facial pain, discomfort or difficulty chewing. The Social Services Director (SSD) was interviewed on 05/17/23 at 11:37 a.m. She said she was responsible for coordinating dental care for residents. The SSD said usually a Certified Nursing Assistant (CNA), nurse, or family member would tell her if a resident wanted or required dental services. During the interview, the SSD confirmed Resident #12 was not on the dental referral list. She consulted the Electronic Medical Record (EMR) and said the last time Resident #12 was seen by dental was on 10/18/21. The dental note from 10/18/21 was reviewed and indicated: Pt presents for screening Asymptomatic fractured &damaged teeth No pain or discomfort Pt interested in extractions and upper and lower dentures or upper denture and lower partial by retaining #30. Multiple attempts made to reach family for treatment authorization, no response. Will treat symptomatically. No follow up needed A follow up interview was conducted with the SSD on 05/18/23 at 09:16 a.m. The SSD confirmed Resident #12 requested to see dental services. She was scheduled to see a dentist on 5/19/23 and a dental hygienist on 5/22/23. Review of facility Policy Dental Services Revised December 2063 states: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 13 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure one (Resident #29) of three residents sampled for nutrition were provided with special eating equipment when consuming meals. Residents Affected - Few Findings included: A review of Resident #29's electronic medical records revealed the resident was admitted to the facility on [DATE], readmitted on [DATE], and had a Brief Interview for Mental Status score of 7 which indicated severe cognitive impairment. An observations of Resident #29 on 05/15/23 at 09:11 a.m., revealed him sitting up in bed, with his morning meal tray still in front of him. It was noted that the resident had eaten his bowl of oatmeal and was still finishing his juice. The residents plate contained sausage patty, toast, and scrambled eggs untouched. The resident reported that he did not want anymore and did not want anything different. The resident was noted to have tremors to his hands. The resident was noted to utilize a regular plate and regular eating utensils. An observation of Resident #29 on 05/16/23 at 12:22 p.m., revealed him eating his midday meal in the main dining room. The resident was noted to eat independently and slowly using a regular plate and regular eating utensils. He consumed 25% of his meal. The resident was noted to have tremors to his hands. An interview with Staff F, Certified Nursing Assistant (CNA) at this time revealed the resident was encouraged to eat more, however, the resident refused. She reported the resident was offered other food, but declined. An observation of the resident's meal tray on 05/17/23 at 9:09 a.m., revealed his tray consisted of a regular plate and regular eating utensil. Also noted on the tray was his meal ticket that did not indicate the use of adaptive equipment during meals. (Photographic evidence obtained) A review of the Occupational Therapy Evaluation and Plan of Treatment with a Start of Care date of 4/18/23 revealed Fine Motor Coordination=Impaired (pt demonstrates new onset of intention tremors and observed shakiness during meals with utensils and spillage of food over plate Review of the residents current physician orders revealed the following: OT Clarification Order: Patient to have weighted utensils with all meals to increase independence with self feeding 4/24/23 OT Clarification Order: Patient to have divided plate with all meals to increase independence with self feeding 4/24/23 Review of the Quarterly Dietary Profile dated 5/11/23 Dietary profile Quarterly which reflected the following: -NAS diet, Regular texture, thin consistency -Snacks available prn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 14 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 0810 -Meal portions regular Level of Harm - Minimal harm or potential for actual harm -Eats in room -Regular utensils Residents Affected - Few -Resident is currently on a NAS diet, Regular texture, Thin consistency. Per documentation, PO intake is good. Last weight of 178.6 lbs with no significant change. Malnutrition risk factors include depression. A review of the resident's weights revealed on 12/16/2022, the resident weighed 190.6 lbs. On 05/08/2023, the resident weighed 178.6 pounds which is a -6.30 % Loss. A interview on 05/17/23 at 9:41 a.m. with Staff D, Registered Nurse (RN), revealed the resident on a regular diet and received regular eating utensils and a regular plate for all meals. He reported that he did not think the resident spilled any food. An interview on 05/17/23 at 9:45 a.m. with Staff C, CNA revealed that she worked with the resident often and was very familiar with him. She reported the resident utilized regular eating utensils and regular plates for all food with no spillage. An interview on 05/17/23 at 9:52 a.m. with Staff A, Registered Dietician (RD) and Staff B, Certified Dietary Manager (CDM) revealed they both did not currently work for the facility but were covering the facility in the staff's absence. Both reported the resident did not utilize adaptive equipment. Staff A and Staff B confirm the resident had current orders to include weighted utensils and divided plate. An interview on 05/17/23 at 10:04 a.m. with Staff E, Certified Occupational Therapy Assistant (COTA) revealed the resident was to utilize weighted utensils and a divided plate. She reported the request ticket was provided to the kitchen to ensure adaptive equipment was provided. She reported she was unsure if the intervention was being utilized. An interview on 05/17/23 at 10:20 a.m. with Staff F, CNA revealed the resident utilized regular plates and regular eating utensils. Staff F returned to the room five minutes later and reported per therapy notes the resident was supposed to utilize weighted utensils An interview on 05/17/23 at 10:36 a.m. with the Director of Rehab revealed after orders are written, dietary communication forms were sent to the kitchen. She reported she did not recall if the dietary communication form was taken to the kitchen by the Occupational Therapist who wrote the order. She reported she was not sure if the order for adaptive eating equipment was communicated to dietary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 15 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain the kitchen in an clean and sanitary manner related to staff personal items, and failed to ensure that kitchen equipment is functioning appropriately related to an un-lit pilot light. Findings included On 05/15/23 at 6:56 a.m., an initial tour of the kitchen was conducted with the Assistant Dietary Manager. The kitchen housed a 6 burner stove. Close observation of the stove revealed the right front pilot light was not lit. When asked to light the right front burner, the Assistant Dietary Manager obtained a long nose lighter and