Inspection·September 16, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm clothing and said, I think she needs help. Staff G removed the pepper packet that was still stuck to the spoon and removed some of the large clumps of food that had fallen on the resident's chest and shirt. At 12:39 p.m. on 09/14/21, the resident was observed again alone in her room, no staff were present, and she was licking the outside of an empty bowl. Food debris remained on her shirt, and her hands and fingers were coated with food. Residents Affected - Few Observation of the lunch meal was conducted on 09/15/21. At 12:28 p.m., a CNA delivered Resident #24's tray and exited the room at 12:31 p.m. At 12:35 p.m. on 09/15/21, Staff F, Registered Nurse (RN) was heard in the resident's hallway asking where a certain CNA was because she had feeds. At 12:38 p.m. on 09/15/21, Resident #24 was observed in bed with her lunch tray engaged in feeding herself. There were no staff present in the room providing assistance or supervision. The resident smiled when addressed but did not otherwise engage. She was using her fingers to feed herself and both hands were coated with pureed food. Food had been dropped on her chest and on the gown she was wearing. There was a scoop plate containing pureed food items on the bed near her lap. During the observation she picked up a bowl that contained what appeared to be pudding, brought it to her mouth, and began licking the outside of the bowl. Immediately following this observation, Staff F was asked to enter the room for interview. When Staff F entered the room, the resident was still licking the outside of the pudding bowl. Staff F observed the resident's actions, the food all over her hands and chest and said that clearly the resident needed to be fed. Staff F said nobody had made her aware this was going on and if she had known she would have assigned someone to feed her. Staff F observed the placement of the scoop dish on the bed and said it wasn't of any help since the resident could not use it properly. She said Resident #23 had not been a feed and said she needed to be a feed. She then began feeding the resident from a standing position over her. When questioned about the use of the term feed to refer to a resident and about standing over a resident to provide dining assistance, Staff F said she had not been aware she was using that terminology and said if she had been planning to feed the resident, she would have arranged to be seated next to her. (Photographic evidence of setup obtained). On 9/15/21 at 2:49 p.m., Staff F followed up to report that she had entered dining assist required for Resident #24 into the [NAME] (CNA task list) and that in-servicing with staff had begun. An interview was conducted on 09/16/21 at 9:02 a.m., with Staff H, Registered Dietician (RD). She confirmed she had visited Resident #24 on 09/14/21 after Staff G reported to her that the resident was dropping food during meals. Staff H confirmed she had initiated trial of a scoop plate. Staff H said she followed up with Staff G the evening of 09/14/21. Staff G reported the scoop plate was helpful and so Staff H did not follow up further. Staff H said that she told Staff G that the resident would need at least supervision with the scoop plate to make sure she was using it correctly. Photographic evidence of the scoop plate observed on the resident's bed during the lunch meal on 09/15/21 was revealed to Staff H. She confirmed that was not the correct setup and confirmed that the resident needed someone to assist her with eating. An interview was conducted with the facility Director of Nursing (DON) on 09/16/21 at 9:52 a.m. She said the expectation for identifying residents who needed assistance with dining for dignity or safety was that facility staff monitor the patients, monitor their behaviors, some of my patients that becomes a battle with their dementia, limiting their independence is not exactly dignified either. Observations made of Resident #24 throughout the survey were shared with the DON. Regarding food on clothing and covering hands the DON said the expectation was when it comes to that point CNAs who pick up the trays would identify change in condition. She said the expectation was that the CNA would identify the change and report it to a nurse, a manager, the dietician, or a therapist. Regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 2 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #24, the DON said, I don't think eating with hands and getting food all over her clothes is appropriate .not dignified. The facility procedure titled Meal Service dated 02/2019 revealed the purpose of meal service was to promote dining with dignity and enjoyment of meals. The procedure for service of meals in resident rooms included: Place tray squarely on over-bed table and position table for convenience of patient .Assist with adaptive equipment when necessary .Sit next to the patient while assisting them to eat, rather than standing over them .Provide supervision, limited assistance, extensive assistance, or total assistance as required by current level of self-performance in eating. Event ID: Facility ID: 105436 If continuation sheet Page 3 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 observations, interview, and record review, the facility failed to ensure that a resident centered care plan was developed and implemented related to Oxygen use for one (Resident #53) of five sampled residents and failed to implement fall interventions for one (Resident #68) of forty-two residents in the sample group. Findings included: 1. On 09/13/2021 