Inspection·September 6, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation was made on 9/5/2023 at 10:04 AM, in the bathroom of resident room [ROOM NUMBER]. The baseboard was protruding from the wall, in front of the toilet. Behind the toilet in both corners the floor was pulling away from the wall. (Photographic Evidence Obtained.) An observation was made on 9/5/2023 at 10:10 AM, in the bathroom of resident room [ROOM NUMBER]. The front edge of the sink counter was pulling away from the particle board leaving an uncleanable surface. The bathroom toilet had a black and brown substance at the base of the toilet, a space between the base of the toilet and the floor was visible. At both corners behind the toilet, the floor was separating away from the wall. (Photographic Evidence Obtained.) An observation was made on 9/5/2023 at 10:20 AM, and 9/6/2023 at 10:15 AM, in resident room [ROOM NUMBER] and the bathroom. A square piece of foam, with a protective covering that had brown and yellow staining over the entire foam piece was leaning up against the headboard wall, next to the resident's nightstand. A blanket and basin were observed underneath the a/c unit, with a wet floor sign propped up against the wall. The bathroom toilet had a brown substance at the base of the toilet, a space between the base of the toilet and the floor was visible. (Photographic Evidence Obtained.) An observation was made on 9/5/2023 at 10:26 AM, in resident room [ROOM NUMBER]. The baseboard was protruding away from the wall underneath the closets. (Photographic Evidence Obtained.) An observation was made on 9/5/2023 at 10:47 AM, in resident room [ROOM NUMBER]. The baseboard was protruding away from the wall underneath the a/c and the wall was chipping above the a/c. (Photographic Evidence Obtained.) An observation was made on 9/5/2023 at 10:55 AM, in resident room [ROOM NUMBER]. The baseboard was protruding away from the wall next to the a/c. The drywall behind the baseboard was crumbling and black in color. In the bathroom, the counter holding the sink on the front edge was pulling away from the particle board, creating an uncleanable surface. (Photographic Evidence Obtained.) An observation was made on 9/5/2023 at 9:02 AM and 12:15 PM, in the first-floor community shower/spa room, directly to the right of the nurses' station. The sink was being utilized to store various items (gloves, empty trash bag, grey cables, and other that were not-visible without pulling out the items mentioned). Multiple wheelchair leg rests were laying around the right edge of the floor. A washcloth was in a corner on the floor, by another wheelchair leg rest. (Photographic Evidence Obtained). The first-floor community shower/spa room (near the entrance of room [ROOM NUMBER]) was observed on 9/5/2023 at 10:15 AM and 12:30 PM. There was visible space between the counter and sink, the caulking was pulling away or missing and had black bio growth around it. The side boards surrounding the sink had a brownish substance built up on the top edge. The shower chair, four of four wheels appeared to have oxidized brown substance where the wheels met and connected. All the joints of the chair had pink and brownish bio growth surrounding them. A purple washcloth was sitting on a shower bench. The knob that turned the water on to the shower was missing, leaving an open pipe. (Photographic Evidence Obtained). The second-floor community shower/spa room was observed on 9/5/2023 at 10:35 AM. The sink had visible space between the sink and the wall, the caulking was cracking. The knob that turned the water on to the shower was missing, leaving an open pipe. The shower chair had four mesh straps. Four of four of the straps were soiled with a brown and blackish substance. The seat base of the chair had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 2 of 3 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 09/06/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few black spots staining. Two of two shower drains were lacking the drain cover. A different shower/over the toilet chair had debris and brownish substance on the piping underneath the toilet seat. The knob that turned the water on to the shower was missing, leaving an open pipe. (Photographic Evidence Obtained). On 9/6/23 at 10:15 AM, an interview was conducted with the Maintenance Director (MD). He stated his department was responsible for upkeep of the facility physical plant. He stated he had been in his position for about 7 months. He explained the process of reporting issues in resident rooms was, if a staff member was informed by a resident/family or if they just noticed something themselves, they just tell him. The repair was then completed by the maintenance director or his assistant. This writer and the maintenance director went to room [ROOM NUMBER], knocked on the door, obtained permission to enter the resident room and looked in the bathroom. Upon entering the room, the maintenance director stated the towel and basin underneath the a/c was from the weekend. Upon entering the bathroom, he noted the toilet base, and stated oh yes, we have numerous toilets like this, the seal is gone. We continued into the hallway to room [ROOM NUMBER]. Knocked, and obtained permission to look around the room and bathroom from the resident. The maintenance director stated there were many baseboards like that in the facility, falling off the wall in resident rooms and bathrooms. He observed the pipe in the shower and stated, that is interesting, oh I know how to fix this. He needed to step away from the tour to address a resident's need. The maintenance director returned at 10:25 AM and stated he just spoke with the Regional Director of Operations (RDO) who had a Performance Improvement Plan (PIP) for the physical plant. When asked to see the PIP he stated, oh, it's not completed, RDO is starting one now. He stated he had been working on these issues for a while now. He had nothing in writing or rooms written down with issues. He stated, Just been going about it, we have a lot to do. A facility policy titled, Maintenance Service, dated on the bottom © 2001 MED-PASS, Inc. (Revised December 2009) Version: 1.2 (H5MAPL0477). Policy Statement: maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy interpretation and implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2 Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with the current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. f. Establishing priorities and providing repair service. i. Providing routinely scheduled maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. A facility policy titled, Homelike Environment, dated on the bottom © 2001 MED-PASS, Inc. (Revised May 2017) Version 1.2 (H5MAPL1202). Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105436 If continuation sheet Page 3 of 3