proceeded to light the burner with the lighter. The Assistant Dietary Manager was asked to turn the burner off, when the burner was turned off the pilot light also went out and the Assistant Dietary Manager re-lit it the burner with the lighter. An interview with the Assistant Dietary Manager at this time revealed she did not know why the pilot light kept going out and said she would have maintenance look at it. (Photographic Evidence obtained) Continued initial tour of the kitchen revealed an open can of [brand named energy drink] on the counter of the steam table, an open can of [a different brand named energy drink] was noted on the prep counter, and an article of clothing was noted to be stored on top of clean drying food equipment on a shelf. (Photographic Evidence obtained) On 5/17/23 at 9:01 a.m. during a comprehensive tour of the kitchen with the Assistant Dietary Manager and Staff B acting Certified Dietary Manager (CDM) revealed the front right front pilot light was still not lit. The Assistant Dietary Manager proceeded to utilize the long nose lighter to light the burner. She reported the Maintenance Director was notified of the concern related to the pilot light. A policy related to maintenance of the kitchen was requested and not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 16 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to 1. ensure staff and visitors appropriately donned Personal Protective Equipment (PPE) prior to entering two (106 and 112) of seven rooms posted for Droplet precautions and to 2. ensure the facility's laundry room had cleanable surfaces related to ceiling tiles and a door frame between the washing and dryer/folding room that had flaking paint. Residents Affected - Few Findings included: 1. On 5/15/23 at 7:41 a.m., the Social Service Director (SSD) was observed, wearing black pants, blue shirt, and no PPE, standing in between the two beds of room [ROOM NUMBER], which was posted for Droplet precautions. A photo was obtained on 5/15/23 at 7:45 a.m. of the sign posted outside of room [ROOM NUMBER] which instructed Stop. Attention. Please carefully review the instructions below. EVERYONE MUST: Clean their hands, including before entering and when leaving the room with Alcohol based Hand Rub (ABHR). PPE REQUIREMENTS: Gown & Gloves, Face Shield or Goggles, N95 or higher-level respirator must be worn at all times while in patient room. The SSD came out of room [ROOM NUMBER] at 7:46 a.m. on 5/15/23 with water cups and stated she did not know why it (the room) was posted, no one had COVID and there should be a cart next to the door. The staff confirmed not wearing PPE other than gloves while in room [ROOM NUMBER]. On 5/15/23 at 8:12 a.m., an observation revealed room [ROOM NUMBER] was posted that Droplet precautions were to be observed by everyone entering the room. Staff O, Certified Nursing Assistant (CNA) was observed entering the room without wearing any PPE and stand next to the door then come back out. The staff explained knowing that PPE was to be worn and asked a staff near the nursing station for face shields, then informed another that faceshields/goggles were needed on the floor. On 5/15/23 at 8:19 a.m., the Director of Nursing (DON) stated Droplet precautions were for residents who came back from the hospital and PPE should be available to staff. A caddy directly across from the nursing station (next to room [ROOM NUMBER]) revealed a package of faceshields. Staff J, Medical Records, pulled open a drawer in back of the nursing station revealing a package of face shields. On 5/15/23 at 11:09 a.m., an unknown housekeeper was observed leaving room [ROOM NUMBER], posted for Droplet precautions, wearing a gown, surgical mask and eyeglasses. The housekeeper was not wearing either a faceshield or a pair of goggles. The housekeeper returned to the room wiping down the window sill and dressers while wearing the same PPE. On 5/15/23 at 11:53 a.m., an observation was conducted of a female provider standing next to the first bed in room [ROOM NUMBER], which was posted for Droplet precautions, the resident was lying in bed and recently admitted from an acute care facility. The provider was wearing street clothes covered by a white lab coat and not PPE as required. On 5/15/23 at 11:54 a.m., Staff P, CNA, was observed wearing a gown, gloves, and surgical mask while setting up the resident with a meal. Staff P's goggles were sitting on top of her forehead next to the hairline. On 5/15/23 at 2:06 p.m., Staff R, Registered Nurse (RN), stated the facility was in the process of taking Droplet precautions off of residents due to COVID not being a thing anymore. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 17 of 18 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 105426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615 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 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/18/23 at 12:49 p.m., the Infection Preventionist (IP) stated that Droplet precautions were implemented prophylactically for monitoring COVID, it was a policy. The IP stated Droplet precautions required gown, gloves, surgical mask, and/or faceshield/goggles and staff were to don before going into the rooms. The IP reported the expectation was that if posted and/or ordered they (staff) have to do it (don PPE). Residents Affected - Few 2. On 5/18/23 at 2:03 p.m., an observation of the laundry service area was conducted with the Regional Environmental Manager, the Environmental Manager, and the IP. The observation revealed 2 approximately 24 x 24 inch ceiling tiles did not have a plastic coating but was a yellow fiberglass-type material. The Regional Environmental Manager confirmed the areas were not cleanable. The steel door frame in between the dryer area and the washer area had peeling paint on top of the door frame. Photographic evidence was obtained. The policy - Isolation Categories of Transmission-Based Precautions, revised September 2022, indicated that Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infections; and is at risk of transmitting the infection to other residents. The policy identified that Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets (larger than 5 microns in size) that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). The procedure indicated that Residents on droplet precautions are placed in a private room if possible and when a private room is not available residents may share a room with a resident infected with the same microorganisms or with limited risk factors, when a private room is not available and cohorting is not achievable, decisions regarding resident placement are made on a case-by case basis after considering infection risks to other residents in the room and available alternatives. The precautions are that masks are worn when entering the room and Gloves, gown, goggles are worn if there is risk of spraying respiratory secretions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105426 If continuation sheet Page 18 of 18