at 12:14 p.m., Resident #53 was observed from the hall to be receiving Oxygen with bilateral nasal cannula. (NC) On 9/14/2021 a subsequent observation was conducted of Resident #53, laying in bed in her room. During the observation the oxygen concentrator was dialed at two (2) Liters. The resident confirmed that she wears oxygen continuously. A medical record review for Resident #53 indicated she was originally admitted on [DATE] and re-admitted on [DATE] with multiple diagnoses that included chronic respiratory failure with hypoxia, and Spinal Stenosis, Thoracic. A review of the physician orders revealed Resident #53 did not have an active physician's order for Continuous Oxygen by Nasal Cannula (NC) 2 Liters (L). Record review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident #53's Brief Interview for Mental Status (BIMS) score was 11, (indicating moderate cognitive impairment). Section O Special Treatments, Procedures and Programs lists under 0100, O signed 08/10/2021 Oxygen Use while resident is in the facility. Record review of Resident 53's care-plan with a target date of 11/13/2021 did not include a focus area, goals, or interventions for Oxygen use. On 09/15/21 at 8:50 a.m., an interview was conducted with Resident #53's nurse, Staff B, Registered Nurse (RN), on the [NAME] Wing Hall. Staff B indicated the resident was supposed to be receiving Oxygen. She reviewed the active physician's orders and indicated that she could not find a current or discontinued order in the Electronic Medical Record (EMAR) for Oxygen use for Resident #53. An interview was conducted with the Director of Nursing (DON) on 09/15/21 at 04:57 p.m., The DON verified that Resident #53, was not care planned and did not have an active order to receive supplemental oxygen An interview was conducted with Staff C, RN Assessment Coordinator on 09/16/21 at 11:25 a.m. Staff C stated, When a new order comes in everyone is responsible to add or take things out of a resident's care plan, and it can be done anytime. They are expected to put it on the care plan if they are getting oxygen or something new ordered by a physician. She revealed that she was not the only one that made changes to a resident's care plan, especially if new orders were given off hours when she was not working 2. Resident #68 was observed in her bed in her room on 09/13/21 at 10:30 a.m. Her mattress was a standard mattress without a scoop and was not in a lowered position. Bruising was noted around the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 4 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 resident's left eye and at the left side of her neck. The resident said the bruises were from a fall in her room. She could not provide specific on when the fall occurred or the exact circumstances but said her nursing aide told her she had fallen getting out of bed and hit against the foot of the bed. A review of Resident #68's medical record was conducted. The admission Record revealed diagnoses including senile degeneration of the brain and Parkinson's disease. The care plan revealed a focus area for fall risk and included interventions of bed in low position (initiated 12/12/20) and scoop/perimeter mattress (initiated 01/08/21). Observation of the Resident #68's bed was made with Staff F, Registered Nurse (RN) on 09/15/21 at 1:05 p.m. Staff F confirmed there was no scop mattress present. An interview was conducted with the Director of Nursing (DON) on 09/16/21 at 10:37 a.m. She confirmed the resident fell on [DATE] while attempting to get out of bed unassisted. Observation of Resident #68's room was made with the DON during the interview. The DON confirmed that there was no scoop mattress and that the bed was not in a low position. Regarding the interventions for fall prevention identified in the care plan versus what was observed the DON said, unfortunately the interventions that were supposed to be in place for fall prevention were not in place. She said she did not know why the scoop mattress was removed from the bed and said she had asked the staff and they did not know. Regarding the bed not in a low position she said, I think she's (Resident #68) putting her bed up and down. A review of the facility policy titled Interdisciplinary Care Planning, with revision date of 03/2018 reads as follows: Comprehensive Care Plan Requirements The facility must develop and implement a comprehensive person centered careplan for each Patient that includes measurable objectives and timeframes to meet a patient's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The services provided or arranged by the facility, as outlined in the comprehensive care plan, must- meet professional standards of quality, be provided by qualified persons in accordance with each patient's written plan of care, be culturally competent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 5 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 0694 Provide for the safe, appropriate administration of IV fluids 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 failed to provide Intravenous (IV) care according to professional standards for two (Resident's #71 and #357) of four sampled residents by failing to ensure the IV dressings remained intact. Residents Affected - Few Findings Included: 1. During an interview and observation of Resident #71 on 9/13/21 a.m. at 11:45 a.m., the resident stated she received IV medication for a left hip infection. The right upper arm IV dressing was dated in black marker, difficult to read as 9/7/21 or 9/9/21. During an interview and observation of Resident #71 on 9/14/21 9:30 a.m., she stated she received her IV antibiotic this morning and the IV dressing remained with the same date. During observation on 9/15/21 at 11:48 a.m., the IV dressing was loose on the right upper inner arm and not completely intact on the outer edge. The date was the same on the dressing. During observation of Resident #71's dressing on 9/16/21 at 9:16 a.m., she stated the dressing had not been changed recently and the date was the same 9/7/21 or 9/9/21. The right inner portion of the dressing was peeling and not attached to the arm exposing the IV catheter at the point of insertion. The morning IV medication was observed completed and the IV line was connected to the resident. During an interview and observation on 9/16/21 at 9:30 a.m. with Staff A, RN, she stated the IV medication should have been disconnected by now and stated the date on the IV was not recognizable. She removed the dated sticker and placed it in her pocket while flushing the IV line. She stated the dressing would be changed today and confirmed the IV dressing was not intact. Review of physician orders Included: Triple lumen PICC (Peripherally Inserted Central Catheter) right upper extremity valve adapter change as needed, dated 8/17/21. Triple lumen PICC right upper valve adapter change every day shift every 7 days, dated 8/17/21. Triple lumen PICC line right upper extremity: flush with 10 cc before and after antibiotic administration every shift and as needed, dated 8/17/21. PICC triple lumen right upper extremity: change dressing every 7 days with sterile dressing kit every day shift and as needed for soiled or dislodged dated 8/18/21. PICC line/midline: Measure arm circumference on admission and as needed dated 8/17/21. Meropenem solution reconstituted 1 gram. Use 1 gram intravenously every 8 hours for prosthetic joint infection for 4 weeks dated 8/27/21. Review of the medication administration record (MAR) for September documented: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 6 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 0694 Level of Harm - Minimal harm or potential for actual harm Triple lumen PICC line right upper extremity: measure arm circumference one time only for placement until: dated 9/16/21 at 11:59 p.m. completed on 9/16/21 at 12:03 p.m. measuring 36.5. Triple lumen PICC line right upper extremity: measure external catheter length one time only until 9/16/21 at 11:59 p.m. measured on 9/16/21 at 11:57 a.m. measured (0). Residents Affected - Few Triple lumen PICC, right valve adapter change: every day shift every 7 days, checked off as completed on 9/7/21 and 9/14/21. PICC triple lumen right upper extremity: change dressing every 7 days with sterile dressing kit every day shift every 7 days, checked off as completed on 9/7/21 and 9/14/21. Triple lumen PICC line right upper extremity: measure external catheter length every day shift every 7 days for placement not completed for the month of September. Triple lumen PICC line right upper extremity: measure external catheter length every day shift every 7 days for placement not completed for the month of September. Triple lumen PICC line right upper extremity: flush with 10 cc before and after antibiotic administration every shift completed daily for the month of September. Meropenem solution reconstituted 1 gram: use 1 gram intravenously every 8 hours for prosthetic joint infection for 4 weeks completed daily for the month of September. Monitor insertion site of PICC line for signs and symptoms of infection every shift for PICC completed daily for September. PICC triple lumen right upper extremity: change dressing every 7 days with sterile dressing kit as needed for soiled or dislodged dated 9/3/21 and 9/10/21. Review of the care plan revealed a focus area for Infection, sepsis left hip infection initiated on 8/18/21. Interventions included administer medication per physician orders initiated on 8/18/21. Review of the Minimum Data Set, dated [DATE], Section C. revealed a brief interview for mental status of 14, no cognitive impairment. Section O. Special treatments, procedures and programs completed section H. checked off as IV medications used. 2. During an interview and observation with Resident #357 on 9/16/21 at 10:15 a.m., the resident was observed with a PICC line dressing on the right upper arm. The right upper arm dressing was not intact from the bottom 1/2 and exposed the catheter at the insertion point. The date was barely visible on the dressing. During an interview on 9/16/21 at 10:16 a.m. with Staff L, LPN, he confirmed the dressing said 9/10/21 and was coming off exposing the IV catheter. He stated the nurse should have secured the IV catheter dressing during infusion and stated that the dressing was due to be changed today,9/16/21. During an interview with the Assistant Director of Nursing (ADON) on 9/16/21 at 11:05 a.m., she confirmed that the dressing should be dated and secured not exposing the catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 7 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 0694 Review of physician orders revealed: Level of Harm - Minimal harm or potential for actual harm Discontinue PICC line upon completion of antibiotics dated 9/3/21. Residents Affected - Few PICC line flush with 10 cc normal saline, before and after IV antibiotic administration every shift and as needed dated 9/3/21. Single lumen PICC right upper arm dressing change every 7 days with sterile dressing kit and as needed dated 9/5/21. Single lumen PICC line right upper arm: change needless device every 7 days and as needed dated 9/5/21. Single lumen PICC line right upper arm: measure arm circumference with each dressing change and as needed dated 9/5/21. Single lumen PICC line right upper arm: measure external catheter length with each dressing change every 7 days dated 9/5/21. Ceftriaxone sodium solution reconstituted 2 gram IV one time a day for right toe Osteomyelitis for 6 weeks dated 9/3/21. Review of the MAR revealed: Cetriaxone given daily with last dose on 9/16/21 at 6:00 a.m. Single lumen PICC line right upper arm: change dressing every 7 days with sterile dressing kit last changed on 9/9/21. Single lumen PICC line right upper arm: measure arm circumference with each dressing change and as needed last completed on 9/9/21 and centimeters is not documented. Single lumen PICC line right upper arm: measure external catheter length with each dressing change completed on 9/9/21 with centimeters documented. PICC line flush with 10 cc normal saline every shift before and after IV antibiotic administration completed on 9/16/21 day shift. Review of minimum data set (MDS) Section C. revealed a brief interview for mental status (BIMS) of 14 dated 9/7/21. Review of section O, dated 9/13/21 revealed the resident was on IV medications. Review of facility policy for Midline/peripherally inserted central catheter (PICC) dressing change, 3 pages, revealed: To maintain catheter site integrity by keeping catheter in correct position and covered by an intact dressing; and to reduce the risk of local infection at catheter insertion site and catheter related bloodstream infection. Change TSM dressing every 7 days per physician order. Change sooner if dictated by resident condition or dressing becomes damp, loose, or visibly soiled. Change dressing immediately if soiled, loose or integrity is compromised. Take and document external catheter measurements in cm at each dressing change whenever catheter migration is suspected. Measure and document the circumference in centimeters of the mid-upper portion of the upper extremity with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 8 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 0694 the catheter present, as needed, to detect and monitor possible retrograde edema of the arm. Compare the measurements to the baseline mid-upper arm circumference done at the time of insertion. 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: 105436 If continuation sheet Page 9 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 observation, interview, and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-eight medications were observed, and eleven late medications were verified for one (Resident #206) of six (6) residents observed. These late medications constituted a medication error rate of 39.29 percent. Residents Affected - Some Findings included: On 09/15/2021 at 09:28 a.m., an observation was conducted of Staff A, Registered Nurse (RN), on the East Wing, administering medications to Resident # 206. Staff A, (RN) was seen administering the following medications: - Baclofen Tablet 10 mg orally every 12 hours - Flonase Suspension 50 mct/act (Fluticasone Propionate) One (1) Spray in both nostrils one time a day - Lasix Tablet 40 mg orally daily - Loratadine Tablet 10 mg orally - Vitamin C Tablet Give 500 mg orally - Spironolactone Tablet 25 mg Two (2) Tablets orally - Alprazolam Tablet 0.25 mg Give 0.5 tablet by mouth every 12 hours - Guaifenesin Tablet Give 400 mg orally two times a day - Propranolol HCL Tablet 10 mg orally every 12 hours - Vitamin C Give 500 mg orally -ProSource Liquid Give thirty (30) ml orally two (2) times a day On 9/15/2021 at 9:45 a.m., an interview was conducted with Staff A, (RN). She revealed that she had a late start, at 7:30 a.m., because of getting report from the prior nurse. She said she did not tell the Unit Manager (UM) or anyone else in a supervisory role that she was running late administering medications to residents. She said she did not call the physician. Record review of active Physician Orders and the Medication Administration Record (MAR) for Resident #206, revealed that the medications administered to the resident were given late, and scheduled to be administered at 8:00 a.m. An interview was conducted on 09/15/2021 at 12:26 p.m., with the Director of Nursing (DON). During the interview she stated, My expectations is that all meds are given on time, if they are late they can talk to the physician and see if there are any orders for giving them late. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 10 of 11 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 105436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowpark Health and Rehabilitation Center 870 Patricia Ave Dunedin, FL 34698 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 - Some On 09/15/2021 at 12:40 p.m., and interview was conducted with Pharm-D Pharmacy Consultant from Heartland Health Care Services, who was in the facility. During the interview, he said the regulation indicated that medications could be given one hour before and one hour after the prescribed time. A facility provided policy titled, Medication and Treatment Administration Guidelines, with revision date 03/2018, Pages 01 and 02 of 04 revealed under General: Medications are administered in accordance with standards of practice and state specific and federal guidelines. Medication And Treatment Orders: A complete medication order includes: Date and Time. Medication Administration: Medications are administered in accordance with the following rights of medication administration-right time (including duration of therapy). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 11 of 11